Inspection on 10/08/05 for Southwest Road (7)

This inspection was carried out on 10th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southwest Road (7) 16/10/07

Southwest Road (7) 05/05/06

Southwest Road (7) 08/12/05

Southwest Road (7) 03/02/05

Southwest Road (7) 23/09/04

Southwest Road (7) 25/02/04

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

CARE HOME ADULTS 18-65 7 Southwest Road 7 Southwest Road Leytonstone London E11 4AW Lead Inspector Vivienne Patchett Unannounced Inspection 10 August 2005 at 03:40pm th 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 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 Stationary 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. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 7 Southwest Road Address 7 Southwest Road, Leytonstone, London, E11 4AW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8556 4286 020 8539 1770 Mind in Waltham Forest Greg Shelock Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) including one named person over of places 65 years 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2005 Brief Description of the Service: A care home for 3 adults with mental health histories, managed by MIND in Waltham Forest (a registered charity) and operating as part of the Forest Community Project, which offers a range of dispersed social housing - together with outreach support. This is the only registered provision in the project, although the service offered is the same for all service users i.e. support, supervision and accommodation. Staff are not on the premises for the full 24 hours - only on duty for 5 hours or less over the day, with a member of staff asleep on the premises at night. Staff are contactable via a 24-hour pager system and can respond within 20 minutes. The Forest Community Project is an innovative scheme, offering flexible support to service users. However, the way it is organised, run from a central point with peripatetic workers, does not sit comfortably with the requirements of the law governing registered care homes. The home opened at a time when a “lighter touch” was used in the registration and inspection of small homes. The home therefore does not meet some current environmental standards e.g. no wash hand basins in bedrooms, inadequate office space, limited facilities for the storage of staff belongings. The premises consist of a 3 bedroomed terraced house in a residential area of Leytonstone, with community facilities accessible by public transport. Service users share a sitting room, kitchen/ diner and back garden. There are two bathrooms, one on each floor. There is no lift and the kitchen is on the first floor so the home is not suitable for people with limited mobility. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a late afternoon from 3.40pm to 6.15pm in August 2005. The main focus of the visit was to speak to service users and check on progress in the implementation of the requirements and recommendations from the report of the last announced inspection visit in February 2005. No staff were on duty at the beginning of the inspection and a service user welcomed the inspector. A member of staff arrived for the afternoon shift at 3.55, left just after 5.00pm and helped the inspector during the inspection. The inspector spoke to all three residents who were happy with the care being provided. A full inspection of the premises was not undertaken at this time but the sitting room, kitchen/diner, garden and a bedroom were seen. The inspector looked at various documents and records, such as care plans, medication records etc. The inspector would like to thank the staff member and residents who contributed to the inspection. This inspection found that most requirements from the last report of the Regulation inspector in February 2005, many of which had been outstanding from previous inspection reports, and many of those from the report of the Pharmacy Inspector in March 2005 remained outstanding. As a result of the visit a Notice of Breach of Regulation was served regarding visits on behalf of the provider. What the service does well: What has improved since the last inspection? The kitchen has been refurbished and repainted with new cupboards, worktop and fridge. Residents were very pleased with the outcome. Digital TV is available in the sitting room. One resident has a new chest of drawers. An occupational therapist did an assessment in April 2005 and designed a shower to replace the bath in the downstairs bathroom. A noise-activated doorstop 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 6 was fitted to the sitting room door. Amendments have been made to the design of the staff rota and Medication Administration Records. User Involvement Meetings have been held monthly at the MIND Head Office for all service users across the project. One Southwest Road resident has attended. Service users are able to attend Senior staff meetings if they wish and minutes are available in the home. 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. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 standard(s) 1, 3 The Statement of Purpose and Service Users Guide developed by the home give a range of information but do not provide sufficient information and detail to enable prospective service users to make an informed choice about coming to the home. There was insufficient written information available within the home for the inspector to make a judgement about the homes capacity to meet assessed need. EVIDENCE: The Statement of Purpose had been laminated and pinned on the wall in the sleeping-in room/office. It consisted of 2 sheets of A4 paper, was signed and dated 13.1.05. There was one Service Users’ Guide available in the sitting room dated October 2004. Neither document included all the information set out in the Standards and Regulations and no more recent documents were available for inspection. The requirements of the last inspection in February 2005 are therefore repeated. The latest inspection reports were available in the sleep-in room. No new admissions had taken place since the last inspection so standards 2 and 4 were not looked at. The needs of existing residents have been assessed. See standard 6 re evidence of the homes capacity to meet assessed need. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8,10 Care plans included valuable information, were clearly laid out and being reviewed. However, records within the home were insufficient to show how the care plans were being implemented, how residents assessed and changing needs were being addressed and goals met. Service users can make decisions about their lives and the provider has been extending ways in which service users can participate in the running of the organisation. EVIDENCE: A sample of the Care plans was inspected. These were dated December 2004. The member of staff said that subsequent reviews had taken place fairly recently. There were no records since January 2005 to show the service offered or how the care plans had been implemented. There were no records completed by key workers (client support workers) and no evidence of their involvement in one-to-one meetings or direct work with residents other than attendance at the weekly residents meetings. There was a Daily Record Book, which had been started on the 5th August 2005. This had been completed by care workers but only described domestic tasks undertaken by them in the home such as cooking and cleaning. There was no indication of the service users condition, their needs or how the workers were implementing the care plans or interacting with residents. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 10 Residents were able to make decisions about their lives and were being encouraged to participate in User Involvement Meetings for the whole organisation. Residents felt that their views were listened to and acted upon but some would like to the more involved in day to day decision-making within the home. There was no evidence of this being discussed at the residents meeting when the findings of the inspection report were discussed. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 standard(s) 12, 13,14,15,16,17 The inspector was satisfied that residents take part in appropriate activities in the local community of their choice and are encouraged to maintain family relationships. Service users have choice in their diet. EVIDENCE: Residents described contact with their families and friends and outings offered to them and trips made e.g. to the cinema or shopping with staff. Residents are able to choose when to be alone or in company and when not to join an activity. Minutes of the residents meetings confirmed that the residents were encouraged to look at the local newspaper to find out local activities and to research interesting places to visit. Residents had been provided with a pack of leaflets describing local facilities and encouraged to use these opportunities. One of the residents said that they would like to go on holiday. Residents have keys to their bedroom doors. There have been some disputes between residents about individual responsibility for housekeeping tasks. This should be specified in the Service Users Guide and individual plan. Some residents appeared to be heavy smokers and rules on smoking, as well as alcohol and drugs should be clearly 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 12 stated in the Service Users Guide and contract. Service users are involved in the planning and choice of meals, assist with the shopping and prepare their own breakfast and evening meal, as staff are not on the premises at these times. Care staff usually prepare the lunch offering different options to each resident, although residents often prepare their own. There is usually one communal meal per week prepared by staff. One resident has their own fridge in which to keep specific foods. A record of food served was being kept but did not show what one resident had eaten during the week of the inspection. In the opinion of the Inspector, this was not sufficient detail to enable any person inspecting the record to determine whether the diet was satisfactory, in relation to nutrition. Fresh fruits were available and staff described efforts to interest residents in healthy eating. Drinks are available at all times. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 standard(s) 18,19, 20 Service users do not require assistance with personal care. The inspector was satisfied from discussion that, in general, health care needs were assessed and addressed. However the documentation was not adequate to confirm this. EVIDENCE: Client support workers act as key workers, and the inspector was told that they visit the home and accompany service users outside the home when necessary. However, there were no records to support this. Staff said the GP for one resident has agreed that blood pressure readings no longer need to be recorded by staff. However, there was no documentation to confirm these comments or indicate how health needs had been met in the preceding 6 months. The requirement from the last report that written protocols or guidelines should be available to assist staff in knowing what might constitute an emergency relating to residents individual health care remains outstanding. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 14 Currently none of the service users have been assessed as able to retain, administer and control their own medication. Medication is administered by staff from weekly dosettes prepared by the pharmacist. The format of the medication administration records (MAR sheets) had been amended in line with the requirement from the last report to provide a stock control system. The medication file did not include procedures for staff to follow and the member of staff did not know where these would be, although confirmed that staff had had some training in the administration of medication recently. No updated procedures were included in the main policies and procedures file. Requirements of the February 2005 report and that of the pharmacy inspector in March 2005 therefore remained outstanding. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 standard(s) 22, 23 Residents knew whom to approach if they had concerns and were confident that their comments and complaints would be listened to and acted upon. EVIDENCE: Systems were in place to respond to complaints although the complaints record was not inspected on this occasion. There was no evidence on the policies and procedures file that the adult protection policy and procedures had been amended in line with previous requirements. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24, 25 The home is of a domestic scale, comfortable and homely. The refurbishment of the kitchen has made a marked improvement to the shared spaces offered in the home. However, the small size of the house does seem to lead to some tensions between the residents. Not all the bedrooms had furniture and fittings suitable to meet individual needs. EVIDENCE: The home meets the National Minimum Standards (NMS) that apply specifically to a pre-existing home in relation to the size of bedrooms and the number of bathrooms and toilets. However, the home does not meet some of the other current minimum standards in relation to the environment e.g. no wash hand basins in bedrooms, inadequate office space and private communal space to meet visitors, limited facilities for the storage of staff and residents’ belongings. Because the three residents choose to lead very separate lives, the lack of a separate communal room means that two residents spend a lot of time in their bedrooms and there have been disagreements about visitors going into the kitchen. The house is owned by East Thames Housing Association who are responsible for repairs and redecoration. There is a budget of furnishings and equipment. The lino in the kitchen and the worn carpeting on the stairs are due for 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 17 renewal. One of the bedrooms was seen on this occasion and was personalised with the residents possessions. Although a new chest of drawers had been provided, there was not enough storage for the persons belongings. There were two chairs but one was broken and the other was a second-hand put-u-up, overlarge for the room. The resident requested more suitable items. The glass over the door does not allow the resident to eliminate the light from the hall, as they would like to do. There are two bathrooms, one on the first floor and one on the ground floor. Funding is being sought to replace the bath on the ground floor with a shower, to meet the needs of one of the residents who had had falls in the bath. This had been ongoing since April 2005. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 Records within the home were insufficient to show the level of staffing or demonstrate that it was appropriate to adequately support residents. Written records did not reflect the work described as being undertaken in the home or the training undertaken by staff. EVIDENCE: The staffing consists of client support workers who are qualified mental health nurses or social workers. They take it in turns to be on duty as overall coordinators of the service and act as key workers, coming into the home for specific purposes e.g. the residents communal meeting. Care workers come into the home each day, although 24-hour cover is not provided. All staff are contracted to work across all the houses operating under the scheme (35 hours per week for client support workers, 25 hours plus 2 sleep-ins per week for care staff) – no one is specifically employed to work in the home but visit 4 different premises each day. The Rota indicated that Care staff were on duty at the premises from 10.30am to 2.0pm and 3.0pm to 5.00pm (i.e. 94.5 hours per week which is well below the usual staff levels of a residential provision) plus a member of staff is asleep on call on the premises from 10.00pm to 6.00am. At other times or in emergencies, additional staff are contactable via a 24-hour pager system. One of the residents described incidents where problems had been encountered which would have benefited from a 24-hour staff presence. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 19 On the day of inspection the care worker did not arrive at the home until nearly 4 p.m. and explained that on Wednesdays, because of staff meetings, the hours staff spend on the home were 10.30 a.m. to 12.30 p.m. and from 4 p.m. to 5 p.m. This was not consistent with the Rota. The rota showed the name of care workers on duty but not the hours proposed or actually worked by client support workers, so it was not possible to judge how much input they had to the home. No domestic or cooking staff are employed in the home, as the philosophy of the home is that service users are supported to develop daily living skills. However, they are not required to do household tasks and feedback to the inspector, confirmed by the minutes of the residents meeting, indicated that this led to some tension between residents. The member of staff said that they had had a lot of training recently on a range of topics including medication administration, health and safety, fire precautions, policies and procedures and National Minimum Standards. Infection control and first aid were not included although food safety and hygiene training had been given in the past. However, no records were available of training received by the staff. Discussion indicated that Staff meetings are held every week. Staff work on their own in the home most of the time but have 24 hour backup available through the pager or telephone. Staff spoken to felt well supported and that communication systems were good. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,49,41,42 The day-to-day running of the home is well coordinated and the manager and senior staff have competence and professional knowledge and skills. More needs to be done to ensure that the legal responsibilities of the manager and provider are carried out appropriately, including quality monitoring visits, upto-date policies and procedures for the guidance of staff, appropriate record keeping to protect residents and health and safety practices to protect residents and staff e.g. from the risks of fire. EVIDENCE: The registered manager is the Chief Executive of MIND in Waltham Forest and also registered as the responsible person on behalf of the organisation. His job description is therefore much wider than running Southwest Road. Most of the tasks usually undertaken by the registered proprietor and manager of a registered care home are delegated to other staff, e.g. one client support worker is designated as house manager, others are responsible for supervising care workers, drawing up the rota or developing care plans. Previous inspection reports asked the organisation to carry out a review to ensure that 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 21 the job description of the registered manager is in accordance with this Standard, in particular his duty to ensure that the home complies with the Care Standards Act and Regulations and other legal requirements under allied legislation. The revised job description was out for consultation at the time of the last inspection. The registered manager has a professional social work qualification so has a suitable qualification in care but, although an experienced manager, does not yet hold a qualification in management. This is necessary by the end of 2005 to meet the standards. The responsible person/manager had visited the home to attend house meetings on 3.5.05, 1.8.05 and 8.8.05 and the Inspector was satisfied from previous inspections that there was a constant two-way communication between care staff, support workers, the development officer and manager. However, despite requirements dating back to 2003, statutory unannounced monthly visits on behalf of the proprietor had not been done and reports of these visits had not been received by the Commission since January 2005. There was a wide-ranging and comprehensive set of policies, procedures and practices available for staff, covering the organisation as a whole although not specific to a care home. These did not appear to have been amended in line with the February 2005 report. Previous requirements and recommendations are therefore repeated with new compliance dates. The Fire risk assessment stated that smoking was limited to the sitting room. However, residents were smoking in their bedrooms as well as in the sitting room at the time of the inspection. The only room in which residents do not smoke is the kitchen/diner. Fire doors to the kitchen and to the sitting room were propped open, despite previous requirements in the last two reports. A noise-activated doorstop had been provided for the sitting room but this was not being used and the door was held open with a chair. A fire extinguisher and blanket were available in the kitchen. 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 22 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 2 x 2 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 2 x x Standard No 11 12 13 14 15 16 17 x 3 3 2 3 2 2 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Southwest Road Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 2 1 2 x G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1,41 Regulation 4, 17 Requirement Timescale for action 1 December 2005 2. 