Inspection on 19/10/05 for Streatham Common South, 22

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Streatham Common South, 22 27/07/07

Streatham Common South, 22 11/05/06

Streatham Common South, 22 19/05/05

Streatham Common South, 22 06/01/05

Streatham Common South, 22 06/10/04

Streatham Common South, 22 25/02/04

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 Streatham Common South, 22 22 Streatham Common South Streatham London SW16 3BU Lead Inspector Sonia McKay Unannounced Inspection 19th October 2005 09:00 Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Streatham Common South, 22 Address 22 Streatham Common South Streatham London SW16 3BU 0208 769 0668 0208 679 2364 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) Crown Wise Limited Mr Emmanuel Wilson-Addo Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: 22 Streatham Common South is a private residential home for seven adults with mental health issues. It is one of three homes in the locality owned by the same proprietor. The home is in a residential street overlooking Streatham Common, within walking distance of transport links, shops and leisure facilities. It is located in the ground floor and basement of a large house and is decorated and furnished to a good standard. The majority of service users have been at the home for many years and the home aims to provide them with the various degrees of support. Where appropriate, the home also helps to prepare service users for independent living. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in nine hours over one day. It involved talking with the home managers, the registered provider and three of the service users. Records relating to care, support and health and the safety of the premises were examined. A health professional, involved in the care of three of the service users, was contacted by telephone to obtain feedback about the service provided and the ability of the staff team to work with other professionals. What the service does well: What has improved since the last inspection? 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. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 6 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 Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 7 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, 4 & 5 Prospective service users have an opportunity to visit and test drive the home before moving in. Each service user has a written contract with the home, although failure to include an initial care plan and the arrangements for reviewing the plan means that service users cannot be assured that the home can meet their needs and aspirations. However, staff work well with mental health professionals to provide service users with adequate care. EVIDENCE: No new service users have admitted been admitted to the home since the last inspection visit. Prospective service users have an opportunity to visit and to test drive the home before moving in. The service user most recently admitted had visited the home on a number of occasions with a member of his family. This had provided him with an opportunity to meet other service users and staff, view his bedroom and have a meal. The local authority generated summary of assessed care needs and care plan had been obtained during the referral process. Each service user has a written and costed contract/statement of terms and conditions with the home. Whilst the contract specifies the majority of information required, it does not include a copy of the service users initial care plan and the arrangements for reviewing and updating it. (See requirement 1) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 8 A mental health professional said that the staff are professional in their approach and swiftly notify mental health services of any significant changes in the mental health of service users living in the home. The staff-training plan includes training sessions on schizophrenia, working within the Care Programme Approach (CPA), cultural awareness and ethnicity, confusion and its management, stress, bipolar disorder, the Mental Health Act, risk assessment and communication. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Service users assessed and changing needs and personal goals are not reflected in their individual plans. Although service users are able to make decisions about their lives, some may need more assistance to make informed decisions. Service users are not consulted on, and do not participate in, all aspects of life in the home. Service users take risks as part of their independent lifestyles. Risk management strategies must be developed to minimise dangers. EVIDENCE: Each service user has an individual care plan. Care plans are reviewed regularly, but do not contain sufficient detail. For example, the home manager spoke at length about the challenging needs of one service user, but these needs are not noted in the care plan. The in-house care plans do not reflect the current CPA meeting assigned actions for home staff. For example, home staff are asked to support and encourage a service user to attend a drug addiction clinic and a GP appointment for a routine health check. The in-house care plan does not Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 10 mention this. In addition, records of key worker meetings with the service user do not show that this support and encouragement has been offered. (See recommendation 1) It is essential that the in-house care plans contain a sufficient amount of upto-date information about each service user to inform care staff of their current support needs. (See requirement 2) Overall, there is a need to consolidate in-house care plans and key-worker focus with external review or CPA meeting decisions. The home manager