Inspection on 27/01/06 for St Helier Avenue (374)

This inspection was carried out on 27th January 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Helier Avenue (374) 24/09/07

St Helier Avenue (374) 09/02/07

St Helier Avenue (374) 04/11/05

St Helier Avenue (374) 07/02/05

St Helier Avenue (374) 12/08/04

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 St Helier Avenue (374) 374 St Helier Avenue Morden Surrey SM4 6JU Lead Inspector David Pennells Unannounced Inspection 27th January 2006 11:00 St Helier Avenue (374) DS0000007157.V281570.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 St Helier Avenue (374) DS0000007157.V281570.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. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Helier Avenue (374) Address 374 St Helier Avenue Morden Surrey SM4 6JU 020 8648 0661 020 8646 4165 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) www.caremanagementgroup.com Care Management Group Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents with challenging behaviour A variation had been previously granted to allow one specified service user under the age of 18 to be accommodated. 4th November 2005 Date of last inspection Brief Description of the Service: 374, St Helier Avenue is managed, maintained and staffed by the Care Management Group (CMG). The care home is registered with the Commission to provide residential care for up to eight adults with learning disabilities and associated challenging behaviours. Two of these users currently occupy small independent living flats attached to the main house (one of which is soon to be integrated / ‘mainstreamed’ within the main project building). The home itself is a large detached brick built house converted to its current use in 1999. Situated close to the ‘Rose Hill’ roundabout on the A297 at its junction with the A217, the home is conveniently situated close to a variety of local shops, eating establishments and bus links. There is a hardstanding at the front of the home for parking a few vehicles, and extra free ‘on street’ parking is available nearby on the designated dual carriageway verges. Accommodation within the home comprises of six single bedrooms one on the ground floor and five on the first in the main building, and a self-contained flatlet attached to either side of the property a large garden with a patio at the rear. The communal facilities include a large dining / activities room, a separate comfortable lounge area, a conservatory at the rear of the house overlooking a pleasant back garden, a well-organised kitchen, and a laundry room. There are sufficient numbers of bathroom / shower and toilet facilities located throughout the home to meet most service users needs. In addition, there is a staff sleeping-in room and an office on the first floor. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted across the morning of an ordinary weekday, when service users were all up - but out and about taking part in activities and leading their independent lives. The inspector was able to engage with a number of service users and to meet -for the main part - with the newly appointed manager, Diane Hussey (in post since 05/12/05), who was able to assist the inspector to review the previous inspection’s requirements & recommendations, and to speak about current practices in the home and the future of the project. This relatively short visit had an introductory and also a monitoring purpose; the inspector was encouraged to find that issues were being proactively addressed and positively ‘moved on’ from previous situations. The inspector is grateful to all at the home for their welcome, co-operation and hospitality. What the service does well: What has improved since the last inspection? The new incoming manager has arrived and provided a fresh perspective to the house and its operation - the ‘new broom’ approach is welcome - to sort out some of the longer-term issues mentioned in this and previous reports. The inspector noted that the recording systems and other related approaches such as to risk assessment and medication records - have improved. New handover record sheets and night shift task lists have been created as well. Approaches to difficult situations regarding a service user and their relationship to other service users was being approached in a creative and proactive way of working - which showed that results were forthcoming from this change of practice. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 6 A safe has been provided for the safe storage of the house and service users’ valuables. Steps have been taken to address the majority of the premises issues raised, however the speed at which these have been implemented has left the house wanting. It is unfortunate that a number of requirements in this report could have been avoided if the issues relating to premises /maintenance were dealt with more speedily. 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. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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 St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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): 3. The home provides service users & other interested parties with full details to enable them to make an informed choice about choosing to live at the home. Service user’s needs and aspirations are assessed, understood and implemented at the home – through the thorough and considered exploration of behaviours, wishes and needs, fully including the service user’s views. EVIDENCE: Standards 1 & 2 were found ‘met’ at the previous inspection and the inspector and the manager focused on Standard 3, due to concerns previously raised concerning the need to more definitively identify that a service user’s needs can be met prior to admission to the home. In the past year or two, some ‘failures’ of placement had led the inspector to require that a more concise statement of the aim of the project be evolved; the width of need identified in the home currently also indicated a breadth of identified needs - and a stricter selection criteria was advised. Following discussion, it is clear that the new manager intends to ‘focus down’ on providing an excellent service to the core of service users; the second flatlet is due to be ‘broken through’ to the main building -this leaving just one independent living flatlet for use - and incorporating the seven bedrooms within the main service provision. