Inspection on 09/02/06 for St Martins Haven

This inspection was carried out on 9th February 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Martins Haven 12/06/07

St Martins Haven 04/10/06

St Martins Haven 22/09/05

St Martins Haven 23/12/04

St Martins Haven 09/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 St Martins Haven 86 Culverley Road Catford London SE6 2JY Lead Inspector Kate Matson Unannounced Inspection 9 February 2006 09:30 th St Martins Haven DS0000025644.V284334.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 Martins Haven DS0000025644.V284334.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 Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Martins Haven Address 86 Culverley Road Catford London SE6 2JY 0208 465 0020 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) Elizabeth Peters Care Homes Limited Jayne Bird Care Home 6 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (6), Mental disorder, excluding learning of places disability or dementia (6), Mental Disorder, excluding learning disability or dementia - over 65 years of age (6) St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 persons with dementia or mental health problems over 50 years 22nd September 2005 Date of last inspection Brief Description of the Service: St Martins Haven is a small care home in a quiet residential street in Catford. The home provides care for six adults with past or present mental health problems who are aged 50 and above. The home does not currently have any vacancies. The home is located a good walk away from the town centre, although has a parade of shops within a much shorter distance. Public transport is readily available in the form of local buses and two train stations, both of which provide links into London. The home is a converted property, which means that it is in keeping with the surrounding buildings. The home is one of a group of homes run by Elizabeth Peters Care Homes Limited. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 4.5 hours. The inspection included discussion with four service users, the registered manager and one staff member and examination of care plans, all staff files and other records. The manager had just returned from a long period of planned leave. What the service does well: What has improved since the last inspection? What they could do better: Medication systems are safe but service users need to have homely remedies more easily accessible to them. Systems in the home protect service users from abuse but the restraint policy needs to be reviewed to offer better strategies for dealing with aggressive St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 6 incidents and the most recent multi agency adult protection procedures should be obtained in order to ensure up to date information. Although the home has a training plan and staff have individual assessment of their training needs, induction and foundation training must be to sector skills council specifications. Although some staff are supervised regularly some are not and all areas required by national minimum standards need to be covered to ensure staff are well supported and supervised to care for service users effectively. The manager is competent and experienced to run the home but needs to complete an NVQ level 4 in care in addition to the qualification she already holds in management in order to meet national minimum standards. Some effective quality assurance systems are in operation, however only one report of monitoring visits had been received by the inspector and more consistency is required in addition to an annual development plan to ensure that the quality of service is effectively monitored and improved in accordance with service users views. 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 Martins Haven DS0000025644.V284334.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 Martins Haven DS0000025644.V284334.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): 2 Service users needs are assessed before moving into the home. EVIDENCE: At the last inspection it was found that most service users had lived at the home for some time. All of the files examined included an assessment of needs completed by the home. Most personal files also included a needs assessment completed under the care management process. However one service user had very little information on file relating to their mental health condition. The registered provider stated that this was because they had lived at the home for many years and the information had been archived, however it was recommended that information about service users past is easily accessible on service users files so that all staff working with the service user know about their needs and can communicate with them about their past where appropriate. At this inspection it was found that one service users file still did not include information about their previous history, however the manager had only just returned from several months of planned leave and stated this would be easily addressed. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 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 and 9 The homes care recording and planning system is under review to ensure less duplication and that service users needs are met. Service users are supported to make their own decisions however care plans should be developed to ensure that ‘move on’ needs are fully addressed. Service users are supported to take risks though the work staff do around risk management could be better evidenced. EVIDENCE: St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 10 At the previous inspection four care plans were examined, and these were well organised and easy to follow. They were regularly updated and evidenced that service users participated in the process. The care plans initially examined only covered a few specific areas of need for service users and did not evidence that care provided is holistic. However later in the inspection a file of further care plans was found to include this missing information. These were almost exclusively completed by the manager, and it was unclear if other staff had been involved in their development. It was recommended that the home uses one care planning system and ensures that all staff are aware of the system in use. Staff should also be encouraged to participate in the care planning process to ensure that they are as informed as possible about the needs of service users. At this inspection the manager stated that a new care planning system was being developed incorporating both systems seen at the previous inspection and this would ensure that all areas of need were covered. Key workers were also now responsible for care plans. At a previous inspection it was found that staff supported service users to make decisions and provide information and assistance as required. It was recommended that the format and agenda of the service user meeting be developed to ensure the meeting is as productive and