Inspection on 08/12/05 for Southwest Road (7)

This inspection was carried out on 8th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 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) 05/05/06

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 Vivienne Patchett Announced Inspection 8th December 2005 10:00 Southwest Road (7) DS0000007298.V258716.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 Southwest Road (7) DS0000007298.V258716.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. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 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 Gregory Shelock Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. For one named service user over the age of 65 to be accommodated in the home 10th August 2005 Date of last inspection 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, 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.V258716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over a day in December 2005. The morning from 10am until 2 pm was spent in the home, seeing residents, staff and examining records. The afternoon was spent at the Mind in Waltham Forest headquarters seeing more documentation and in discussion with the current registered manager, his designated replacement and the Quality Manager for Mind responsible for personnel issues, complaints and Quality assurance. Comment cards were received from most staff, residents and relatives and from both placing authority and health care professionals. All of the people who responded expressed satisfaction with the overall care being offered. However, some dissatisfaction related to residents wanting to be more involved in decision-making in the home, not feeling safe in the home or their privacy not respected. Staff indicated that more activities could be encouraged. Relatives highlighted the lack of privacy when visiting residents, staffing levels sometimes not being sufficient and a lack of access to inspection reports. A full inspection of the premises was not undertaken at this time but the sitting room, office, kitchen/diner and one bedroom were seen. 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? The current registered manager is responsible for running Mind in Waltham Forest and the whole Forest Community project, not just the home. One of the Client Support Workers has been appointed to replace him as manager and will be applying to be registered with CSCI. Many of the outstanding requirements repeated from previous reports have been addressed or met. Improvements have been made in the administration of medication and the general record keeping within the home. Policies and procedures have been reviewed and amended. Following a Notice of Breach of Regulations being Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 6 served, the responsible person for MIND had been making unannounced visits to monitor the standard of care and the running of the home and sending written reports as required by law to the Board of Management and CSCI. Discussions have been held with residents in respect of involvement in the running of the house and a suggestions box introduced. New carpet had been laid in the communal areas and new flooring in the kitchen and bathrooms. Trees in the front and back gardens have been pruned and the garden tidied up. 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. Southwest Road (7) DS0000007298.V258716.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 Southwest Road (7) DS0000007298.V258716.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 The Statement of Purpose and Service Users’ Guide gave a considerable amount of information although more detail of how the service at Southwest Road differs from that in the other MIND houses may assist prospective service users in considering their different options. EVIDENCE: No new admissions had taken place for some years so standards 2 and 4 were not looked at. The needs of existing residents have been assessed. The Statement of Purpose and Service Users’ Guide required amendment as described in the requirement. Southwest Road (7) DS0000007298.V258716.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 10 The residents know that their needs are assessed and included in a care plan. However, the plans need to be more detailed to ensure they cover all areas (See standard 19 re health needs), to set goals and to assist all staff in knowing their role in implementing the plans. Residents can make decisions about their lives and have opportunities to participate in the running of the organisation. EVIDENCE: CPA reviews had not been undertaken by the Health Trust for some time. However, the system of in-house care planning is comprehensive with reviews approximately every 6 months (set for 22.12.05) to which residents and relatives are invited. Discussion was held during the inspection about defining care plan goals and agreeing individual programmes for meeting these. The Community Team may be able to assist in this by offering advice about incentives to reward positive behaviour rather than punitive responses to challenging behaviour. The role of care workers, as well as support workers, in the implementation and monitoring of the care plans needs to be clear. Keyworker and care worker notes should be linked to the care plans to assist in monitoring progress. Care workers had been making daily records but these were being written in the communication book and were therefore not Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 10 confidential. The record of complaints included details of tenants of other houses, which should be removed to ensure confidentiality. Discussions have been held by keyworkers with residents in respect of involvement in the running of the house and a suggestions box introduced. Written feedback still noted one resident wanting to be more involved in decision-making in the home. This may therefore be an area to keep under review or to involve an independent advocate in order to be able to identify the issues. See standard 24 re privacy of phone conversations. Southwest Road (7) DS0000007298.V258716.