Inspection on 13/09/05 for Sylvan Road (16)

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sylvan Road (16) 28/02/07

Sylvan Road (16) 23/02/06

Sylvan Road (16) 21/02/05

Sylvan Road (16) 14/09/04

Sylvan Road (16) 15/03/04

Sylvan Road (16) 08/03/04

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 Sylvan Road (16) 16 Sylvan Road Wanstead London E11 1QM Lead Inspector Jackie Date Unannounced Inspection 13 September 2005 12.00 Sylvan Road (16) DS0000025929.V249828.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 Sylvan Road (16) DS0000025929.V249828.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. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sylvan Road (16) Address 16 Sylvan Road Wanstead London E11 1QM 020 8518 8004 020 8618 8004 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) Redbridge Community Housing Limited [RCHL] Miss Louise Elizabeth Prendergast Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 named people over 65 years. Date of last inspection 21st February 2005 Brief Description of the Service: Sylvan Road is a home for six people with mental health problems. It is one of a number of homes run by RCHL, Redbridge Community Housing Ltd. The house is in Wanstead in the London Borough of Redbridge. The ground floor has a bedroom with a shower, a lounge, dining area, kitchen and conservatory. The conservatory has a smoking and non-smoking sitting area and there is also a garden. Upstairs there are three single bedrooms, one double room and a bathroom. The home is near to bus stops and the train station. There are shops close by. Most of the residents have lived together for a long time. None of the residents go to regular day services but they do go to clubs and most of them can go out on their own and go where they want to go. The staff also organise some trips. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about four and a half hours and took place during the late morning and afternoon. It was the first of the two inspections that each home must have during the inspection year. The manager, two staff and all of the residents were spoken to. All of the communal areas and one of the residents’ rooms were seen. Care and other records were checked. In addition to this the inspector had previously visited the organisation’s head office to view staff records. What the service does well: What has improved since the last inspection? The manager and staff team continue to work to provide a good service for the residents and to meet each persons needs. Since the last inspection some of the residents have been given additional support due to their health. The destination for the holiday has been changed and also the time of the main meal. This was as a result of further discussions with residents. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 6 The care plans of the older residents are being reviewed more often to make sure that they are up-to-date, as peoples needs change. A score of four, indicating that the minimum standard has been exceeded, has been given for this. 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. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 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 Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 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, 3 and 4 Information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. EVIDENCE: There have not been any new admissions for several years. The organisation has an admissions procedure that includes gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. The staff would be able to assess and introduce a new resident to the home if needed. Each resident has a care plan that contains information about what they can do, their likes and dislikes and what help and support they need. The staff team know residents well and know what they can do, their likes and dislikes and what help and support they need to meet these needs. Sylvan Road (16) DS0000025929.V249828.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 and 9 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs safely. Residents’ needs are reviewed regularly and care plans updated when needed. The care plans of the older residents are reviewed more regularly as a matter of good practice and this exceeds minimum standards. Residents are encouraged and supported to be involved in decisions about what they do and what happens in the home. EVIDENCE: Each resident has a detailed care plan which takes into consideration the personal, health care and social support needs of the residents. Each resident has a six monthly review with other professionals as part of the Care Programme Approach (CPA). Changes are made to care plans after these reviews if necessary. Residents are involved with these reviews and with writing their care plans. Two of the residents are now aged over 65 and as a result of this, their care plans are being reviewed each month, in line with good practice for older people and this ensures that the staff team always have current information to work to. This good practice is to be commended and Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 10 exceeds minimum standards. Risk assessments relevant to each individual are made. For example one person specifically has risk assessments for finances and bathing. These risk assessments are reviewed regularly and updated when needed. Residents’ meetings are held each week and a variety of topics are discussed. This includes everyday things like the menu and shopping and also changes in the home and plans for the future. For example the manager and housing officer asked the residents what was needed to improve the environment of the home. They then agreed what could be done within the budget available. A planned holiday was also discussed and residents decided that they would like to change the venue. Residents spoken to said, “the staff ask us what we want to do”. An independent advocate from the North East London Advocacy Service visits the home every six weeks to meet with the residents. Sylvan Road (16) DS0000025929.V249828.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): 11, 12, 13, 14, 15, 16 and 17 Residents are encouraged and supported to do as much as possible for themselves and to be independent. Most residents go out when they want to and can keep in contact with their friends and families. The residents take part in a variety of activities and are part of the local community. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: Residents are encouraged to develop their skills. They participate in household tasks on a rota basis. This includes the cooking as well as domestic chores. During the course of the visit residents were observed to make drinks when they wanted to. Most of the residents are able to go out independently and can choose where they want to go. They are encouraged to do as much as they are able. For example some residents will go to the doctor on their own and also go to the bank to collect their money. Residents said that they go to Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 12 the cinema, the pub, out for meals, to church and to concerts. They all go to clubs on Mondays and Saturdays and some of them go to church on Sunday. A holiday to Dublin was being planned but the residents have decided that, due to the smoking ban in parts of Ireland, they dont want to go there now and are going to organise a different holiday. Residents’ families are welcome to visit and one resident regularly goes to visit his mother. As previously stated the residents discuss the menu at the weekly residents meeting. Residents recently decided that they would like to have the main meal in the evening and therefore now they have a lighter lunch. For example sandwiches, soup or jacket potatoes. The residents said they enjoyed the food and particularly complimented one of the staff on duty about their cooking. One of the residents has diabetes and he is supported to have a low sugar diet. Sylvan Road (16) DS0000025929.V249828.