1, 41 5,17 The home’s Statement of Purpose to be amended to include all the information listed in Standard 1 of the NMS 2003, and Regulation 4 & Schedule 1 of the Care Homes Regulations 2001. When completed, this document to be sent to the Commission. [Outstanding from the report of 10.9.02 and each subsequent report. Previous target dates of 1 November 2004 and 1 June 2005 unmet]. The Statement of Purpose to be regularly reviewed and updated as necessary. The Service Users’ Guide to be 1 amended to include all the December information in Regulation 5 and 2005 Standards 1 & 16 of the NMS 2003, in a format, which is accessible and appropriate to the needs of service users. When completed, the Guide to be sent to the Commission. [Outstanding from the report of 10.9.02 subsequent reports. Previous target dates of 1 November 2004 and 1 June 2005 unmet]. The Service Users’ guide to be regularly reviewed Version 1.40 Page 24 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc 3. 3, 41 12,14, 17 & schedule 3 4. 6 15 5. 8 12 6. 10 12,17 and updated as necessary. The latest inspection report to be included in the Service User’s Guide. The responsible person/registered manager to ensure that up-to-date written evidence is available in the home to demonstrate the homes capacity to meet the assessed needs of residents. [Outstanding from the report of February 2005. Date for compliance of 1 June 2005 unmet]. The care plans to specify service users responsibility for household tasks and records to show how the plans are being implemented by staff on a dayto-day basis e.g. Client support workers and care workers to demonstrate in the daily records how they are implementing care plans in their interaction with residents. The manager to discuss with residents their wish to be more involved in decision-making within the home and how this can be achieved. [Outstanding from the report of February 2005. Date for compliance of 1 May 2005 unmet]. The organisation’s policy and procedures on confidentiality to be amended in line with the Care Standards Act and Regulations to ensure that running records of the home are kept for not less than 3 years from the date of the last entry. All Service users’ records must therefore be kept for 3 years after they leave the home. [Outstanding from 27.11.03 and each subsequent report. Date for compliance of 1 June 2005 unmet]. 1 October 2005 1 September 2005 1 October 2005 1 December 2005 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 25 7. 17, 41 8. 19 9. 20 10. 20 A record of food served must be kept in sufficient detail to enable any person inspecting it to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. [Outstanding from September 2004 and each subsequent report. Dates for compliance of 15 October 2004 and 1 April 2005 unmet]. 12,13, 17, Written protocols or guidelines to schedule be available to assist staff in 3 knowing what might constitute an emergency in relation to residents individual health needs. Written records to be kept of action taken by care staff in the home. [Outstanding from September 2004 and each subsequent report. Dates for compliance of 1 November 2004 and 1 May 2005 unmet]. 13 Procedures for the administration of medication to be available for use by staff, preferably kept with the medication records. [Outstanding from the report of 23.9.04. Previous date for compliance of 1 November 2004 and 1 July 2005 unmet]. 13 Written confirmation to be held in the home that all staff who administer medication have received appropriate training. A record to be kept in the home of all staff authorised to administer medication, the date they were authorised and ceased to be so authorised, with an example of the signature (at least 2 initials) used by them on the MAR sheets. [Outstanding from the report of November 2003 and each subsequent report. Dates for compliance of G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc 17 1 September 2005 1 October 2005 1 September 2005 1 September 2005 7 Southwest Road Version 1.40 Page 26 11. 23 13 12. 24,27 23 1 November 2004 and 1 March 2005 unmet]. All requirements of the pharmacist inspectors report to be met within timescales set for compliance. The Adult Protection policy and procedures, to be amended to include:an overall protection strategy with safe working practices in place to minimise the potential for abuse, avoidance of institutional abuse, protection of residents from financial abuse etc. - procedures for staff on how to link into Local Authority Adult Protection Services and work in partnership with other professionals in the event of an allegation of abuse. - clarification that responsibility for investigating incidents of abuse does not rest within the organisation or the home but would be decided at a strategy meeting. - procedures for staff to inform appropriate agencies without delay of an allegation, including CSCI and referral to local authority Adult Protection Services. [Outstanding from the report of November 2003 2003 and each subsequent report. Dates for compliance of 1 November 2004 and 1 March 2005 unmet]. The registered person to submit an action plan for bringing the home up to current minimum standards for an existing home in relation to the environment e.g. wash hand basins in bedrooms, private space to meet visitors, adequate office space and facilities for the storage of service user and staff G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc 1 October 2005 1 December 2005 7 Southwest Road Version 1.40 Page 27 13. 