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): 14 16 The outcomes for Standards 12, 13 and 15 were assessed as met at the last inspection and no issues arose on this occasion to alter the inspectors view. More could be done to encourage and enable residents to take holidays. Some other issues raised in the last report, e.g. smoking, household tasks, had not been addressed and have been restated in the requirements of this report. EVIDENCE: Recording of the food served had been improved since the last inspection. Feedback from residents indicated that they had not had holidays this year despite their wish for this being raised in the last report. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 12 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): 19 20 Arrangements for monitoring physical health needs and ensuring adequate access to community medical resources need to be strengthened. Improvements had taken place to ensure the residents are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: One resident was in urgent need of chiropody services. Although a future appointment had been booked, records showed that the nails had last been cut in July 2005. Given the residents medical condition, this should not have been left so long and needs to be part of the care plan. The requirement from previous reports that written protocols or 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. Two residents appeared to be heavy smokers and rules on smoking, as well as alcohol and drugs should be clearly stated in the Service Users Guide and contract. Health aspects should be included in the care plan. The CSCI pharmacist inspector had been involved in assisting the home with regard to the safe administration of medication, which generally appeared to be satisfactory. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 13 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): 23 Improvements had been made to the written Adult Protection procedures, although they required minor amendment. EVIDENCE: The Quality Manager for MIND had been liaising with the adult protection service of the local authority regarding procedures. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 14 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 The home is of a domestic scale and there have been some improvements to the fabric of the building. However, more could be done to offer a brighter, fresher environment, suitable to meet joint and individual needs. The small size of the house does seem to lead to some tensions between the residents and lack of choice and privacy. EVIDENCE: The refurbishment of the kitchen has made a marked improvement to the shared spaces offered in the home and carpet and lino had been replaced in the home. Furnishings and decor were showing signs of wear and tear e.g. cigarette burns on 3-piece suite, marks on walls, smoke stains. A resident 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. Although East Thames Housing Association owns the house, the responsibility for ensuring health and safety and meeting the needs of residents lies with MIND. Air purifying machines were available but did not appear to be operational during the inspection and the smell of cigarette smoke was strong in most areas of the house. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 15 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 and regulations in relation to the environment e.g. no wash hand basins in bedrooms, inadequate office space and no 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 lack of office or separate communal space was particularly apparent during the inspection when the presence of the manager and inspector meant the residents did not use the sitting room. Also the only telephone for the home is in the sitting room, allowing no privacy. There are plans to have a second line and cordless handsets. The one bedroom seen on this occasion required more storage provision to meet the needs of the resident. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 16 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 There had been an improvement in the record-keeping in the home to show the level of staffing and the work being undertaken in the home but more attention was needed to demonstrate that outcomes were being met. Recruitment procedures were not always robust enough to safeguard residents and a strategy needs to be in place to ensure staff have the required level of supervision, training and qualification. EVIDENCE: 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. The acting manager/client support worker, a qualified mental health nurse, was on the premises at the time of inspection and a care worker came for her shift from 10.30 until 2pm. The staffing establishment consists of two other client support workers, one of whom is a qualified social worker and the other one in training. The client support workers 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 Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 17 day, although 24-hour cover is not provided. 