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 and 21 When required residents receive personal care that meets their individual needs and preferences. The staff team administer medication appropriately but must ensure that it is administered directly from containers dispensed by the pharmacist. Residents receive good support to ensure that they get the medical and health care that they need. This exceeds minimum standards Residents who are getting older or may be experiencing serious ill health are closely monitored and if necessary the service is adjusted to meet their changing needs. EVIDENCE: Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 14 The residents are quite independent and require little support in terms of their personal care. The care plans contain details of the support needed. Some of the residents go to the doctor on their own and others are supported by the staff. One of the residents refuses to go to the dentist but the others visit a dentist in the community. Some of the residents go to a private chiropodist, others go to the NHS chiropodist. On the day of the inspection the optician was also visiting the home to carry out eye tests. This seems to be a practice that was started some time ago and has just continued. There is no apparent reason as to why the residents do not use opticians in the community. It is recommended that this is reviewed and if appropriate that residents are encouraged and supported to use community facilities. Records are kept of medical appointments and outcomes. One of the residents has a serious illness and the staff team monitors this person’s condition. He is supported by his mother and by his key worker to attend appointments and discuss and decide on treatment. Recently one of the service users was involved in a road traffic accident and was admitted to hospital. The manager and staff were very active in advocating on his behalf and insisting that the proper support was available in the home before he was discharged from hospital. As a result of this he was provided with walking aids and also with two carers to assist him to get up and bathe in the morning and to go to bed at night. This was closely monitored and when the staff felt he was much better they were again very active in getting the intermediate care team to reassess him. The intermediate care team also visited on the day of the inspection carried out their assessment and confirmed that the person no longer needed the support and advised him and staff of this. The staff team are commended for the support that is given to residents in terms of their health care needs and this exceeds minimum standards. As previously stated the care plans of older residents are reviewed more regularly to identify any additional needs they may have because of the ageing process and the resident who has a very serious illness is given the support that he needs. Medication is stored in a locked cabinet in the office and is administered by the staff team. Medication records are up-to-date and have been properly completed. The psychiatrist had changed one resident’s medication and he made the alteration to the record and signed it. This ensures that residents receive the correct medication. Another resident used to be able to self medicate but due to a relapse in his health can no longer do this. However staff take the tablets from the bottles that are dispensed by the pharmacist and fill a dossette box. They then administer the medication from this. All of the other medication is in blister packs that come directly from the pharmacist. Medication must be administered directly from the containers provided by the pharmacist. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 15 Sylvan Road (16) DS0000025929.V249828.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 &23 There is a complaints procedure that would be followed in the event of any complaints being made. Staff are aware of issues of abuse and work to protect residents from abuse but access to the safe and to residents’ personal moneys needs to be restricted. EVIDENCE: There is a complaints procedure and this is displayed in the home. Residents said that they could talk to staff or the manager if they werent happy about things. As stated previously an independent advocate visits the home every six weeks and residents could talk to this person as well. Residents are involved in discussions and decisions about what happens in the home and changes are made if they are not happy with anything. For example, the time of the main meal has been changed and also the holiday destination. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff spoken to were aware of the issues of abuse and aware of their responsibility to residents. When residents go out the staff usually check where they are going and when they expect to be back. They said that they know the usual pattern that each person has and if anything is different they will follow this up. For example, one resident went to the bank and did not return when expected. Therefore staff went to check if everything was okay and found him waiting outside the bank as it was unexpectedly closed. All of the residents go to the bank or building society to sign for and withdraw their own cash. Some need support from the staff to do this. Records are kept Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 17 of financial transactions. The organisation carried out a financial audit in July this year and the recommendations from this are being dealt with by the home. Therefore systems are in place to ensure that residents are in general protected from financial abuse. Some of the residents keep their own cash and others cash is kept in the safe. Access to the safe is not restricted and therefore any member of staff could access residents’ monies at any time. This aspect of the service does not protect residents and must be reviewed. Access to the safe must be restricted at all times with a designated key holder on each shift. It is recommended that cash is checked as part of the handover procedure and therefore any errors or discrepancies can be quickly identified and addressed. This will provide added protection for both staff and residents. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The residents live in a clean and comfortable home that is suitable for their needs. EVIDENCE: The house is near to the local shops, bus routes and the tube station. The communal space consists of a lounge/diner, kitchen, conservatory, laundry room and a garden. The lounge diner is comfortable and has sky TV, video and a DVD player for the residents use. The conservatory has both smoking and no smoking areas and provides additional communal space and an area where residents can meet visitors in private if they want to. The two female residents share a large double bedroom and there are four single bedrooms. The ground floor bedroom has an ensuite shower. The inspector visited the double room with one of the residents and it was appropriately decorated and furnished. The resident said they were happy to share the double room. In addition to the ensuite facility there is a bathroom on the first floor and three toilets around the home. None of the residents need any special aids and bathing and toilet facilities meet their needs. At the time of the inspection the home was clean. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 19 The staff and residents have discussed and agreed areas that need decorating during the coming year to ensure that the home is maintained to a satisfactory standard. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. The Commission for Social Care Inspection (CSCI) cannot yet be confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank of agency staff. However, CSCI is satisfied that the organisation is actively addressing deficiencies in this area. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: An inspection of a sample of personnel files at the organisations head office showed that not all of the required checks on staff could be demonstrated to have taken place. This was of particular concern, as many of the files inspected related to staff who have joined the organisation in the past year, and for whom the recruitment process should have been robust, as matters regarding recruitment have been discussed previously with the organisation. Since raising serious concerns about the recruitment practice with RCHL, the organisation has undertaken a detailed audit of staff files and reviewed their Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 21 recruitment procedure and practice to identify and rectify deficiencies and to safeguard service users. At a further visit to the organisations head office CSCI were informed of the changes made. However only one new member of relief staff had been recruited recently, and therefore insufficient information was available to test the new procedures fully. An extension of the timescale for compliance has been given, to allow for more evidence of staff recruitment to be available. Two of the staff have achieved NVQ level 2 in mental health. Staff training records are kept and training for the coming year has already been booked. Staff on duty confirmed that they receive regular supervision and good support from the manager and from each other. They also said that the staff worked well together as a team and are all involved in what is happening in the home and looking at ways of improving the service. They were clear about their duties and responsibilities towards the residents. Although staff supervision takes place regularly and staff said that they do have the opportunity to discuss problems and to be involved in development at the service, staff meetings are not being held regularly. The last staff meeting was in April and this was because it was difficult to arrange the meetings and to get everyone to attend. Although communication in the home does appear to be good it is important that staff meetings do take place and that all of the staff team are involved in these. This will ensure that staff have an opportunity together to discuss issues, concerns and the development of the service. Regular staff meetings must take place, a minimum of six per year. From Monday to Friday two staff are on duty from 8am to 8pm, on Saturdays there is only one member of staff on duty from 2.30pm and on Sundays from 3.30pm. At night there is one waking night staff. Staffing levels have been discussed with the manager and with the staff team. The times when one staff is on duty are when residents usually all go out. For example on Saturdays they go to a club between 1 p.m. and 7 p.m. This arrangement is flexible and recently when one of the residents could not attend the club due to an injury two staff were on duty. Staffing levels are sufficient to meet the assessed needs of the residents. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 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, 41 and 42 The home is well managed and provides a safe environment for the residents. However the organisation has not been robust in maintaining staff records or ensuring that policies and procedures are relevant to this service. This could potentially place service users at risk. EVIDENCE: The manager has experience of services for people with mental health problems and has worked at the home for seven years. The manager was recently registered by the Commission and has enrolled for the Registered Managers Award. Staff and residents are involved in the running of the home and the staff team discuss any developments and changes. For example the change in venue of the holiday and the change of time for the main meal. The quality of the service provided to the residents is monitored by the home manager and by the organisation. The service manager carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 23 to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In addition to this the organisation carries out a quality audit each year. All of the required residents’ records are kept, but an inspection of staff records held at the head office found that staff records as required by Schedule 2 of the Care Homes Regulations 2001 were not available in all staff files. The organisation had given an undertaking that all of the staff records, in accordance with Schedule 2 will be available in the home for inspection, commencing with records relating to all newly recruited staff. Records relating to existing staff will also be available in the home, and the Commission has set 31 December 2005 as a timescale for this to be implemented. All of the necessary health and safety checks are carried out and a safe environment is provided for the residents. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sylvan Road (16) Score 3 4 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 2 3 X DS0000025929.V249828.R01.S.doc Version 5.0 Page 25 NO 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 YA20 Regulation 13 Requirement Medication must be administered directly from the containers provided by the pharmacist. Timescale for action 31/10/05 2 YA23 13 3 YA33 18 Access to the safe must be 31/10/05 restricted at all times with a designated key holder on each shift. Regular staff meetings must take 31/03/06 place, a minimum of six per year. The registered persons are required to ensure that their recruitment procedure is robust and in line with regulation. The registered persons are required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001. For new staff, before appointment. The registered persons are required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001. For existing staff an extended period for compliance has been given. DS0000025929.V249828.R01.S.doc 4 YA34 19 30/11/05 5 YA41 17 30/11/05 6 YA41 17 31/12/05 Sylvan Road (16) Version 5.0 Page 26 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 Refer to Standard YA19 YA23 Good Practice Recommendations It is recommended that the practice of community opticians visiting the home be reviewed and that is appropriate residents visit their local optician. It is recommended that cash is checked as part of the handover procedure and therefore any errors or discrepancies can be quickly identified and addressed. Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Sylvan Road (16) DS0000025929.V249828.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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