participative as possible. It was also recommended that where service users had expressed a desire to move they should be made aware of alternative living options and supported to make any changes they wished to make. At the last inspection it was found that service user meetings were held every 2 or 3 months. The minutes of the meeting were being recorded more fully and evidenced that service users were consulted about various things. However one service user said they didn’t have meetings, another said that they didn’t attend and three others said they didn’t find them that useful. It was also noted that service users did not receive an agenda to contribute to or a copy of the minutes and previous meeting minutes were not discussed. The acting manager and registered provider were able to demonstrate how service users who had expressed a desire to move on had been supported, however in order to evidence work around this issue better, a new recommendation was made that service users have a care plan around this area where appropriate. At this inspection it was found that service users were now given an agenda to contribute to before the service user meetings and received copies of the minutes after the meeting. The manager stated that care plans would be drawn up where service users had expressed the desire to move on but this had not yet been done. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 11 It was noted at a previous inspection that service users were encouraged and supported to take responsible risks as part of developing a more independent lifestyle. Risk assessments had been devised in relation to service user issues and these were reviewed on a regular basis. However it was recommended that service user risk assessments should be further developed. At the last inspection it was noted that there were two risk assessment systems. One in the care plan largely focussed on physical risks such as falling and other risks such as those related to mental health issues were in another file. It was recommended that only one system be used and that staff are all made aware of the system in place so that staff are fully informed of all risks relating to each service user. Also although these risk assessments were thorough it was not clear what the risk management strategies were. The inspectors were told of some of the risks that service users took such as not telling staff where they were going or refusing to seek medical help when necessary. However risk assessments should evidence the work that staff do with service users around risk. At this inspection it was found that both recommendations were still to be implemented but the manager was implementing a new risk assessment and management system that she felt would address both issues. St Martins Haven DS0000025644.V284334.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): 12, 13, 14 and 15 Service users are largely independent in accessing the community and the activities in which they take part; though more organised activities could be offered at the home on an individual and group basis to meet service users educational and leisure needs. Although service users had been offered the opportunity of a holiday they need to be consulted about this in order to ensure that it meets their preferences as far as possible. Service users are supported to maintain appropriate relationships. EVIDENCE: At the last inspection it was found that one service user goes to a day centre three days per week and another attends a support group once per week. Other service users chose to spend their time mainly independently. It was clear that staff encouraged service users to go out but service users were often reluctant to do so. It was recommended that more organised activities are offered in the home on an individual and group basis to ensure that service users are given as many structured activity opportunities as possible for personal development and for leisure. At this inspection it was found that activities had been discussed at a recent meeting and planned activities included, film afternoons, board games, walks to local parks, trips to St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 13 Greenwich Park, museum visits, cinema, and current affairs discussions. However these were yet to be implemented. All of the service users are able to access the community independently. One service user attends a day centre, another occasionally goes to church, and others use local shops, and pubs and cafes. At the last inspection it was found that service users tended to spend their leisure time independently going for walks, visiting local shops and cafes, going to the pub and betting shop, and watching television. However some service users had been with staff on trips out to the coast, theatre productions, and concerts. One service user had gone with a member of staff to a Bob Dylan concert. All of the service users had been offered the opportunity of a holiday though only one had taken the opportunity and had enjoyed a week in Margate. One service user who had declined the holiday stated that they would prefer a holiday with different people. In order to ensure that service users preferences and wishes are met as far as possible it was required that they are consulted about different holiday options. At this inspection the manager stated that service users would be consulted individually but this had not yet been done. Discussions and care plans evidence that where possible links with family and friends are encouraged although for some service users contact is limited. The home operates an open visiting policy and service users can meet their visitors in communal rooms or in private in their rooms. The manager stated that the home only intervenes in service users relationships in order to protect the safety of service users or others. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 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): 18, 19 and 20 Service users receive individualised support though support received from professionals outside of the home could be better evidenced. Service users are supported in addressing their physical and mental health needs. Medication systems are safe though service users need to be able to access homely remedies more easily. EVIDENCE: At the last inspection it was found that a key worker system was in operation to ensure consistency and continuity for service users. Care plans indicated the level of support that service users require with their care including personal hygiene. Staff described the support that was given to service users who needed a lot of encouragement with their personal care. Service users had received visits from health professionals and this was recorded by the home but it was recommended that visiting professionals be encouraged to make their own entries in the service users care plan to better evidence the multi agency care that service users receive. It was also noted that some of the service users