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, residents are not required to do household tasks and this has led to some tension between them. 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 visit 4 different premises each day. The staff rota did not show the correct times that staff were in the home on Wednesdays (which is less than the other days) and did not record the times that the client support workers were in the home. Weekly meetings of staff are held at the MIND headquarters for a variety of purposes, including group supervision of care workers approximately 2 wkly. Client support workers meet for peer supervision. Staff meetings are held monthly for all MIND employees. Records of supervision sessions were available in the headquarters for the client support workers but not for the care workers. Staff records were being kept at headquarters. A brief summary was held in the home of the information held on file. This indicated that two members of staff had been employed prior to POVA First or CRB checks being obtained. This was confirmed by records at head office and by the registered manager and quality manager. The members of staff had also not had the required level of supervision prior to CRB checks being received. Induction training had been given but records consisted of a tick list and did not appear to meet Skills for Care specifications. Eight staff are employed, two of whom have qualifications above NVQ 2 in care. One member of staff is half way through obtaining the qualification and another intends to do so. Therefore only a quarter of staff have the required level of training instead of the minimum 50 set down in the standards. The training needs assessment was not available. Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 18 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, 41, 42, 43 There has been a change in the management arrangements with the intention that the proposed manager can focus on ensuring that the home meets current regulations and standards and offers the best possible outcomes for service users. There are early signs of improvements in the general record keeping within the home and many of the requirements repeated from previous reports, and outstanding for some time, have been tackled or met. However, important issues remain to be addressed and MIND needs to ensure that the acting manager has a job description to enable him to continue and sustain this improvement. Future non compliance may lead to enforcement action. Arrangements for fire safety were not satisfactory. EVIDENCE: The acting manager has a wide range of responsibilities in addition to the management of the Care Home. These include being keyworker for one resident and 3 other service users across the project, house manager for other properties (although he will relinquish this role sometime in 2006) and being responsible for organising the care planning process for all the service users Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 19 across all the projects properties. a MIND Domiciliary Care Agency. He has also been proposed as manager of There are no fax or photocopying facilities in the home and the only telephone for the home is in the sitting room. New fire extinguishers had been fitted but there is no emergency lighting, despite this being recommended in the fire risk assessment done in March 2004. Fire drills have taken place although some residents had not responded to the alarm or staff instruction. This issue had not been addressed to satisfactorily protect staff as well as residents. Fire alarm checks had not been recorded as they took place. Monthly Health and safety checks on the building are carried out. The noise activated door closure on the sitting room door was not operational but others had been ordered for the office and the kitchen doors (the latter being propped open during the inspection). Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 20 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 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 2 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southwest Road (7) Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X 2 2 2 DS0000007298.V258716.R01.S.doc Version 5.0 Page 21 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 YA1 Regulation 4, 5, 17 Requirement The Statement of Purpose to have minor amendments for accuracy [e.g. name and qualifications of the current registered manager, staff qualifications, CSCI not NCSC; and to describe the physical environment in relation to standards 24.9 (Accessibility) & 28.2 (separate smoking & visitors rooms). The Service Users Guide to have minor amendments for accuracy [e.g. name and qualifications of the current registered manager, staff qualifications] and to include residents views and house rules on smoking and the use of alcohol and substances. These documents to be sent to the Commission, reviewed regularly and updated as necessary. Individual Care plans to: - record aspirations and set goals. - identify and record all physical health needs and describe how these will be monitored and met. - include how staff will address DS0000007298.V258716.R01.S.doc Timescale for action 01/02/06 2 YA6 YA16 YA19 12, 15 01/02/06 Southwest Road (7) Version 5.0 Page 22 the issues of ‘Healthy Eating’ and choice. Nutritional