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 9 The inspector reminds the service again that despite staff having opportunities for training covering mental health awareness - which is invaluable for staff working with this ‘challenging behaviour’ service user group - such training should not, however give ‘license’ to the home to overstep the category limits for the home. People assessed as more clearly requiring a service based on mental health skills input, rather than a learning disability focus - which is the primary registration category for 374 - should not be admitted. The inspector is now confident that standard 3 will be well ‘met’, once the Admission Criteria and Statement of Purpose is revisited and suitably amended following the reintegration of the single ILU flatlet within the main premises. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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): 9 & 10. The home creates and maintains care plans and assessment documents that are designed to ensure that the needs of service users are realistically met in a focused way. Service users can be assured that their rights to individuality and selfexpression are protected, whilst acknowledging the community aspect of living in a shared environment. Consultation and sharing of information will involve, and take into account, the wishes and aspirations of the service user. Service users can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home, though ‘special needs’ require recognition and focused documentation. Service users and staff can be assured that the home is taking steps to ensure that information kept personally relating to them will be kept appropriately, in line with legislative requirements. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 11 EVIDENCE: At the previous inspection visit, Standards 6, 7 & 8 all found ‘met’. Standards 9 & 10 were inspected and found to be partly met and so were revisited at this inspection visit - and both found met this time. Concerns about specific risk assessments relating to special needs aspects of a person’s assessment were in hand and being thoroughly addressed. It was clear that the manager has a strong grasp of the need to both create and fully document such areas of risk. In addition to this recording, the manager was also considering innovative monitoring devices to assist staff unobtrusively ‘keep an eye’ on the specific service user, in case problems should arise. The concern the inspector previously had about the need to ensure that documentation was safely and securely stored, had been addressed by documentation no longer being kept in the kitchen cupboards and hence being semi-openly accessible to all. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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): None inspected at this visit. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home, and to adopt a lifestyle suited to their individual needs and preferences. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choice and decision-making. Service users can expect to be provided with a good standard of nutritious and wholesome food, ensuring that mealtimes are a pleasant and enjoyable time. EVIDENCE: All standards - including all the key standards - were inspected at the last visit and found ‘met’. During his inspection focus, the inspector had no cause to believe that this section of standards was not fully continuing to be ‘met’. The above judgement statements are reiterated from the previous report for the information of the reader. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s service input, through timely medical practitioner interventions, and through the home’s longer-term assessment and care planning programme. The systems adopted by the home regarding medication – once adjustments have been made to staff practice – will ensure the safety and consistent treatment and support for each service user. EVIDENCE: The first three standards were inspected at the last inspection visit and Standards 18 & 19 were found ‘met’. The inspector had to revisit the standard on medication to monitor concerns regarding correct storage, and the maintenance of medication profiles. These concerns were all addressed and found to be in good order at this visit; a fridge is now in place for the correct cold storage of certain medication, the profiles were accurately kept and all prescribed medication was properly and neatly kept. One concern was raised, however, in that a service user’s ‘prn’ (‘when required’) medication was not clearly described - and left staff open to the St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 14 possibility of holding different interpretation of the ‘guidance’. The specific case involved a maintenance dose of twice daily administration, with a possible additional four doses being permitted 0- but it was not clear whether this could be given in one dose or had to be split into four - and the span of time between the standard doses and discretionary doses was unclear. All ‘prn’ medication is a highly difficult area - and guidance must be as ‘watertight’ as possible to avoid any possibility of error. The manager had clearly reviewed the medication system in its fullest perspective, and described that the local pharmacist was visiting the house on an advice visit that week. It was hoped to move from the less satisfactory monitored dosage system currently being used to the much safer and easierto-monitor blister pack system which held each tablet in its own individual blister. The inspector fully supported the intention to move over to this method of storage. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Service users can be confident that their comments and complaints are responded to, with appropriate action being taken in a timely fashion. The home provides support to service users to ensure that they are protected from harm and any form of abuse, however the in-house policy and procedure relating to investigating allegations of abuse and dealing with vulnerable adults does not blend in with the local authority procedure adequately – thus putting service users at possible risk of mishandling of such situations. EVIDENCE: Standard 22 was found ‘met’ at the last inspection visit and was not revisited on this occasion. The first judgement statement reflects this. Standard 23 was partly met at the last inspection, due to the need for the home to have a secure location -such as a small safe -in which to store monies and valuables belonging to service users / the house. This has now been obtained, and is in situ in a locked room. This Adult protection standard - has also contained a ‘strong recommendation’ requesting that the registered provider take urgent steps to ‘tie in’ the CMG Adult Abuse policy with that of the host local authority (London Borough of Sutton – a newly revised procedure being issued in 2005). This has not been done, and the inspector is concerned that the two policies continue not to concur. The ‘current’ CMG policy (April 2002) does not cover immediately reporting the issue directly to the local social services care management team – a protocol that is now established with all care providers within the Borough (and common to other Boroughs too). St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 16 Most of the staff team have undertaken training on ‘Vulnerable Adults’ however the possibility of confusion, and therefore potential delay of correct reporting and seeking advice in such incidents, could put service users at possible risk from mis-management of such a situation if & when it arises. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once the first floor toilet has been reinstated and emergency lighting and extraction systems regularised, the home will be a safe environment in which to live, without unnecessary risk to service users or staff. EVIDENCE: All Standards were inspected at the last visit and generally found ‘met’ excepting issues arising from Standards 27 & 30. In the main building, there would be a sufficient numbers of toilet / bathroom / shower facilities (i.e. two baths, a shower, and three toilets to the six service users), however steps to urgently reinstate the single toilet facility on the first floor of the home are still awaited. The current situation leaves only the toilet in the bathroom available upstairs (someone bathing can often occupy this, leaving no toilet provision on this floor). The number of toilets on the ground floor has reduced since one of these was ‘earmarked’ for conversion use by a St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 18 single service user with special physical needs. This therefore reduces the number of toilets to an insufficient two. Extraction from the ground floor toilet and the laundry room is also to be urgently addressed - plans are apparently afoot, but the provision is yet to be installed. Stronger, individual extractors are to be provided to both locations. Currently the laundry extractor fan draws the air / odours from the toilet through the laundry space to the outside air; and when the extractor fan is not on, steam and odour from the laundry travels into the toilet area – evidenced by damp on the walls. This situation remains unacceptable. Both rooms will, the inspector was assured be separately, mechanically vented. The home generally was clean and free from offensive odours throughout the time of the inspection. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 19 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. Service users can be assured that they will be supported at all times by staff who are experienced and competent in their work, being provided in sufficient numbers to meet their identified needs. Service users can expect to be provided a service that generally ensures their safety and protection from abuse – though management vigilance is needed to ensure that full checks are undertaken using the (usually) thorough recruitment processes, and ongoing staff support arrangements. EVIDENCE: Standards 31 - 35 were previously inspected and found ‘met’, but now the timescale-related recommendation made under Key Standard 32 - to ensure that at least 50 of the care staff members are trained minimally to NVQ Level 2 - has been exceeded and is ‘not met’. The CMG organisation is taking significant steps to speed up their training programme to ensure that the required level of qualified staff is in place. It was understood that three staff were undertaking training at the present moment - but until their portfolios had been completed, no further staff were able to commence the training. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 42 & 43. The home operates management systems that ensure that service users benefit from a well-run, competently managed environment. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures, and the day-to-day conduct of the home. Service users can be assured that their welfare, health and safety is, in general, safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice, though a number of major safety issue requirements remain outstanding for ‘one-off’ attention from previous inspection visits. EVIDENCE: Previously Standards 37 - 40 were found ‘met’. Only Standard 41 was not inspected - but the inspector is confident about the general level of recording kept at the home. Standards 42 and 43 both had requirements set against them and they reappear with requirements outstanding in this report. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 21 Checks of the fire alarm test records again suggested that the two ILU flatlets had not been included in the regular break glass checks conducted by the home; so that whilst now being conducted regularly, only four out of the possible six were actually being monitored. A previous requirement that ALL fire alarm break glasses must be individually identifiable (by numbering) – including the ILU flatlets - and systematic records of tests against these must be kept - is, therefore, reiterated. A requirement that sufficient fire drills be held to ensure that all staff members at the home are regularly involved in such an event is also reiterated; a matrix recording system is needed to monitor regular annual involvement by each staff member; One drill had been undertaken since the last inspection visit but this was clearly not enough to address the previously identified deficit. An Immediate Requirement Notice was served on the registered provider at the last inspection to address the previous requirement (over two inspection visits) that radiator covers must be installed throughout the house to ensure the safety of service users. Priority has been given to bathrooms / toilets - and the remainder are to be installed within a week of this inspection visit. Staff members have remained vigilant that isolated heaters in high-risk areas were not turned back on, in the interim The recommendation that the marble fireplace surround and mantelpiece (previously clad in foam) has been clad with a more satisfactory surround - to remove the possibility of harm to service users – especially those with compromised mobility, or a liability to experience a fit. The provision of electrical sockets, particularly in the independent living flatlet, remain to be increased – to avoid the current situation of heavily overloaded extension cables being used. The issue of the absence of emergency lighting both within and leading from the independent living flatlet remains outstanding. The need to provide light to a safe passage through their flats and out and away from the home in an emergency must be a high priority. The inspector is also concerned that the safety of service users will also be severely compromised if the front garden area is not more securely secured and protected; the provision of a garden gate and reasonable protection from the road - through adequate fencing / walls - is required, to ensure that service users are immediately protected from the risk of this busy dual carriageway at all times. The above issues relating to health & safety are within the CMG’s remit of works to be undertaken; it is regretted that it has taken quite so long to effect the changes; a more speedy response after the last inspection visit would have resulted a significantly shorter list of requirements against the home. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 22 The need for sight of a copy of the CMG Company’s Business, Financial & Development Plan remains - especially in regard to this project, as it changes it statement of purpose to centrally accommodate seven rather than six and slightly realigns its purpose. This document should be available at the home to assist the manager, and also for inspection purposes. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 1 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 1 2 St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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 YA3 Regulation 4(1) & 6 Requirement A revised selection criteria and Statement of purpose are required to be developed for the home - especially to reflect the change to the independent living units. Timescale of 15/01/06 not met. ‘PRN’ medication must always have precise and inconvertible instructions attached to them, to ensure that no error or misadministration takes place. The provider’s policy on adult abuse must be amended to accurately tie in the approach required locally under the jointly agreed LB Sutton Vulnerable Adults Procedure Guidelines. A previous recommendation now a requirement. Steps must be taken to urgently reinstate the single toilet facility on the first floor of the home. Timescale of 24/12/05 not met. DS0000007157.V281570.R01.S.doc Timescale for action 07/04/06 2. YA20 13(2) 07/04/06 3. YA23 13(6) 07/04/06 4. YA27 13(3) & 23(2)(j) 07/04/06 St Helier Avenue (374) Version 5.1 Page 25 5. YA30 23(2)(p) Extraction from the ground floor toilet and laundry room must be urgently reviewed and stronger and individual - extractors provided to both locations. Timescale of 24/12/05 not met. The inoperative extractor fan in the upstairs bathroom requires urgent replacement / repair. Timescale of 24/12/05 not met. 07/04/06 6. YA30 23(2)(p) 07/04/06 7. YA32 18(1)(c) A minimum of 50 of the care 31/05/06 staff team must be qualified nominally to NVQ Level 2 in care. Previously a ‘time-scaled’ recommendation - now a requirement. A new requirement: Fire alarm break glasses must be individually identifiable including in the ILU flatlets - and systematic records of tests against these must be kept. Sufficient fire drills must be held to ensure that all staff members at the home are regularly involved in such an event. Timescale of 30.09.04, 30.05.05. & 31.12.05 not met. The provision of electrical sockets particularly in the independent living flatlets must be renewed and increased - to avoid the current situation of extension cables being used and (still) heavily overloaded. Timescale of 24/12/05 not met. 07/04/06 8. YA42 23(4) 9. YA42 23(4) 07/04/06 10. YA42 13(4) 07/04/06 St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 26 11. YA42 23(4) The home is required to explore the issue of the absence of emergency lighting both within and from the independent living flatlets - an essential provision in case of an emergency. Timescale of 30/01/06 not met. A business and financial plan must be made available in the home to evidence both the ongoing planning for the home and its financial viability (43). Timescale of 30.09.04, 30.05.05 & 30/01/06 not met. 07/04/06 12. YA43 25(1) 07/04/06 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 YA40 Good Practice Recommendations It is recommended that the policies and procedures files within the house be split down - to enable ease of access to such documents by staff members. St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Helier Avenue (374) DS0000007157.V281570.R01.S.doc Version 5.1 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!