Inspection on 12/10/05 for Springbank Road 152

This inspection was carried out on 12th October 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springbank Road 152 17/07/07

Springbank Road 152 31/10/06

Springbank Road 152 25/04/05

Springbank Road 152 22/09/04

Springbank Road 152 05/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 152 Springbank Road Lewisham London SE13 5BD Lead Inspector Ornella Cavuoto Unannounced Inspection 12th October 2005 10:00 152 Springbank Road DS0000025641.V257755.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 152 Springbank Road DS0000025641.V257755.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. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 152 Springbank Road Address Lewisham London SE13 5BD 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) 0208 6973816 L.I.N.C Sally Ann Ferguson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 4 persons with learning disabilities of whom 1 may also have a physical disability and be over 65 years 25th April 2005 Date of last inspection Brief Description of the Service: 152 Springbank Road is a small home that provides long term care for up to 4 persons with learning disabilities. There were no vacancies at the time of the inspection and there have been no new admissions since 1999. The home consists of a two-storey house that has been converted. It is located in a quiet residential street in the Hither Green area and is conveniently located near to several bus routes and a mainline station. A variety of shops, pubs, cafes and facilities, such as hairdressers, are within walking distance of the house. The house has a small front garden and a larger one to the rear. There is limited parking available at the home with the majority of the street given over to permit holder parking, although metered parking is available a short walk away. This could be a problem for visiting friends and relatives. The home aims to provide a homely atmosphere where staff can support individuals to develop and maintain their skills and independence as much as possible and lead a fulfilling life. LINC, the company that previously owned and managed the home has recently merged with another company and since August 2005 the management and ownership of the home has been taken over by PLUSProvidence LINC United Services. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced visit that was carried out over two days due to the manager and deputy manager not being available on the first day of the inspection and the inspector not being able to access necessary records or information. The inspection included speaking to two service users and a volunteer who regularly visits one of the service users and offers support with painting. There was discussion with the deputy manager and staff on duty. Other inspection methods used included a tour of the premises and inspection of care records. What the service does well: The service provides a high standard of care to service users and is flexible and responsive to their individual needs. The staff ensure that the home is run in a way that it is inclusive of the service users who are encouraged to participate as much as possible in the daily routines of the home. Positive relationships are maintained between staff, service users and others who have an involvement with the home. One service user stated “I do like it here and I like my key worker”. Another service user who has communication difficulties responded positively when asked about whether he enjoyed living at the home. A volunteer who supports one of the service users to do painting said in reference to staff “they are wonderful here”. Service user plans contain comprehensive and detailed information about individual’s life histories, personal and health care needs. Regular reviews are held and the home works closely with a variety of health and social care professionals to ensure service user’s needs are being addressed and to identify future goals with service users. Risk taking behaviour is encouraged to facilitate service user’s personal development. The staff are supported to carry out their duties and roles in supporting service users. There is a commitment to ensure staff receive training as part of their induction and also on an ongoing basis as part of their development individually and also as a team. One staff member spoken to said, “I really enjoy working here at the home”. The environment of the home is generally well maintained, clean and well decorated. It is homely, safe and comfortable. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Each service user’s file contains a contract outlining terms and conditions of the placement. However, two are not signed which may adversely affect the rights of those individuals and needs to be addressed. The information within service user plans needs to be consolidated into a more concise and clearer format that uses a more person centred approach to make it a more effective working tool for staff and service users. Service user plans and risk assessments have not been signed by service users or by family or a representative where appropriate to show service user involvement. Service review meetings, although held regularly, do not clearly indicate that service users are involved and are not signed to demonstrate that service users understand or agree with decisions made with regards to their care. Documents containing confidential information about service users are not being secured breaching service users rights. Staff have not received adequate training in respect to the administration and handling of medication, which requires urgent attention to ensure the safety and welfare of service users. An outstanding issue in relation to the transfer of appointeeship for one of the service users needs to be resolved as it is compromising the rights of that individual. Work needs to be carried out on the rear garden to make it more attractive and accessible to service users. Minor maintenance issues need to be addressed. The registered manager must ensure that all certificates required by regulation are fully displayed within the home at all times. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 7 Quality assurance needs to be improved, as the home does not presently have in place adequate systems to ensure effective self-monitoring involving service users and other stakeholders. Internal audits and an annual development plan for the home reflecting aims and outcomes for service users need to be implemented. The service needs to ensure that an up to date health and safety risk assessment has been carried out in respect to the building and fire safety. 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. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 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 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 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): 2&5 Service users needs are assessed prior to admission. Service users are in receipt of a written contract but two have not been signed which may impinge on the rights of those individuals. EVIDENCE: There have not been any new admissions to the home since 1999. However, the files of present service users demonstrate that admissions only take place on the basis of a full assessment undertaken by people competent to do so. A copy of the care management assessment is kept on file from which it is evident the service user plan has been drawn up. Two service users have not signed their contracts. The service users in question are not able to sign themselves. It was reported to the inspector that numerous copies of the contract have been sent to a relative of one of the service users who has failed to return it. The other service user requires the assistance of an advocate who has not responded to attempts made by staff to establish contact. One service user who had not signed their contract from the last inspection has now been signed by a relative and is on file. Therefore, the requirement from the last inspection remains partially met and is re-stated in this report. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 10 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, 8,9 &10 Service user plans comprehensively address the individual needs of service users. However, the information is not easily accessible and the plans do not clearly reflect the changing needs and personal goals of service users. Service user plans and reviews do not demonstrate service user involvement or the involvement of relatives, friends and or advocate as appropriate. Service users are consulted on and do participate in many aspects of life in the home. Risk taking is encouraged as a means of supporting service users to lead an independent lifestyle. Confidential information on service users is being recorded but is not kept secure, breaching service users rights. EVIDENCE: Three service user plans were inspected and were found to contain extensive information pertaining to individual backgrounds and daily routines in terms of personal care needs and activities. There was evidence that health care needs and needs relating to behavioural issues are comprehensively addressed with good liaison with a variety of healthcare professionals. Risk assessments were in place. In addition, regular reviews are being held with the involvement of significant professionals and, where appropriate, family members. However, 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 11 annual reviews by the purchaser have not been held regularly nor has there been attendance at the reviews held by the home despite efforts by staff to invite them. This was subject to a previous recommendation and is restated in this report. The service user plans are not easy to follow and neither do they demonstrate that a person centred approach is used to address service users’ needs. The information in relation to service users is detailed making key information less easy to find, does not clearly reflect their changing needs and personal goals and may prove difficult for service users to understand. It was noted that the format for service user plans is under review. However, the previous recommendations in this area have not been met and a requirement is made in this report. In addition, a recommendation is made as regards the format of the service user plan. Service user plans did not clearly indicate service user involvement or family or a representative where appropriate. It was reported that service users are involved in review meetings but this was not evident from notes examined and neither these nor risk assessments were signed. Where possible all documents and guidance held on service user files need to be signed by relevant parties. This was previously a recommendation and will be re-stated as a requirement in this report. Observations and speaking to service users indicate staff encourage service users to participate as much as possible and where practicable within the daily routines of the home. It was also reported that policies and procedures are to be put on video as a means to make them more accessible to service users. Advice has also been sought from Speech and Language Therapy about ways to increase service involvement within the home and also to facilitate greater understanding of service users’ communication needs. There is evidence of guidelines on service user files to address communication difficulties. Subsequently, the previous requirement stated in this area is now met. It is evident that from service user plans and risk assessments that risk-taking behaviour is encouraged. The home has a policy on risk taking and risk assessments cover a range of activities in and outside the home. Minutes of staff meetings and quarterly reports examined were found to contain a lot of detailed and confidential information on service users which is not being kept in a secure place. This is a breach of service users rights to confidentiality and is subject to a new requirement. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 Service users are supported in accessing opportunities for personal development. Service users are supported to engage in a range of leisure activities that are appropriate. EVIDENCE: There was evidence that service users have opportunities to learn and use practical life skills through the undertaking of daily household chores including the weekly food shopping for the home. In addition, service users are supported to undertake a range of activities in and outside the home to support their personal development. These include attendance of cookery classes and other adult education classes. In addition, service users are offered specialist interventions and opportunities by trained staff to address issues presented by their disabilities and behaviour to maximise their individual potential. All service users have been given the opportunity to fulfil their spiritual needs although only one attends church on a regular basis. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 13 In respect to leisure activities, service users are supported to undertake a range of pursuits and interests including rock climbing in the past, motorcycle and sidecar racing and aerobics. Service users are also supported to go on a holiday of their choice. However, they are expected to pay for themselves as well as the cost of accommodation and travel for those staff who support them Subject to a previous recommendation, the deputy manager reported the situation remains unchanged. This is inappropriate. Alternative ways to fund this need to be explored without preventing service users from having a holiday of their individual preference. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 14 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): 20 &21 Service users are not being protected by the home’s policies and procedures for dealing with medication. Service users and, where appropriate, family have been consulted about their wishes for illness and death. However, this is not explicitly outlined within service user plans. EVIDENCE: In respect to medication, none of the service users administer their own medication. There are robust policy and procedures for the receipt recording, storage handling and administration and disposal of medicines. All service user records were examined and mistakes were noted in the administration and signing of medication. For one service user, medication had not been given but had been signed for and medication had also been signed for in the incorrect place on the MAR sheet. In respect, to another service user there were gaps on the MAR sheet for a PRN medication instead of the appropriate code being used. All medication stored corresponded to the MAR sheets. There were no homely medicines currently in use. The community pharmacist carries out six monthly reviews. The inspector viewed the last report that highlighted issues in relation to gaps in MAR sheets, concern about a medication being stored incorrectly in the fridge and stock not 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 15 being recorded clearly. All staff administer medication, which is checked at every handover. It was reported that all staff receive basic internal training as part of their induction. However, not all staff had received training from a pharmacist around the system being used within the home. The inspector was informed that this training has been arranged and is to be held shortly. However, a new requirement is stated in this area. In respect to service users, family or a representative being consulted about their wishes in the event of illness or death, it was reported that this has been discussed as part of service review meetings and arrangements have been put in place. However, this was not clearly evident within the service user plan. Therefore, a recommendation is to be stated that this information should be recorded more clearly within the service user plan to ensure its accessibility. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 16 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 Service users are protected from abuse, neglect and self-harm. However, the delay in transferring appointeeship for one service user does not adequately protect that service user’s rights. EVIDENCE: In respect to standard 22 this was not fully inspected but complaints records were checked and no complaints have been made since the last inspection. It was noted that a copy of the complaints policy was not visibly displayed in the home which would make it more accessible to service users, family/friends and representatives. The service has robust policies and procedures in place in respect to adult protection and whistle blowing. Staff have received training in adult protection and one staff member spoken to was clear about what action to take in the event that it was suspected that a service user may be suffering abuse. The inspector was also informed that the home is in the process of arranging further adult protection training for the staff team that is more specifically related to working with individuals with learning disabilities. In respect to service user finances, all the service users have appointeeships. The manager is appointee for three of the service users. However, there have been ongoing problems in trying to transfer the appointeeship of the fourth service user from the previous manager of the home. This issue has been the subject of a requirement of several inspections, as the rights of the service user are not being protected. The deputy manager did report that a corporate appointeeship has been arranged which has enabled the home to access some money on behalf of the service user. However, there have been problems in extending the appointeeship to the other bank account held by the service user 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 17 to which the ex-manager remains the only person who has access. The deputy manager assured the inspector that every effort is being made to resolve the situation. The previous requirement has been partially met but it is to be restated until the situation is brought to a satisfactory conclusion. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 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 &30 The home is homely, comfortable and safe. Service user’s bedrooms suit their needs and promote independence and toilets and bathrooms provide sufficient privacy and meet individual needs. However, minor maintenance issues need to be addressed. Shared spaces of the conservatory and rear garden need improvements to complement and supplement service users individual rooms. The home is generally clean and hygienic. EVIDENCE: The home is suitable for it’s stated purpose, accessible safe and generally well maintained. All the bedrooms are a good size and are furnished to required standards. One bedroom is on the ground floor and is wheelchair accessible with a large ensuite bathroom. The other bedrooms do not have en-suite facilities. Each bedroom is well decorated and service users were involved in choosing the colour of their bedrooms when the home was recently re-decorated. The rooms have also been personalised by the service users reflecting their individual interests, needs and culture. However, the inspector noted that the carpets in two of the service users rooms were stained and in need of cleaning. Also, one 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 19 of the service users had a curtain missing, which impinges on their right to privacy. In addition, although subject to a previous requirement, the flooring in the upstairs bathroom remains in need of cleaning or replacement as there was a notable smell of urine. In respect to communal areas, a previous requirement with regards to the rear garden remains unmet, as it still requires work to make it more user friendly and attractive, although there was evidence to indicate that efforts are being made to try to recruit the services of volunteers to address this matter. In relation to the kitchen, this was clean and well maintained. Yet the previous requirement that one of the cabinet doors needs to be replaced remains unmet. The conservatory overlooking the rear garden is bare of any furnishings and consequently restricts its use to service users. It was reported that the conservatory is possibly in need of extensive repairs and may be have to be removed completely. Subsequently, plans for improvements have been put on hold until the matter has been addressed. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 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 &36 Service users are supported by competent and qualified staff. Service users benefit from well supported and supervised staff. EVIDENCE: The service has a strong commitment to training. All permanent and bank staff undergo a thorough induction process and are required to undertake statutory training before commencing work, which is regularly updated. In addition, all permanent staff are supported to do the LDAF (Learning Disability Award Framework) and also NVQ Level 2 in care. In respect to the previous requirement that 50 of care staff must have achieved the NVQ level 2 by the end of 2005 this has now been met. Three staff files were examined and there was evidence to indicate that staff are in receipt of regular supervision. Supervision is monitored closely to ensure that staff receive supervision every 4 – 6 weeks and where supervision has not been able to take place the reason is recorded. In addition, all staff have an annual appraisal. Therefore the previous requirement in this area is now met. Regular staff meetings are now being held and a copy of the minutes is retained for records. Therefore, the previous requirement in this area is now met. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 The home is generally well run, yet the manager must ensure that all licences and certificates required under regulation are fully displayed within the home at all times. There was no evidence of service users views being sought as part of a selfmonitoring. Health and safety is addressed within the home, but the lack evidence of an up to date health and safety including a fire safety risk assessment potentially places the safety and welfare of service users at risk. EVIDENCE: The home is well run. However, it was noted during the inspection that the home’s registration certificate was not fully displayed. It is the responsibility of the registered manager to ensure all certificates and licences are obtained and displayed. There was no evidence of formal quality monitoring systems in place based on independently seeking the views of service users, family/friends and other stakeholders by the use of questionnaires. Furthermore, apart from monthly 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 22 provider reports that have not been carried out regularly, there was no evidence of any other quality assurance systems being in place within the home. It was reported that the Business Manager carries out an annual audit of the home, but there were no records available to substantiate this. The home does not have an annual development plan in place, although a business plan in respect to the organisation was seen. All required policies and procedures are in