raised concerns about service users who refuse to attend health-care appointments and accident and emergency departments. He has devised a form for service users to sign to accept responsibility for their decision. Whilst it is acknowledged that the home has a responsibility and a duty of care, it is important that home staff adopt an approach of offering sensible advice and information to service users and informing the multidisciplinary team of the service users decision. The best interests of the service user can then be discussed, and alternative interventions arranged if necessary. It is recommended that when a service user refuses to attend an appointment, staff record this decision in the service users healthcare record. Other professionals should be informed of this decision within a time dictated by the level of risk posed to the service user. (See recommendation 2) There has been one service users house meeting in 2005. Four service users have completed a questionnaire about the activities provided by the home, but have not received any feedback about this consultation. This is an inadequate amount of consultation and involvement. (See requirement 3) The home manager completes a risk assessment for each service user. The risk assessment tool uses a scoring system. Service users are assessed as having a low, moderate or high risk of self-neglect, suicidal behaviour and physical aggression based on their scores against risk indicators. Whilst risk levels are also reviewed during CPA reviews there is a need for the home to develop risk management strategies for those service users assessed as having a moderate or high risk of these behaviours. The risk management strategies devised should be in accordance with CPA decisions. (See requirement 4) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 & 17 Service users have opportunities to develop and maintain appropriate personal and family relationships. Service users are offered a healthy diet but could be more involved in planning, shopping and preparing meals. EVIDENCE: Service users maintain their relationships and friendships themselves. Family and friends are welcomed, and with the service user agreement are involved in meetings and activities. Service users choose whom they see and when and can see visitors in their bedrooms and in private. Service users have opportunities to meet people and make friends. Records are kept of all main meals served in the home. Meals are served in the communal dining room at reasonably set times, although service users wishing to have a meal later can do so. A reasonably varied range of meals has been provided. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 12 Service users have access to a hot and cold drinks and snacks at all times. There is a small drinks preparation area in the communal lounge. Food provisions are stored in a locked pantry. Provisions available include fresh produce and food is stored hygienically. Staff on duty prepare the main meals. Service users are not routinely involved in planning menus, food preparation or shopping. Step should be taken to involve service users in these areas. (See recommendation 3) One service user regularly misses meals. Staff are concerned and sometimes note the service users food intake in the general daily log. It would be better to maintain an individual and accurate record of meals eaten in instances where a lack food intake is of concern. (See recommendation 4) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 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): 18, 19 & 20 The assistance that some service users need with personal care is not adequately documented. Service users physical and emotional health needs are generally met, although assistance with taking medication is inadequate and unsafe. EVIDENCE: Service users are able to get up and go to bed at times of their own choosing. They have their own clothes and their appearances reflect their personality. Six of the service users are male and one is female and the supporting staff team is comprised of both males and females. Three of the service users require assistance with their personal care. The degree of assistance required is not adequately documented. For example, a care plan says that a service user needs assistance with shaving, bathing and dressing but does not say what type of assistance is necessary. (See requirement 5) Records of health care have improved since the last inspection. Each service user has a log of the health-care appointments they have attended. These logs do not include home visits. Service users are receiving regular visits from Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 14 community psychiatric nurses, although these visits are only recorded in the visitors log. (See requirement 6) The records of health-care appointments attended indicates that service users have access to an appropriate range of health care in keeping with their individual health needs. A health professional from the community mental health team said that home staff are providing a good standard of care and that they liaise effectively with mental health support services. One service user has epileptic seizures. These seizures are recorded in the communal incident log. This is inappropriate. The home manager should seek advice from the appropriate professional involved in the care of the service user as to an effective method of recording seizure frequency and intensity. (See recommendation 5) Staff are not trained to meet the needs of the service user who has epileptic seizures. Although staff training has been arranged it has not been provided within the timescale given in a previous requirement. (See requirement 7) Accidents are recorded. There are three separate accident books available in the staff office. Entries are being made into accident books simultaneously. Only one of the accident books is in accordance with Data Protection legislation. This accident book is not being used. (See recommendation 6) Medication is stored in a secure medicine cabinet in the office and is administered by staff. Medication policy and procedures are in place and are adequate. Staff training includes the safe administration of medicines. Medicines are supplied by a local pharmacy in blister packs. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 15 Medication administration records (MAR) and supplies examined highlighted a number of problems: • • • • • • • • • • • • • (See The supplying pharmacist inspected the home in July 2005. The report notes that some medication administration records were missing Medication administration records did not include information on any allergies One service user had refused to take antipsychotic medication for five out of eight days. There is no record of what action was taken as a result. There is no information available about individual medications prescribed There is no information available about possible side-effects of medications prescribed There is no medication identification information available for medicines supplied in blister packs A course of antibiotics for one service user had not been completed. The MAR recorded that the course had been completed although one tablet remained in the blister pack. The MAR for a course of antibiotics comprising of 14 tablets had 19 signatures of administration The dosage of one medication had been changed. Administration information on the MAR had been crossed through and altered The MAR for one medicine recorded that two tablets should be taken at night. The pharmacy administration sticker on the blister pack said that one tablet should be taken in the morning and the other in the evening. Tablets from one blister pack had been decanted, by a member of staff, into another container. This container was not labelled The member of staff had done this as they had noticed a mistake in the filling of the blister pack This mistake had not been identified when the medication was delivered by the pharmacist as the pharmacist had delivered the medication to a neighbouring residential care home run by the same company requirement 8) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 More must be done to ensure that service users views are listened to and acted on. EVIDENCE: There is a complaints procedure, which includes timescales for investigation and feedback. The complaints procedure is given to service users in their service users guide and includes contact information for the CSCI. The home manager said that there had been no complaints made. The record of complaints could not be located. The complaints procedure must be suitable to the needs of the service users, and although some service users may feel comfortable making a complaint in writing, it is likely that most complaints would be made verbally to staff. The complaints book should be easily accessible so that staff can record a complaint made in this way. (See recommendation 7) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 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): 24, 25, 26, 27 & 30 The home is comfortable and clean, and service users bedrooms meet their individual needs and lifestyles. EVIDENCE: The home is well decorated, furnished and clean. There are five single bedrooms and one double bedroom. The service users sharing a double bedroom have made a positive choice to do so. There is an adequate number of bathrooms and toilets, with appropriate privacy locks and thermostatically controlled hot water temperature controls to prevent scalding. There is a communal lounge, dining room and laundry area in the basement section of the home. New lounge chairs have been purchased. The home is not suitable for people with significant mobility needs. There is a, recently paved, level access patio area with seating at the front of the property. Adequate safeguards are in place to ensure good home security. There is good access to local amenities, local transport and relevant support services. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 35 & 36 Staff have clear roles and responsibilities. Training and development is available but must be better organised to ensure that each member of staff undertakes appropriate training and regular updates. Staff recruitment does not provide service users with adequate protection. EVIDENCE: Roles and responsibilities are clearly defined in job descriptions for support staff. Staff are able to get to know and develop relationships with the service users. There is a core team of twelve staff (including the managers) and a neighbouring home, when needed, provides additional staff cover. Two staff are on duty during the daytime. An additional member of staff provides four hours of supported community activity access, using the company vehicle, each day. One member of staff provides night waking cover. The home manager and the registered provider provide out of hours on-call emergency cover. Four out of the eleven care staff have achieved a National Vocational Qualification (NVQ) level 2 or above. (See requirement 9) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 19 Staff duty rosters show that there is insufficient time for staff on one shift to verbally hand over information to staff coming on duty on the next shift. (See requirement 10) Staff recruitment and induction records are not kept in the home. They are stored in the company Central office. The recruitment records for the most recently recruited member of staff were examined. They were incomplete. Only one reference was available and evidence that a