33, 41 17, schedule 4 14. 26 23 15. 35 18 belongings. [Outstanding from the report of November 2003 and each subsequent report. Dates for compliance of 1 March 2005 & 1 June 2005 unmet]. The registered person to ensure that the format of the rota demonstrates that sufficient staff are on duty to meet residents’ needs and is a record of who worked in the home e.g. by showing the names of all staff, including Client support workers, working at the home, the hours worked and in which capacity. This to include instances where staff accompany residents outside the home or come in for short periods or go out for breaks. Copies of the proposed and worked rotas to be kept in the home. [Outstanding from the report of November 2003 and each subsequent report. Dates for compliance of 1 November 2004 & 1 April 2005 unmet]. The downstairs bedroom to be provided with two comfortable chairs of good quality and appropriate size and sufficient storage space for clothes and other belongings to meet the residents needs and wishes. The window above the door to be covered. The manager to seek guidance from TOPSS/ Skills for Care, and confirm in writing to the Commission, that the Induction and foundation training meets their specifications and the timescales set by this standard. The manager to send the Commission a copy of the training needs assessment done for the whole staff team. [Outstanding from the February 2005 report. Compliance date of 1 September 2005 1 December 2005 1 December 2005 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 28 1 May 2005 not met. 16. 37 10 The organisation to complete the review of the registered managers job description in accordance with standard 37. The registered manager to have qualifications in management as well as care to NVQ level 4. Unannounced monthly visits to be made on behalf of the proprietor, reports of which must be kept in the home, sent to the Commission and submitted to each member of the governing board. [Outstanding from the report of 23.9.04. and each subsequent report. Dates for compliance of 15.10.04 & 1 April 2005 unmet]. A Notice of Breach of Regulation has been served. The registered manager must ensure that residents and staff are aware of their respective responsibilities under Health and Safety legislation. Fire doors must not be propped open. [Outstanding from the report of 23.9.04 and each subsequent report. Dates for compliance of 1 November 2004 and 1 April 2005 unmet]. The noise activated, battery operated doorstop fitted in the sitting room to be used. Additional units to be considered e.g. for the kitchen and office. All records required by the regulations and listed in schedules 1- 4 to be in place, up-to–date, accurate and available for inspection in the home at all times. 1 October 2005 1 January 2006 1 October 2005 17. 18. 37 39, 41 9,10 26, 17 19. 42 13 1 September 2005 20. 41 17 1 October 2005 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 29 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 2 Good Practice Recommendations The referral form to include the reason for admission, make a distinction between the application for registered provision and other services offered by the project and include religious, cultural and dietary needs of potential residents. Service users should should have, as part of the basic contract price, the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. How to address, and balance, the issues of ‘Healthy Eating’ and choice should be recorded in individual care plans. Nutritional assessments should be carried out preferably by a dietician, recorded and regularly reviewed in accordance with this standard (i.e. risk factors associated with low weight, obesity or eating disorders). The record of complaints to include more description of the investigation and overall analysis of issues raised. The Manager to submit to the Commission a programme of planned maintenance, re-decoration/ re-furbishment for at least the next twelve months. Where facilities recommended in the standards are not available in bedrooms, either because the residents do not wish to have these or there are practical/ room-size difficulties, this to be recorded in the care plans with a note of who made the decision and regularly reviewed. [Outstanding from the report of 27.11.03 and each subsequent report.] Additional policies as recommended in the Standards to be developed, including Emergency admission and detention, nursing/treatment/care or guardianship under the Mental Health Act and Regulations 1983, discharge, smoking and the use of alcohol and substances. The manager to submit to the Commission a business plan for Southwest Road for the next 12 months. [Outstanding from the report of 10.9.02 and each subsequent report.] 2. 14 3. 17 4. 5. 6. 22 24 26 7. 40 8. 9. 43 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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 7 Southwest Road G56-G06 S7298 Southwest Road V244116 100805 Stage 4.doc Version 1.40 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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