Inspection on 31/07/06 for Stoke Newington Common, 6

This inspection was carried out on 31st July 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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stoke Newington Common, 6 28/08/07

Stoke Newington Common, 6 05/01/07

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 Stoke Newington Common, 6 6 Stoke Newington Common London N16 7ET Lead Inspector Sandra Jacobs-Walls Key Announced Inspection 31st July 2006 10:00 Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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 Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoke Newington Common, 6 Address 6 Stoke Newington Common London N16 7ET 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) TBC TBC Hillgreen Care Ltd Mr Benedict Kigozi Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the home’s first inspection following registration with CSCI. Brief Description of the Service: Stoke Newington Common, 6 is a care home that offers support, guidance and accommodation to a maximum of six service users who have learning disability. The registered provider is Hillgreen Care Ltd. The home’s premises is a well maintained large three storey terraced house opposite to Stoke Newington Common grounds in the London Borough of Hackney. Bus and rail links are very good and the home is near to local amenities. The service has a well-established staff group and a registered manager in place. At the time of the inspection, five service users were accommodated. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection of Stoke Newington Common 6 was conducted on July 31st 2006 for the duration of seven hours. Assisting the inspector was the home’s registered manager. The inspection process included discussions with the home’s registered manager, the review of key policies and procedures and other key documentation, the review of two service user files and five staff personnel files. The inspector also participated in an accompanied tour of the building. On this occasion, the inspector did not have the opportunity to meet with service users or staff. Prior to the inspection, the inspector reviewed a completed pre-inspection questionnaire, two comment cards completed by relatives of service users and six completed comment cards from involved professionals. As a result of the inspection fifteen (15) requirements and three (3) recommendations were made. The inspector would like to thank all staff and service users who co-operated and contributed to the inspector. What the service does well: What has improved since the last inspection? This was the services’ first inspection following registration. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 6 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. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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 Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The inspector reviewed the home’s Statement of Purpose which was a comprehensive document outlining the service and its purpose. With the exception of one area, the document contained all information as outlined in Schedule 1 of the Care Homes Regulations. Omitted from the document however was information pertaining to the general experience and qualifications of staff. The home’s Service User Guide was also reviewed and found to be missing key information as outlined in Standard 1 of the National Minimum Standards. Information omitted included key contract terms, fees charged, and a copy of the home’s complaints procedure. The service is encouraged to amend its Service User Guide to be compliant with information outlined in Standard 1 and Schedule 1 of the Care Homes Regulations. The inspector reviewed two service users’ files in detail. Both files evidenced good background information about the then prospective service users, however, files did not evidence the initial assessment completed by the service. The registered manager explained that the home’s service manager generally completed initial assessments and that these documents were kept off site at the organisation’s head office. It was the inspector’s view that service users’ initial assessment document should be kept on site on file in order to confirm and evidence the service’s initial assessment process. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 9 The registered manager explained that all prospective service users were encouraged to participate in a number of visits to the home, culminating in overnight stays. Files seen evidenced that these visits were in fact being conducted prior to service users’ being admitted to the home. Files reviewed evidenced no written agreement/contracts between the service, service users or their advocates. Written contracts must be developed by the service and provided to all service users. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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): 6,7,8,9 & 10 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: Service users files that were reviewed by the inspector contained very comprehensive care plans that identified issues pertaining to every aspect of service users’ lives; care plans explored personal care needs, interests and hobbies, physical and mental health needs, diet and mobility issues amongst others. Care plans were detailed and relevant to the individualistic needs of service users and efforts were made to consult with service users despite significant communication issues for some. Risk assessments were evident on files reviewed; these addressed some very specific issues of individual service users for example, the management of sexualised behaviour, issues regarding safe travel on public transport and the safe use of kitchen equipment. The registered manager was able to give examples of service users participating in the decision making process despite in some cases communication issues and some very challenging behaviour. The inspector reviewed the home’s record of residents meetings, which are held monthly. Records evidenced that three residents’ meetings had been convened since the Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 11 home’s opening. The registered manager commented that other meetings had been scheduled but not attended by service users. The inspector recommended that on these occasions the non-attendance of service users were similarly recorded. The minutes reviewed of meetings held indicated that issues such as visitors, the home’s complaints procedure, adult protection issues and the home’s fire precautions were all discussed. The registered manager commented that on an individual basis, service users were encouraged and made decisions for themselves independent of staff. When and where service users went, meal choices and decisions about personal items kept in individual bedrooms were given as examples. With regards to confidentiality, the inspector reviewed the home’s confidentiality policies, which were comprehensive and included information to service users and their advocates about accessing service user information. Staff were informed of these policies during their induction. The inspector noted that all service user information was kept securely locked in the staff office and that computers used for work purposes were password protected and staff have restricted access to some information stored via the organisation’s computer system. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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): 11,12,13,14,5,16 & 17 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The registered manager explained that the personal development of service users was assisted by the input of external professionals such as occupational therapists and behavioural therapists. Some service users attend day centres that facilitate access to resources and activities that enhance development; activities include discussion groups, music and art & crafts activities. The home is currently exploring college enrolment for one service user, while another service users is being registered with a local gym. Service users are encouraged to access the local community to participate in a range of activities. For one service user in particular there is a need for frequent trips away from the home for walks etc. Service users frequently access the local community, in particular parks, for shopping, swimming, places of worship and the local pub. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 13 The registered manager commented that most service users enjoyed very frequent contact with their family members, particularly over the weekend. Two service users have weekly visits with their fathers; while another service user has various family members visit her at home over the weekend. Another service user receives occasional visits form her father, but restricted visits from her mother as per an agreement with the placing authority. This service user prefers not to spend time at the family home. With regard to meals offered, staff encourage service users to assist with laying the table, serving food and (low task) meal preparation. The inspector saw written guidance to staff in the dining area regarding foodstuff individual service users are not permitted to eat due to known allergies. Additionally, some service users have particular dietary needs, such food cut into very small pieces to aid digestion and avoid choking. One service user who is of Orthodox Jewish faith eats only kosher foods and had meals prepared in accordance with religious obligations. There was a separate refrigerator, microwave and utensils for his use only. For service users of African/Caribbean and White UK origin, staff prepared traditional meals. Decisions regarding menu choices are based on known preferences and also discussion/communication between service users and staff, sometimes using pictorial cues of foods types. A weekly menu planner was evident in the home’s kitchen area. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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): 18,19,20 & 21 Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The registered manager commented that all service users living at the home at the time of the inspection required personal care support at varying levels. Details of the degree of support required was clearly evident on care plans, which detailed service users ability to complete personal care tasks independently of staff. The inspector noted that one care plan reviewed commented that the service user, “..needed help with zips.” The same file had documented also, “ X prefers bubble bath at the moment. She is not allergic to any soap” The registered manager commented that one service user due to his religious beliefs did not wish his beard to be trimmed. However, when this issue compromised the service user’s personal hygiene, staff negotiated with the Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 15 service user’s father that he alone would be responsible for shaving his son; the service user was in agreement with this arrangement. With regard to physical and mental health needs, files reviewed contained very clear information. All service users were registered with GP practices and records were maintained of all healthcare appointments including dental, opticians and other specialist healthcare services. Files evidenced good liaison between staff of the home and involved mental health professionals such as consultant psychiatrists and CPNs. Medication reviews were well documented. The inspector reviewed the medication information for one service user in detail. Information contained on Medication Action Records (MAR) sheets were largely appropriately detailed in accordance with the home’s written Medication policies and procedures that were also reviewed by the inspector. Changes to medication were well documented and highlighted so that all staff were aware. Medication to the home was received largely in blister packs to help avoid medication error. The medication policy reviewed contained detailed information regarding the receipt, disposal and recording on MAR sheets. During the review of medication administration for one service user, a box of prescribed medication was observed in the medication cabinet. This medication had been prescribed to the service user in question and received at the home some months ago, but this information did not appear on any MAR sheets at the time or subsequent to the date of the prescription. The registered manager could a not account for this discrepancy. Additionally, the label on the medication box indicated that 100 tablets had been prescribed, however the box contained only 18 tablets. Again the registered manager could not explain this discrepancy. Upon further discussion with other staff on shift at the time of the inspection, it was suggested to the registered manager that staff may have used the service user’s prescribed medication. The registered manager was advised to conduct a prompt investigation and report its findings to CSCI. It is unacceptable that 82 tablets are unaccounted for and the suggestion that staff may have taken them for their own use is wholly unsatisfactory. This issue must be resolved as a matter of urgency. The inspector asked to review the home’s policies with regard to ageing, illness and death of service users, but no related policy document was produced. The registered manager commented however, that work was due to commence with one of the service users about the anticipated impact of the loss of his elderly father. The registered manager must ensure that relevant policies and procedures that relate to service user ageing, illness and death are developed and implemented. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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 & 23 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service EVIDENCE: The inspector reviewed the home’s written complaints procedure, which was appropriately detailed and outlined all complaint stages and how the home would respond at each stage. Information reviewed was clear and mindful of the needs of service users. The inspector reviewed the home’s record of complaints made against the home, of which there was one. The inspector was satisfied that this complaint had been appropriately documented and resolved. The inspector also noted that the issue of making complaints was discussed at a resent residents meeting with service users. The inspector reviewed the home’s adult protection policies, which were detailed and included a Whistle Blowing policy. Adult protection training had been provided to staff. The written policy made reference to the adult protection procedures of the local authority and this document was produced. The written policy however did not include the need to inform social services at the earliest opportunity of all allegations made of an adult protection nature and the policy will also needed to include guidance to staff about reporting allegations. The registered manager shared with the inspector an allegation made by a service user against a member of staff. The allegation had been investigated and was concluded as unfounded. There was no documented information regarding details of the investigation or its outcome. The home must develop centralised system to record all allegations, any subsequent investigation and outcomes. The inspector also noted that this incident had not been reported to Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 17 the Commission as required. During the course of the inspection a number of other events had occurred in the home that had required notification to CSCI. The registered manager must ensure that all significant events as outlined in Regulation 37 of The Care Homes Regulations are promptly reported to the Commission. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service EVIDENCE: The inspector participated in a tour of the home’s premises with the registered manager as part of the inspection process. All areas of the home were seen, including service users bedrooms and communal facilities. The home was clean and hygienic; no adapted equipment was in use. The home’s building was generally well maintained, well decorated and comfortable. Service user bedrooms seen were decorated in accordance to service user preference, so for example, some rooms were decorated with stuffed toys, dolls, photographs etc, while others contained fairly sparse evidence of service users’ personal effects. Bedrooms were appropriately furnished, containing bedside tables, wardrobes, chest of drawers etc. One service user made use of an orthopaedic bed to meet specified needs. Service users were consulted over the decor of their rooms; the inspector saw a set of hanging lights previously used in one service users bedroom, but discarded by her when she moved into another bedroom. Another service user had chosen not to have any mirrors in his Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 19 room and had removed his bedroom’s lampshade. Service users’ relatives are also encouraged by staff to assist decorate service users’ bedrooms. The home, a three storey house with a basement has adequate washing and bathing facilities; all service user bedrooms had en suite facilities and service users had the choice of washing, showering or bathing facilities on a daily basis. The inspector noted two broken toilet seats at the time of the inspection; these must be replaced. The home’s communal areas were comfortable and well equipped with appropriate recreational materials (Television/DVD player/board games). The home should install an extraction fan for the corner of the lounge area to counteract the effects of cigarette smoke, as this is the designated smoking area of the home. The front and side garden areas were seen, both areas are in need of some attention and clearance to ensure safe access and use by service users. Currently service users are required to access the vast park commons area across the street. The inspector reviewed the home’s fire precaution strategies and was satisfied that appropriate fire precaution measures were in place. These included the regular checking of the home’s fire systems and monthly fire drills. The inspector recommends that the times fire drills are conducted be also recorded. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 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): 31,32,33,,34,35 & 36 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The service employs nine support workers to work with service users living in the home. The registered manager explained that some staff had transferred from another home within the Hillgreen Care Ltd organisation where some service users had lived prior to moving to Stoke Newington Common, 6. This was to enhance the continuity of the service users’ care. The registered manager commented that as a result service users’ needs were well known to most staff members and they were well experienced in dealing with often very challenging behaviour of service users. The registered manager indicated that he felt the staff team were effective and met service users’ identified needs well. On this occasion the inspector did not have the opportunity to meet with staff individually. The inspector reviewed the staff personnel files for five members of the staff team. Files reviewed evidenced information as required by Schedule 2 of the Care Homes Regulations; this included positive proof of identity, CRB disclosure forms, two written references and a completed application forms. The inspector recommends however that consideration be given to amending the home’s application form to allow applicants to document fully work Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 21 histories where a CV is not provided. A full employment history was not evidenced for two staff members currently working in the home; this is not conducive to robust staff vetting procedures. Staff files reviewed evidenced employment terms and conditions documents. With regard to staff training, the registered manager commented that all staff were required to undergo an induction for one month in the first instance. Staff files reviewed by the inspector contained evidence of staff participating in this process. The registered manager informed