Inspection on 05/05/06 for Southwest Road (7)

This inspection was carried out on 5th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southwest Road (7) 16/10/07

Southwest Road (7) 08/12/05

Southwest Road (7) 10/08/05

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 Southwest Road (7) 7 Southwest Road Leytonstone London E11 4AW Lead Inspector Robert Sobotka Unannounced Inspection 5th May 2006 09:20 Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 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 Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 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. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southwest Road (7) Address 7 Southwest Road Leytonstone London E11 4AW 020 8556 4286 020 8539 1770 mail@mindinwf.org.uk www.mindinwf.org.uk Mind in Waltham Forest Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Felix Nii Ankrah Otoo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. For one named service user over the age of 65 to be accommodated in the home 8th December 2005 Date of last inspection Brief Description of the Service: Southwest Road is 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, has not always sat comfortably with the law governing registered care homes. 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. 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. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second attempt to carry out an unannounced inspection. The inspector visited the home on Wednesday the 3rd of May, however he did not carry out an inspection, as no staff were present in the home and one of the service user’s informed him that no staff would not be on duty until 4 pm. As a result the inspection was postponed and carried out two days later. This inspection took place over one day and was unannounced. The inspector arrived in the home at 9.20 am and he spent first part of the morning talking to one of the service users. He then spent some time with a member of staff on duty, as well as reviewing various documents and also talking to two other service users. Late morning/early afternoon part of inspection was spent at the Mind in Waltham Forest headquarters, where the inspector checked more documents and had a discussion with the Registered Provider and the Development Officer, who is in charge of staff recruitment and training. The last part of the afternoon was spent in the home, when the inspector undertook a tour of the premises and spoke to two members of staff. The inspector would like to thank staff and residents who contributed to the inspection. What the service does well: What has improved since the last inspection? There is a new registered manager in place, who has been approved by the Commission as fit to manage the service. The home has reviewed its Statement of Purpose and the Service Users Guide. Service users care plans have been further developed. This also included recording service users wishes in relation to what facilities are offered to them in their bedrooms. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 6 Cordless telephone has been purchased to improve privacy when making and receiving calls. The home’s Adult Protection policy has been amended to include information about Protection of Vulnerable Adults register and informing the Commission about any abuse. Duty rosters were now appropriately maintained. All staff working in the home has an enhanced Criminal Records Bureau disclosure, as required by law. Staff supervision files were available for inspection. What they could do better: There were 6 requirements and 3 good practice recommendations, which remain outstanding from the previous inspection reports. 7 further requirements were made during this inspection visit. These included: - The registered manager must ensure that appropriate risk assessments are in place and that they are reviewed on regular basis and that this is clearly recorded. - The registered manager must ensure that all healthcare appointments were clearly recorded; this must include outcome of any appointment. - The responsible person must ensure that appropriate systems are in place to ensure that all complaints are dealt with promptly and efficiently. - The responsible person must ensure that appropriate security arrangements are in place to protect those accommodated in the home from bogus callers/intruders. - The registered manager must ensure that all parts of the building are appropriately ventilated. - The responsible person must ensure that staff personnel files include all information listed in Schedule 2 of the Care Homes Regulations. This includes evidence of entitlement to work in the United Kingdom. - It is required that the community care assessments are carried out in respect of the two service users accommodated in the home in order to establish whether the current staffing levels are sufficient. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 7 Failure to comply with the legislation has a negative effect on the quality of care offered to the service users. The Commission may consider taking enforcement action against the provider to ensure that the compliance with regulation is achieved. 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. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5. Prospective service users have the information they may need to make a choice about the home. The home was meeting needs of the service users accommodated there. EVIDENCE: The home’s Statement of Purpose and the Service Users’ Guide have been updated since the last inspection visit and were found up-to-date. Both documents included comprehensive information as to what services were being offered at Southwest Road. There have been no new admissions to the home since the last inspection and there were no vacancies in the home. Standards relating to the admission systems and trial visits could not therefore be assessed on this occasion. There were three service users being accommodated in the home at the time of this inspection. All three residents required minimal level of support from staff employed in the home. None of the service users required help and support with personal care. Staff employed in the home offered emotional and practical support to those accommodated in the home.. One of the service users was over the age of 65, however the inspector felt that the home continued to meet their needs. An exemption has been given to the Mind in Waltham Forest to continue to accommodate that service user in the home. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 10 Each service user had a costed contract, which included terms and conditions, in place. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 11 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, 8, 9, 10. The home had a good care planning system in place. Service users are encouraged to make decisions about their lives and take responsible risks as part of their independent lifestyle. Review of risk assessments required improvement. EVIDENCE: Each person living in the home had a care plan. As part of this visit, the inspector viewed care plans of each service user. Documents viewed were found to be up-to-date and reviewed on regular basis. There was evidence that those who lived in the home were involved in their care planning process. It was noted, however that CPA reviews had not been undertaken by the Health trust for some time. Service users are also consulted as to how the home should be run. Their views are obtained during individual weekly keyworking sessions and residents meetings. Some of the risk assessments viewed by the inspector were due for review after three months, however there was no evidence on file that this had taken Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 12 place. The most recent report from the visit undertaken by the person in control stated that there was a need for the risk assessment for the service user who was declining to participate in fire drills. The registered manager must ensure that appropriate risk assessments are in place and that they are reviewed on regular basis and that this is clearly recorded. Staff working in the home maintained daily notes in respect of each service user. It was highlighted during last inspection visit that care workers had been making daily records, but these were written in the communication book and were therefore not confidential. This practice has now stopped and information was being kept on individual sheets, which were at later stage placed in service user’s individual files. At the time of the inspection daily log sheets were placed in another service users’ files and could have therefore been accessed by other service users. The requirement in relation to confidentiality of daily logs has therefore been repeated. Since the last inspection, new cordless phones have been purchased for the purposes of running the home and to ensure that calls about residents are confidential. This also enabled those who use the service to make and receive calls in private. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 13 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): 12, 13, 14, 15, 16, 17. Those living in the home had an opportunity to access appropriate leisure activities and to be a part of the local community. They are also encouraged to maintain family relationships. Service users had a choice in their diet. EVIDENCE: Following discussion with the service users, staff working in the home and the review of documentation, the inspector was satisfied that those living in the home were able to access a wide range of leisure activities. One of the service users attended a culturally appropriate day centre. Outings organised by the home recently included trips to the London Aquarium, London Dungeon, cinemas, seaside resorts. One of the service users was a football fan and was supported to go to football matched of his favourite football team. The requirement issued during previous inspection visit that individual care plans include arrangements for meeting social and cultural needs, including leisure interests and holidays has now been met. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 14 Those living in the home were also encouraged and supported to maintain family relationships. Records viewed evidenced that families sometimes played a role of an advocate for service users. Service users who spoke to inspector stated that they were satisfied with the choice of food offered in the home. Service users were able to prepare food for themselves. Staff support service users in doing shopping. One of the service users accommodated in the home is diabetic, staff were aware of their dietary needs and were seen offering advice and guidance to that effect to the service user at the time of the inspection. Record of food offered to the service users was being maintained. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 15 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. Improvement was required to ensure that staff have written protocols and guidelines in relation to service users’ medical conditions. Improvement was required in recording medical appointments attended by service users. Medication systems were satisfactory. EVIDENCE: At the time of this inspection, none of the service users required support with attending to their personal care. Care plans viewed showed that those who live in the service received appropriate care from the healthcare professionals. Those who use the service received regular psychiatric reviews. Each person was registered with the General Practitioner and any other healthcare professionals who would be beneficial to meeting his/her needs. The requirement that written protocols and guidelines should be available to assist staff in knowing what might constitute an emergency relating to residents’ individual health care (e.g. diabetes, hypertension) remains outstanding and must be repeated without any further delay. Recording of appointments attended by the service users required improvement. Whilst daily notes kept in respect of the service users stated Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 16 that they attended doctor’s appointments, no entries had been made to that effect in the service user’s individual health appointment record. The registered manager must ensure that all healthcare appointments are clearly recorded; this must include outcome of any appointment. Medication systems were found satisfactory. The home’s medication policy was in line with recommendations from the Pharmacist Inspector, who visited the home in March 2005. Sample signatures of staff authorised to administer medication was kept on file. All administered medication was appropriately signed for. Record of medication brought into the home was also maintained. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 17 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. Efficiency of dealing with the complaints required review. Service users were protected from abuse. EVIDENCE: The home had appropriate complaints policy in place. Service users spoken to stated that they felt confident that they complaints would be dealt with appropriately. Record of complaints viewed was found to be satisfactory, however the most recent report from the registered provider stated that he had lodged the complaint on behalf of the service user and no action had been taken. The responsible person must ensure that appropriate systems are in place to ensure that all complaints are dealt with promptly and efficiently. The home’s Adult Protection policy have now been amended to include information about referrals to the POVA register and the need to inform CSCI without delay of any allegation of abuse. Staff offer support to the service users in managing their financial affairs. Appropriate recording to support this was in place. Record of incidents/accidents was maintained and evidenced that appropriate action had been taken to prevent further incidents/accidents from reoccurring. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. The home is of a domestic scale, comfortable and homely. However, the small size of the home does seem to lead to some tensions between the residents. The home security arrangement required improvement. EVIDENCE: The home meets the National Minimum Standards (NMS) that apply to 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 communal room means that the two residents tend to spend a lot of time in their bedrooms. On the day of the inspection, the inspector was allowed into the home by one of the service users, who went back to their bedroom. The inspector was then free to wander around the premises unaccompanied without a member of staff being present. Even though the inspector introduced himself upon arrival, this incident poses questions in relation to access to the home by intruders and/or Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 19 bogus callers. The responsible person must ensure that appropriate security arrangements are in place to protect those accommodated in the home from bogus callers/intruders. The house is owned by East Thames Housing Association, who was responsible for repairs and redecoration. There is a budget for furnishings and equipment. During the tour of the premises, the inspector viewed two service users’ bedrooms, with their permission. They contained appropriate furnishing and were generally clean. One of the bedrooms had strong smell of smoke. The registered manager must ensure that all parts of the building are appropriately ventilated. The requirement that where facilities are not available, either because residents do not wish to have these or there are practical/room-size difficulties, this is to be recorded in the care plans with a note of who made the decision was now met. One of the residents has been assessed as needing provision of a shower to replace the bath because of falls. This was recommended in April 2005 and was still outstanding at the time of this inspection. Although East Thames Housing Association owns the house, the responsibility for ensuring health and safety and meeting the needs of residents lies with MIND. As previously mentioned, cordless phones have been purchased to allow privacy when making and receiving calls. The home was found to be clean and hygienic at the time of this inspection. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Satisfactory staffing levels were in place. Recruitment procedures required improvement. Service users benefited from a consistent staff team. EVIDENCE: The home currently does not provide 24 hour staffing cover. Duty rosters displayed in the home indicated that care staff were on duty at the premises from 10.30 am to 2 pm and from 3pm to 5 pm. There was also a member of staff doing a sleep-in duty on the premises between 10 pm and 6 am. At other times or in emergencies, additional staff are contactable via a 24-hour pager system. At the time of this inspection the community care needs have not been assessed for a number of years. It is therefore required that the community care assessments are carried out in respect of the two service users accommodated in the home in order to establish whether the current staffing levels are sufficient. The staffing establishment consist of the home manager, who is a Registered Mental Health Nurse, one client support worker, who is also a qualified social worker and 6 support workers who take it in turns to be on duty as overall coordinators of the service and act as keyworkers. At the time of this inspection, only 1 of the care staff had completed NVQ Level 2 in Care and one person was working towards achieving NVQ Level 3. The responsible person must ensure that care staff have NVQ Level 2 or preferably 3, which has a Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 21 mental health component, in care or be working to obtain one by an agreed date. A minimum level of 50 of care staff must have NVQ Level 2 qualification. This is a repeated requirement and must be met without any further delay. The requirement for the manager to seek guidance, from Skills for Care ex TOPSS, and confirm in writing, that the Induction and foundation training meets their specification has now been met. Staff spoken to stated that training offered to them was good. Courses on offer to staff between April and November 2006 were: CSCI requirements, Medication (which has been cancelled), Professional Boundaries, First Aid, Adult Protection, Diabetes – Health Eating, Fire Safety, Complaints (Refresher course), Client recording, Listening Skills, Service User involvement, Harassment, and Moving and Handling. 