P.O.V.A first check (Protection of Vulnerable Adults) had been completed, pending the enhanced criminal records bureau check (C.R.B), was not available. The C.R.B check was satisfactory, but had not been in place at the time the member of staff commenced work in the home. (See requirement 11) An appropriate training programme is available. It includes staff training in a range of topics applicable to the service provided. Individual training needs assessments are not available and it is not clear which staff will be attending the training days. (See requirement 12) Individual training records are not available in the home. Arrangements to ensure that staff undertake periodic Food hygiene, Moving and handling, First Aid and Abuse Awareness training are not in place. A food hygiene inspection carried out in February 2005 noted that food hygiene certificates for each member of staff are not available. (See requirement 13) Training in equal opportunities and disabilities equality training, race equality and anti-racism training is not provided. (See recommendation 8) The home manager meets with each member of staff for formal supervision. Although these meetings are recorded, the format used scores staff in performance areas only. This does not provide staff with an established arrangement to give direct feedback does not identify training and development needs, does not provide an opportunity for monitoring work with individual service users and does not accurately record discussion and action points. Supervision records are not stored confidentially and supervisees are not given a copy. (See recommendation 9) There are no full-time staff, other than the home manager and deputy manager. This situation should be reviewed as it is not conducive to effective key-working. (See recommendation 10) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 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, 38, 39, 40, 41 & 42 The home manager is experienced but must obtain a relevant care and management qualification. Home records are disorganised. More must be done to ensure that service users are consulted on the running of the home. EVIDENCE: The registered manager has been in post for a number of years and has experience of working with service users with mental health needs. He has yet to complete an NVQ 4 in care and management. (See requirement 14) A deputy manager assists the home manager. The deputy manager is experienced and works in a full-time capacity. The home manager must devise strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which the service is delivered. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 21 Although the home manager is closely involved in the day-to-day operation of the home, the processes of managing and running the home are not well organised. Record keeping and office organisation must be improved to ensure that staff can access information easily. There has been little consultation with service users and stakeholders and there is no quality assurance and quality monitoring system in place. (See requirement 15) There are written policies and procedures in a file in the staff office. Policies and procedures are reviewed regularly. It is recommended that out of date policies and procedures be removed to avoid confusion for staff trying to access up-to-date information. (See recommendation 11) Confidential information is stored securely in the staff office (other than supervision records). Record keeping is inadequate in some key areas: • Medication administration records (see requirement 8) • Accident records (see recommendation 6) • Recruitment records (see requirement 11) Health and safety records examined included: • Annual small electrical appliances safety test certificate (March 2005) • Electrical fixed wiring certificate (September 2002) • Annual gas appliance safety test certificate (April 2005) • L.F.E.P.A (Fire Authority) inspection report (February 2005) • Food Hygiene inspection report (February 2005) • Pharmacy inspection report (July 2005) • In-house health and safety check records • The record of fire evacuation drills records that only one drill has been carried out in 2005. (See requirement 15) The records of the temperature checks of hot water supplies were not available. (See requirement 16) Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 3 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 1 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 3 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Streatham Common South, 22 Score 2 2 1 X Standard No 37 38 39 40 41 42 43 Score 2 2 1 3 1 2 X DS0000022760.V255217.R01.S.doc Version 5.0 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 YA5 Regulation 12(5)(a) Requirement Timescale for action 31/12/05 2 YA6 14, 15(2)(a) 12 3 YA8 12(2)(4) 16(m)(n) The registered person must ensure that individual written contracts/ statements of terms and conditions with the home include a copy of the service users initial care plan, arrangements for reviewing that plan and details of any policy or rule that may limit their personal freedom. Service users must be supplied with a copy of the contract that is signed by the service user and the registered manager. Previous timescale of 12/08/05 not met. The registered person must 31/12/05 ensure that in-house care plans are sufficiently detailed and are reflective of the views of the service user and any decisions made in C.P.A meetings and reviews. The registered person must 31/12/05 develop increased opportunities for service users who wish to, to participate in the day-to-day running of the home and contribute to the development and review of policies, DS0000022760.V255217.R01.S.doc Version 5.0 Streatham Common South, 22 Page 24 4 YA9 5 YA18 6 YA19 7 YA19 8 YA20 procedures and services. Previous requirement of 28/01/05 and 30/09/05 not met. 12(1) The registered person must 13(4)(6) ensure that action is taken to minimise any identified risks and hazards, to avoid limiting the service users preferred activity or choice. Risk management strategies must be agreed with the service user and placing authorities. Previous requirement of 28/01/05 and 12/08/05 not met. 12(2) The registered person must 12(4)(a)(b) ensure that the nature of assistance required with personal care tasks is sufficiently detailed and in accordance with the service users preference. 