received mental health care under the Care Programme Approach (CPA) though minutes from previous CPA meetings many months previously had not yet been sent to the home. It was recommended that these be chased up to assist in care planning for the individual concerned. At this inspection it was found that the manager had chased up previous CPA meeting minutes St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 15 though was yet to ensure that professionals made their own entries in service users care plans. Care plan records and discussions indicated that health needs are regularly reviewed. Service users are supported to make informed choices and manage aspects of their own care. Information was seen within the care plans relating to physical and psychological health, GP visits and access to dentists, chiropody and opticians. The homes medication supply and records were examined and these were in order. Only staff who have undergone an assessed training course are permitted to administer medication. It was found however that no homely remedies were available in the home. The manager stated that if service users needed anything, it would be purchased for them after approval from the GP. However homely remedies need to be more readily accessible for service users. The registered manager must ensure that homely remedies are available in the home supported by a list from each service users GP to state which remedies and at what doses they can be used. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 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): 22 and 23 Service users had not made complaints but confirmed that they would do if necessary. Systems in the home protect service users from abuse, though the restraint policy does not offer appropriate advice for dealing with aggressive incidents. EVIDENCE: At the last inspection it was found that the complaints procedure was clearly located in the hallway and included the option of referring a complaint to the Commission, however the details had not been updated to reflect the new name of the commission and referred to NCSC. This needed to be clarified to ensure that service users are clear about their complaint options. At this inspection it was found that this had been done. None of the service users spoken with had made a complaint though they confirmed that they would be happy to raise a concern if necessary. One service user said, “If I had any complaints I’d speak to the manager” and another said “I speak my mind”. The home has the local multi agency adult protection procedures in place though it is recommended that the recently reviewed procedures be obtained to ensure up to date information. The homes restraint policy advises staff ‘to contact the GP if calm measures fail’. This is not an appropriate strategy to deal with aggressive incidents and requires review. All staff have undergone adult protection training to ensure they are aware of signs and symptoms of abuse and action to take if abuse is suspected. St Martins Haven DS0000025644.V284334.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): 30 The home is clean and hygienic. EVIDENCE: At the last inspection the home was found to be clean and arrangements for laundry hygienic and one service user remarked that, “Hygiene is top class”, however unpleasant odours were detected in the lounge, possibly coming from the soft cover chairs. It was required that this problem was addressed as it detracted from the overall pleasant environment for people living at, working at and visiting the home. At this inspection no unpleasant odours were detected and the manager stated that the armchair covers are washed every week and the carpet every four months. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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, 34, 35 and 36 More than half of the homes staff have been trained to National Minimum Standards. The homes recruitment practices have improved though equal opportunities practices could be better evidenced. The home has good training systems in place but induction and foundation training need to be to sector skills council specifications. Although some staff are supervised regularly some are not and all areas required by national minimum standards are not covered. EVIDENCE: The manager stated that four of the staff had completed NVQ training course, and one was currently taking a course. This means the home has above the required number of staff trained to national minimum standards. It had been noted at previous inspections that staff files did not include all of the documents required by regulation and at the last inspection there was no file for one staff member who was working at the home. Also staff rerences were in some instances inadequate for example one was undated and one did not provide any information about the employee. The registered provider was required to ensure as far as possible that references are sought from previous employers, on letter headed paper or with an official stamp and that these are followed up with a phonecall where insufficient information is supplied. At this inspection records for all six staff members on the duty rota were available in the home. These included all of the required documentation and evidence of appropriate recruitment checks. The newest staff member had appropriate references. However it was noted that although notes of an interview were on St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 19 file these did not provide sufficient evidence of recruitment procedures being in accordance with equal opportunities policies. It is recommended that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. The home had a training plan in place outlining mandatory and other training planned for the year. Each staff member had a training plan identifying training completed and training required. The newest staff member was undergoing an induction programme however this was not in accordance with new standards as required. The manager must ensure that the homes induction and foundation training is in accordance with sector skills council specifications. The manager was given the London Skills for Care office details in order to ensure the home’s training meets National Minimum Standards. At previous inspections it was noted that staff were encouraged to comment on and contribute to all aspects of running the home. Staff were given copies of the staff meeting minutes and encouraged to contribute to the agenda. At the last inspection it was noted that although four of the six staff had received regular supervision, two staff files did not have evidence of this. The provider was required to address this to ensure that all staff are supported to meet the needs of service users. At this inspection it was found that three staff had very regular supervision, one had only just started work and the other two had not been supervised for seven months in one case and twelve months in the other. It was also found that the format of supervision appeared to more of an appraisal and included little reference to work with individual service users. The registered manager must ensure that supervision covers the areas listed under Standard 36. St Martins Haven DS0000025644.V284334.