the inspector that it was the agency’s practice to seek staff that had prior experience of working in the care field and in particular, with service users who have similar needs as those living at the home. At the time of the inspection, one staff member had completed NVQ training at level 3, another had completed NVQ training at level 2, while all other staff members were about to embark onto NVQ 2 training courses. The registered manager commented that the organisation was in the process of trying to identify Makaton training to enhance the communication skill level of the staff. The inspector felt that such training was imperative, given the communication challenges posed by some service users currently living at the home. Training previously provided to staff included adult protection training, challenging behaviour issues, food hygiene and epilepsy training. The inspector reviewed the organisation’s staff training programme for 2006, which included mental health training, basic first aid, understanding autism, physical intervention, sex & sexuality Awareness training. The inspector reviewed staff supervision records for five members of staff and was satisfied that in general staff supervision was consistent. In addition the inspector saw evidence of monthly staff meetings being convened. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The inspector was satisfied that the home was generally well run. The management skills of the registered manager appeared effective and this was demonstrated in his candid assessment and management of initial staffing difficulties when the home first opened. The registered manager has a Bachelor of Arts degree in Social Science and a Master’s Degree in Mental Health and a diploma in Guidance and Counselling. He also has extensive experience of working in the care field at various levels. At the time of the inspection, the registered manager was completing the Registered Manager’s Award, this training will need to be completed in order to satisfy Standard 37. The leadership style of the registered manager appears to be based on ‘leading by example ‘ and his approach to his management duties are clearly very ‘hands on’. At the time of the inspection, the service was in the process of interviewing for a deputy manager to support the efforts of the registered manager. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 23 Service users’ rights and best interests are generally safeguarded by the home’s policies and procedures although there is a need for the development and expansion of some policies detailed elsewhere in this report. Equally the health, safety and welfare of service users were generally promoted and protect, although improvement in medication practices and further development of adult protection procedures is required. The registered manager informed the inspector that the home’s quality assurance measures include a range of internal systems and it is anticipated that a service user/advocate/relatives questionnaire will be available for use shortly. In addition, unannounced monitoring visits by senior managers of the home were being conducted. Subsequent monitoring reports must be forwarded to The Commission as per the Care Homes Regulations. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 3 4 3 5 2 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 2 2 3 3 2 3 2 3 Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The registered person must ensure that the Statement of purpose document include the general experience and qualifications of the staff group. The registered person must ensure that initial assessments completed by the service are maintained on site. The registered person must develop and evidence on individual service users’ files written contracts/statement of terms. The registered person must ensure that all medication received into the home is appropriately recorded on service users MAR sheets and is for the strict use of the identified service user. The registered person must ensure that an investigation is conducted establish the whereabouts of (82) tablets prescribed to a service users, unaccounted for on the day of the inspection. The outcome of any investigation to be supplied in writing to CSCI. DS0000065733.V299842.R01.S.doc Timescale for action 01/10/06 2. YA2 17(1)(a) 01/10/06 3. YA5 12(1)(a) 01/10/06 4. YA20 17(1)(a) 15/09/06 5. YA20 13(2) 01/10/06 Stoke Newington Common, 6 Version 5.2 Page 26 6. YA21 12(1)(a) 7. YA23 13(1)(6) 8. YA23 13(1)(6) 9. YA23 37 10. 11. YA24 YA24 23(2)(c) 23(2)(p) 12. YA24 23(2)(0) 13. 14 YA34 YA37 19 9 15. YA39 26 The registered person must ensure that policies and procedures relating to service users’ ageing, illness and death are developed and implemented. The registered person must ensure that the home develops a centralised system to record allegation and that all investigations are reported upon fully and include investigation outcomes. The registered manager must ensure that the home’s adult protection policies are further developed to include the role of social services in adult protection investigations and offer guidance to staff in recording allegations. The registered manager must ensure that all significant events (including all allegations of abuse) as outlined in Regulation 37 of The Care Homes Regulations are promptly reported to the Commission. The registered person must ensure that broken /removed toilet seats are replaced. The registered person must install an extractor fan in the lounge area to counteract cigarette smoke. The registered person must appropriately clear the home’s side and front gardens to ensure safe access and use by service users. The registered person must ensure that staff files evidence full employment histories. The registered manager must complete required management training (Registered Manager’s Award). The registered person must ensure that monthly monitoring visit reports are forwarded to the DS0000065733.V299842.R01.S.doc 01/11/06 01/10/06 01/11/06 01/10/06 01/10/06 01/12/06 01/11/06 01/10/06 31/12/06 01/10/06 Stoke Newington Common, 6 Version 5.2 Page 27 Commission for review. 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. 2. 3 Refer to Standard YA1 YA24 YA34 Good Practice Recommendations The service should produce a Service User Guide that contains all information as outlined in Standard 1.2 of the National Minimum Standards. The service should maintain records of the times fire drills are conducted. The service should consider amending its job application form to ensure applicants have the opportunity to document full employment histories. Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stoke Newington Common, 6 DS0000065733.V299842.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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