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 sleepins per week for care staff). No one is specifically employed to work in the home, but visits 4 different premises on a rotation basis. On Wednesdays hours worked by staff are reduced, as staff attend meeting at the MIND office. Staff personnel files were checked during this inspection visit. It was noted that staff, who have been employed in the home for a long period of time did not have references on file and/or application forms. All staff had a satisfactory enhanced Criminal Records Bureau check in place, as required during last inspection visit. Some of the staff files viewed did not contain supporting evidence to demonstrate their entitlement to work in the United Kingdom. This required improvement. Weekly meetings of staff are held at the MIND office for a variety of purposes, including group supervision of care workers approximately every fortnight. Client support workers meet for peer supervision. Staff meetings are held monthly for all MIND employees. Records of supervision were available for inspection. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41, 42. Appropriate quality assurance systems were in place. Appropriate health and safety arrangements were in place. EVIDENCE: The home has got a new registered manager, who has recently been approved by the Commission as fit to manage the home. He was on annual leave at the time of this inspection. Standard relating to the registered manager’s capabilities was therefore not assessed on this occasion and will be assessed during the next inspection visit. During the discussion with the Registered Provider, the inspector was informed that the MIND Domiciliary Services has been contracted out. The requirement for the application for the registration of a domiciliary care service to be submitted to the Commission has therefore been lifted. Visits from the Registered Provider were being conducted and copies of those were being forwarded to the Commission. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 23 Since the last inspection, emergency lighting has been installed. Appropriate health and safety checks were being carried out. Fire door closures have also been installed. As previously mentioned, improvement is required that all necessary risk assessments are in place and they are reviewed on regular basis. All other health and safety checks appeared to be in place. The home was appropriately insured. Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 x 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x x x 3 x 2 2 x Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA10 Regulation 12, 17 Requirement Timescale for action 01/06/06 2. YA19 12, 13, 17, sch 3 3. YA27 23 4. YA24 23 Daily records made by Care workers referring to residents to be confidential and held on residents files. (Previous timescale of 01/01/06 was not met.) 15/06/06 Written protocols or guidelines to be drawn up by the manager e.g. with the assistance of the specialist diabetes nurse and G.P. and available to assist staff in knowing what might constitute an emergency in relation to residents individual health needs. (Previous timescales of September 2004 and subsequent reports have not been met.) The bath on the ground floor 01/10/06 to be replaced with a shower, to meet the assessed needs of one of the residents. (Previous timescale of 01/03/06 was not met.) The registered person/s to 15/06/06 submit an action plan for bringing the home up to current regulations and DS0000007298.V293015.R01.S.doc Version 5.1 Southwest Road (7) Page 26 5. YA32 18 8. YA42 23(4) 9. YA9 13(4)(c) 10. YA19 17(1)(a) Schedule 3.3.m 22(3) 11. YA22 minimum standards for an existing home in relation to the environment e.g. private space to meet visitors, adequate office space and facilities for the storage of service user and staff belongings. (Outstanding from the report of November 2003 and each subsequent report. Dates for compliance of 01/03/05, 01/06/05, 01/12/05 and 01/04/06 were not met.) Care staff to have NVQ 2 or preferably 3, which has a mental health component, in care or be working to obtain one by an agreed date. A minimum level of 50 of care staff to have NVQ level 2 qualification. (Previous timescale of 01/01/06 was not met.) The issue of residents not responding to the alarm or staff instruction to be addressed within a risk management framework. (Previous timescale of 01/01/06 was not met.) The registered manager must ensure that appropriate risk assessments are in place and that they are reviewed on regular basis and that this is clearly recorded. The registered manager must ensure that all healthcare appointments are clearly recorded; this must include outcome of any appointment. The responsible person must ensure that appropriate systems are in place to ensure that all complaints are dealt with promptly and efficiently. DS0000007298.V293015.R01.S.doc 01/01/07 01/06/06 15/06/06 01/06/06 15/06/06 Southwest Road (7) Version 5.1 Page 27 12. YA24 23 13. YA26 23(2)(p) 14. YA34 7, 9, 19 Schedule 2 15. YA33 18(1)(a) The responsible person must ensure that appropriate security arrangements are in place to protect those accommodated in the home from bogus callers/intruders. The registered manager must ensure that all parts of the building are appropriately ventilated. The responsible person must ensure that staff personnel files include all information listed in Schedule 2 of the Care Homes Regulations. This includes evidence of entitlement to work in the United Kingdom. It is required that the community care assessments are carried out in respect of the two service users accommodated in the home in order to establish whether the current staffing levels are sufficient. 01/06/06 15/06/06 15/06/06 15/08/06 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. Refer to Standard YA7 Good Practice Recommendations The manager to consider involving an independent advocate/s to raise with residents how they might wish to be more involved in decision-making in the home. (This is a repeated recommendation.) Service users to be encouraged to take a minimum sevenday annual holiday outside the home, which they help choose and plan. (This is a repeated recommendation.) The proprietor to submit to the Commission a business plan for Southwest Road for the next 12 months. (This is a repeated recommendation, which has been outstanding from the report of 10.9.02 and each subsequent report.) DS0000007298.V293015.R01.S.doc Version 5.1 Page 28 2. 3. YA14 YA43 Southwest Road (7) Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford 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 Southwest Road (7) DS0000007298.V293015.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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