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): 37 and 39 The manager is competent and experienced to run the home but requires further qualifications in order to meet national minimum standards. Some effective quality assurance systems are in operation, however an annual development plan and consistent reports of monitoring visits are required to ensure that the quality of service is effectively monitored and improved in accordance with service users views. EVIDENCE: The homes manager has worked in care for over 15 years, and worked as a registered manager for 10 years. She has managed St Martin’s Haven for 4 years. She is an NVQ assessor and has completed the NVQ Registered Managers Award. From discussions with staff and service users the manager is well respected within the home. The manager has not completed a care qualification and must register to do so as soon as possible as managers were required to have qualifications in management and care by 2005. At the last inspection it was found that the home had a number of quality assurance systems in place, kept in a quality assurance file. These consist of monthly audits of, the environment, medication system, care plans and other St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 21 records, and quality questionnaires given to service users, relatives and visitors to the home. A service user survey had been completed in June 2005. Although the results of surveys were acted upon, it did not appear that the results of the surveys were summarised and made available to service users. And it was recommended that the registered provider summarise the results of surveys and make them available to all those taking part in order to evidence to service users and others contributing to quality assurance surveys that their views underpin self-monitoring, review and development of the home. Previous inspections had also required that the registered provider make unannounced monthly visits to the home and submit reports of the visits to CSCI. At this inspection it was found that a further satisfaction survey had not been completed though it was noted that service users names were on previous ones. It is recommended that service users be given the opportunity to remain anonymous in order to ensure candid responses. The inspector recently received one report of an unannounced monthly visit to the home but a more sustained response is required before the requirement can be considered met. This requirement has remained unmet over several inspections and CSCI may take enforcement action about this issue. An annual development plan for the home is also required that is based on a systemic cycle of planning, action and review and reflecting aims and outcomes for service users. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 1 X X X X St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 12 (3) Requirement The registered provider must ensure that service users are consulted about different holiday options in order to ensure that service users individual preferences and wishes are met as far as possible. (Previous timescale of 31/03/06 not expired) The registered manager must ensure that homely remedies are available in the home supported by a list from each service user’s GP to state which remedies and at what doses they can be used. The registered provider must ensure that the restraint policy is reviewed to offer more appropriate strategies of dealing with aggressive incidents. The registered manager must ensure that the home’s induction and foundation training is in accordance with sector skills council specifications The registered provider must DS0000025644.V284334.R01.S.doc Timescale for action 31/03/06 2. YA20 13 (2) 31/05/06 3. YA23 13 (6) 30/04/06 4. YA35 18 (1) (c) (i) 31/05/06 5. YA36 18 (2) 31/05/06 Page 24 St Martins Haven Version 5.1 6. YA37 9 (2) (b) (i) 7. YA39 26 (3) 8. YA39 24 ensure that staff receive formal supervision at least six times per year. (Previous timescale of 31/12/05 not met). The registered manager must ensure that she registers for an NVQ level 4 in care in order to attain the qualification as soon as possible. The Registered Person must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI (previous timescales of 30/03/04, 31/07/04, 31/03/05 and 31/12/05 not met though one was received for February 2006). The registered provider must ensure that there is an annual development plan for the home that is based on a systemic cycle of planning, action and review and reflecting aims and outcomes for service users. 30/04/06 31/03/06 31/05/06 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 YA2 Good Practice Recommendations It is recommended that information about service users’ social and mental health history is easily accessible on service users’ files so that all staff working with the service user know about their needs and can communicate with them about their past where appropriate. It is recommended that in order to better evidence work around moving on, service users have a care plan around DS0000025644.V284334.R01.S.doc Version 5.1 Page 25 2. YA7 St Martins Haven 3. 4. YA9 YA9 5. YA12 6. YA18 7. 8. 9. YA23 YA34 YA39 10. YA39 this area where appropriate. It is recommended that risk assessments evidence the work that staff do with service users around risk. It is recommended that only one system is used to assess risk and that staff are all made aware of the system in place so that staff are fully informed of all risks relating to each service user. It is recommended that more organised activities are offered in the home on an individual and group basis to ensure that service users are given as many structured activity opportunities as possible for personal development and for leisure. It is recommended that visiting professionals be encouraged to make their own entries in the service users’ care plans to better evidence the multi-agency care that service users receive. It is recommended that the recently reviewed multiagency adult protection procedures be obtained to ensure up to date information. It is recommended that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. It is recommended that the results of satisfaction surveys are summarised and made available to service users and others taking part in surveys in order to evidence that their views underpin self-monitoring, review and development of the home. It is recommended that satisfaction surveys give service users the opportunity to remain anonymous in order to ensure candid responses. St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 26 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 St Martins Haven DS0000025644.V284334.R01.S.doc Version 5.1 Page 27 - 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!