assessments to be carried out preferably by a dietician, recorded and regularly reviewed in accordance with standard 17 (i.e. risk factors associated with low weight, obesity or eating disorders). - include how staff will address the health risks of smoking (in line with to the NHS Health Development Agency guidelines for people with mental for health problems). - specify service users agreed responsibility for household tasks - include arrangements for meeting social and cultural needs, including leisure interests and holidays. Records to show how the care plans are being implemented by staff on a day-to-day basis and monitor progress 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. Daily records made by Care 01/01/06 workers referring to residents to be confidential and held on residents files. The records of complaints to only include those relevant to the home. Appropriate telephone facilities 01/02/06 to be provided in the office for the purposes of running the home and to ensure calls about residents are confidential. Arrangements to be in place for residents to make and receive calls in private. Written protocols or guidelines to 01/02/06 be drawn up by the manager e.g. with the assistance of the specialist diabetes nurse and DS0000007298.V258716.R01.S.doc Version 5.0 Page 23 3 YA10 12, 17 4 YA10 YA24 12, 16 5 YA19 12, 13, 17, sch 3 Southwest Road (7) 6 YA23 13 7 YA27 23 YA24YA29 YA26 23 8 9 YA27 YA24 YA28 23 10 YA32 18 G.P. and available to assist staff in knowing what might constitute an emergency in relation to residents individual health needs. [Outstanding from September 2004 and subsequent reports. Dates for compliance unmet]. The Adult Protection policy and procedures, to be amended to include:- the need to inform CSCI without delay of an allegation, and refer any Staff suspended because of an allegation to the POVA register. The bath on the ground floor to be replaced with a shower, to meet the assessed needs of one of the residents. Bedrooms to be furnished as per the needs and wishes of the residents and contain adequate storage. Where facilities are not available, 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. The registered person/s to submit an action plan for bringing the home up to current regulations and 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 belongings. [Outstanding from the report of November 2003 and each subsequent report. Dates for compliance of 1/3/05, 1/6/05 & 1/12/05 unmet]. Care staff to have NVQ 2 or DS0000007298.V258716.R01.S.doc 01/02/06 01/03/06 01/03/06 01/04/06 01/01/06 Page 24 Southwest Road (7) Version 5.0 11 YA33 YA41 18, 17 sch 4 12 YA34 19 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. The registered person to ensure 01/01/06 that the format of the rota demonstrates that sufficient staff are on duty to meet residents’ needs and is an accurate record of who worked in the home e.g. by showing the names of all staff, including the Manager or Client Support Workers, working at the home, the exact 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 1/11/2004, 1/4/05 & 1/9/05 unmet]. The proprietor to operate a 01/01/06 thorough recruitment procedure to ensure the protection of residents. Staff must not be employed in the home unless suitable CRB checks and POVA checks have been obtained and the information listed in schedule 2 (as amended 2004) is on file. Staff appointed with a POVA First check to be supervised as per regulation 19 (as amended 2004) until a satisfactory CRB is on file. The manager to seek guidance 01/02/06 from Skills for Care ex TOPSS, and confirm in writing to the Commission, that the Induction and foundation training meets DS0000007298.V258716.R01.S.doc Version 5.0 Page 25 13 YA35 18 Southwest Road (7) 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 1/5/05 & 1/12/05 not met. Records to be available for inspection at all times to confirm that staff are being appropriately supervised and having regular 1:1 sessions with their manager. The revised job description of the registered manager to be sent to CSCI Stratford and the Central registration team for inclusion in the application for manager of the home and the Domiciliary Care Agency. Adequate precautions to be in place against the risk of fire and adequate arrangements made to respond in the event of a fire. Emergency lighting to be fitted as per the fire risk assessment 2004. The issue of residents not responding to the alarm or staff instruction to be addressed within a risk management framework. Fire alarm checks to be recorded as they take place. 14 YA36 YA41 17, 18 01/01/06 15 YA37 10 01/02/06 16 YA42 23(4) 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 Refer to Standard YA6 Good Practice Recommendations The care plans to specify service users responsibility for household tasks. DS0000007298.V258716.R01.S.doc Version 5.0 Page 26 Southwest Road (7) 2 3 4 5 YA7 YA14 YA20 YA43 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. Service users to be encouraged to take a minimum sevenday annual holiday outside the home, which they help choose and plan. The confirmation on MAR charts to be the staff members normal signature of at least 2 initials rather than separate printed capital letters. The proprietor 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.] Southwest Road (7) DS0000007298.V258716.R01.S.doc Version 5.0 Page 27 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.V258716.R01.S.doc Version 5.0 Page 28 - 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!