place. Some of these have been reviewed and updated. It was reported that the company merger has delayed the completion of this process, but a revision of all policies and procedures is expected in due course. This was subject to a previous recommendation and is not restated in this report but will be reviewed further at the next inspection. In respect to health and safety, records indicated that the building and equipment of the home are maintained safely and inspected when required. Appropriate checks are carried out by staff in relation to fire tests and drills and testing of water temperatures to prevent the risk of Legionella contamination. The London Fire and Emergency Planning Authority (LFEPA) visited the home during the inspection to follow up a previous visit to the premises. They had recommended that a fire risk assessment be completed. However, this was not available. In addition, no evidence could be found to indicate that a health and safety risk assessment of the building had been completed. This needs to be urgently addressed to ensure the welfare and safety of service users is protected and is subject to a new requirement. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 2 2 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 152 Springbank Road Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 X DS0000025641.V257755.R01.S.doc Version 5.0 Page 24 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 YA5 Regulation 5 (1) b&c Requirement Timescale for action 30/05/06 2 YA6 15 (1) &(2) 3 YA10 17 (1) (a) 4 YA20 13 (2) The registered person must ensure that the statement of terms and conditions issued to service users are signed by either the service users themselves or their representatives. Previous requirement of 25/04/05 partially met. The registered person must 30/05/06 ensure that the information within the service user plan is easily accessible and understood by service users and all aspects of the plan are drawn up with the involvement of the service user and are signed by the service user whenever capable and or by family or a representative. The registered person must 30/05/06 ensure that any information in respect to service users detailing issues in respect to their care is kept in a secure place within the home. The registered person must 31/01/06 ensure that the systems in place for recording and monitoring the administration of medication are DS0000025641.V257755.R01.S.doc Version 5.0 152 Springbank Road Page 25 5 YA20 13 (2) 18(1)(c)(i) 20 (3) 6 YA23 7 YA26 23(1)(a) &(d) 8 YA27 16(1)(k) 23(1)(a) 7(d) 9 YA28 23(1) (e) &(h) 10 YA37 CSA 28 used consistently and effectively specifically staff sign the medication administration records correctly for all medication administered. The registered person must ensure all staff receive formal training in medication delivered by a pharmacist. The registered person must ensure that the issue of appointee ship is fully resolved to enable the service user full access to their finances and ensure their rights are fully protected. Previous requirement of 25/04/05 partially met. A corporate appointee ship has been set up giving access to one bank account whilst the other bank account held by the service user is still under the appointee ship of the exmanager. The registered manager must ensure carpets are regularly cleaned and furnishings specifically curtains are replaced or repaired as necessary. The registered manager must ensure the home is free from offensive odours and to clean or replace the floor covering in the bathroom. Previous requirement of 25/04/05 not met. The registered manager must ensure the rear garden is made more accessible to service users and is well maintained. Previous requirement of 25/04/05 not met. The registered manager must ensure that all certificates and licences are obtained and are fully displayed within the home at all times. DS0000025641.V257755.R01.S.doc 31/01/06 30/05/06 30/05/06 30/05/06 30/05/06 31/12/06 152 Springbank Road Version 5.0 Page 26 11 YA39 12 YA42 The registered manager must ensure that an effective quality assurance system is in place based on seeking the views and reporting back findings to service users, their families and other stakeholders. Also, to ensure as part of quality assurance that monthly unannounced visits are carried out by the responsible individual and copies of the report sent to the commission. 12(1)(a) The registered manager must 13(4)(a)(c) ensure that a comprehensive 6 health and safety risk assessment of the building to include fire safety is completed and kept on the premises. 24 & 26 30/05/06 31/01/06 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 registered manager should consider a format for service user plans that use a person centred approach and that sets out clearly objectives, targets action and timescales. The registered manager should continue to make efforts to ensure that purchasers actively participate in service user plan reviews. The registered manager should explore alternative ways to prevent service users having to pay staff’s travel and accommodation costs to support them on holiday. The registered manager should try to ensure that where arrangements have been made with service users/family or representative in respect to sudden illness or death, these are clearly recorded in the service user plan to ensure it is accessible. The registered manager should consider visibly displaying a copy of the complaints policy within the home to increase its accessibility to service users, family/friends DS0000025641.V257755.R01.S.doc Version 5.0 Page 27 2 3 4 YA6 YA14 YA21 5 YA22 152 Springbank Road and representatives. 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 152 Springbank Road DS0000025641.V257755.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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