13(1)(b) The registered person must 17(1)(a) ensure that individual healthcare records include the outcome of home visits. 12(1) The registered person must 13(6) ensure that staff receive 18(1) training on epilepsy. Previous requirement of 28/10/05 not met. 13(2) The registered person must 17(1)(a)(b) make arrangements for the recording, handling, safekeeping and safe administration of medicines received into the care home: • M.A.R must be retained • M.A.R must include information on allergies • Action taken by staff when service users are non-compliant must be recorded • drug information must be retained • possible side-effects DS0000022760.V255217.R01.S.doc 31/12/05 31/12/05 30/11/05 30/11/05 30/11/05 Streatham Common South, 22 Version 5.0 Page 25 9 YA32 18(1) 10 YA33 12(1) 18(1) 11 YA34 19 12 YA35 18(1) information must be retained • medicines supplied in blister packs must be individually identifiable • courses of antibiotics must be completed • M.A.R must be signed immediately after staff administer a medicine • M.A.R directions must not be altered by crossing out and adding new dosage • M.A.R directions must tally with directions on blister packs • Staff must not decant medicines into other containers • Medicines must be checked when it is received into the home • A record of these checks must be maintained The registered person must ensure that an appropriate number of care staff are working towards a Care N.V.Q at level 2 or 3. The registered person must ensure that staff have adequate time for a handover of information between shifts. This meeting must be identifiable on the staff duty rota. Previous timescale of 26/08/05 not met. The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The registered person must ensure that each member of staff has an individual training needs assessment and training DS0000022760.V255217.R01.S.doc 30/09/06 30/11/05 30/11/05 31/12/05 Streatham Common South, 22 Version 5.0 Page 26 13 YA35 18(1) 14 YA37 10(3) 15 YA42 12(1) 13(4) 23(4) 12(1) 13(4) 16 YA42 profile. Previous timescale of 28/09/05 not met. A training and development plan formulated on conclusion of a training needs assessment of the staff team as a whole must be supplied to the CSCI Southwark office. Previous timescale of 28/09/05 not met. The registered person must ensure that the registered home manager is supported to commence the appropriate care and management qualifications (N.V.Q level 4 in Care and the Registered Managers Award) by 2005. Previous timescale of 31/12/05 not met. The registered person must ensure that fire evacuation drills are conducted with the required frequency (a minimum of four times per year). The registered person must ensure that hot water temperature checks are conducted on a regular basis. A record of the results of these tests must be maintained. Previous timescales of 18/02/05 and 01/07/05 not met. 31/12/05 31/12/05 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The registered person should introduce a more effective method of recording keyworker/service user meetings. DS0000022760.V255217.R01.S.doc Version 5.0 Page 27 Streatham Common South, 22 2 YA7 3 4 5 6 7 8 9 YA17 YA17 YA19 YA19 YA22 YA35 YA36 10 11 YA33 YA40 These records should be signed by the keyworker and the service user and should detail the progress made in achieving care plan objectives. The registered person should record a service users decision not to attend healthcare appointments or accident and emergency departments in their healthcare records. These decisions should be communicated to the multidisciplinary team working with the individual within a timescale dictated by the level of risk posed to the service user by not attending the appointment. The registered person should take steps to involve service users in planning menus, shopping for provisions and meal preparation. The registered person should maintain an individual record of meals eaten when a service users food intake, or lack of it, is of concern. The registered person should seek professional advice as to an appropriate method of recording the frequency and intensity of epileptic seizures. The registered person should maintain one accident book for the home. This accident book should be in accordance with data protection legislation. The registered person should ensure that a complaints book is available at all times. The registered person should provide training in equal opportunities, disabilities and race equality and anti-racism training The registered person should introduce a format for staff supervision meetings that allows key points of discussion to be recorded and action plans. Supervision records should be kept confidentially and a copy should be supplied to the supervisee. The registered person should consider reviewing staffing arrangements so that full time staff are available to undertake key-working. The registered person should remove out of date policies and procedures from the policy file. Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Streatham Common South, 22 DS0000022760.V255217.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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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