Inspection on 11/05/06 for Therapia Road, 26

This inspection was carried out on 11th May 2006.

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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Therapia Road, 26 27/09/05

Therapia Road, 26 27/06/05

Therapia Road, 26 14/12/04

Therapia Road, 26 10/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Therapia Road, 26 East Dulwich London SE22 0SE Lead Inspector Lisa Wilde Unannounced Inspection 11 & 28th May 2006 09:00 th Therapia Road, 26 DS0000060225.V294922.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 Therapia Road, 26 DS0000060225.V294922.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. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Therapia Road, 26 Address East Dulwich London SE22 0SE 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) 0208 693 3822 lu@odyssey-csft.org www.odyssey-csft.org Odyssey Care Solutions for Today Lu Helen Cope Care Home 5 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: The home is in a residential area of East Dulwich, close to public transport routes and local shops, cafes, pubs and a Post Office. The property is a large semi-detached house with a large garden and patio area to the rear of the house. The home provides care for five people with learning disabilities who have shared the home for many years. There were no vacancies at the time of the inspection. The service user part of the fees for a place at this home are £62.35. There are contributions towards transport of £4.25 if on the lower rate of Disability Living allowance or £11.06 if on the higher rate of Disability Living Allowance. The home discusses the reports of the Commission’s inspection in service users meetings and tells relatives that an inspection has occurred. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day at the home in May 2006. The inspector met with all but one of the service users but as they all communicate in different ways other than speaking, the inspector tried to contact relatives of all service users after the inspection to find out what they thought of the home. The inspector could only get in touch with three sets of relatives in the two weeks following the inspection and then had to write the draft report. Relatives were generally happy with the service. Comments from them were “He loves it there and staff are very good”, “He’s always laughing when I call him on the phone”, “It’s very homely, comfortable and clean”, “Staff are very helpful and the manager is very approachable” and “The manager is excellent, I can talk to her and she makes things clear and will always look into things for me.” Relatives did have some areas that they thought could be improved and these are mentioned in the main part of this report. This is a very good service. The manager and staff spend a lot of time finding out what service users want and need and find creative ways to make sure they are happy. The main problem in the future is going to be that both the manager and the deputy manager will be leaving over the summer and both these people have been at the home for a long time. This will be a big change for everyone and the organisation will have to plan ahead very well to make sure that there are not too many problems for service users when this happens. What the service does well: The areas assessed at this inspection showed that the home makes sure that: • although the work is not yet finished the home provides useful information for service users in ways they can understand. • service users’ plans are detailed and there is lot of information in them that tells staff how they should support service users day-to-day. • risks are assessed and plans put in place to make sure that service users are protected from harm while being supported to go out and live as independent lives as possible. • staff at the home keep trying to find different ways to communicate with service users and find out what they want. • service users are supported to go out during the day and in the evenings. They have individual programmes in place that develop their skills and aim to make them as independent as possible. • service users are supported to keep in touch with their families and visit them as often as possible. DS0000060225.V294922.R01.S.doc Version 5.2 Page 6 Therapia Road, 26 • • • • • • • • • service users are offered healthy and varied meals. staff at the home support service users with their personal care as they choose and service users are taken to regular GP and clinic appointments to make sure that they stay as healthy as possible. although service users at this home could not take their own medication, staff give them their medication safely and record that they have done this properly. complaints are taken seriously and recorded so that they can be looked at every few months to make sure that the home is improving in ways that service users want. there is some decoration that is planned to take place soon but other than that the home is comfortable and clean throughout with service users being involved in how the place is decorated and which furniture is bought. staff are well trained and all have the qualifications they need to do the work at the home. the home is well run and the managers know what they are doing and how staff should meet service users’ needs. the organisation does undertake reviews of care and aims to include the goals of service users in their plans for the home. the health, safety and welfare of service users are protected. What has improved since the last inspection? What they could do better: The areas assessed at this inspection showed that the home must do more to make sure that: • procedures that are in place in the borough for protecting vulnerable adults are always followed properly and staff are fully trained in the issues around abuse. • more evidence is gathered about whether there are enough staff on duty at all ties to meet all service users’ needs. • the home makes sure that service users views (or the views of their families) are part of all development at the home. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 7 • there is a complete system in place that makes sure that all areas of work at the home are assessed regularly and then plans are put in place to make things better for service users. 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. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 8 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 Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Although the work is not yet finished the home is providing useful information for service users in formats they can understand so that they can know what rights they have at the home and what they can expect while living there. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the Service User Guide covers all areas required by Regulation 5 and Standard 1. The home has been working with a media organisation to create videos, DVDs and computer programmes for four of the service users to explain all the issues in the service users guide. This work is due to be completed by the end of July. The speech and language advice for the fifth service user has been that they would find written document as useful as any other media so the staff are working on the original guide with them. All service users have lived together at this home for around fifteen years. It would not be useful to assess the home’s pre-admission procedures because of this. The organisation has a standard procedure in place around admissions and assessments. Therapia Road, 26 DS0000060225.V294922.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ plans are detailed and there is lot of information in them that tells staff how they should support service users day-to-day. Risks are assessed and plans put in place to make sure that any risks are minimised or managed so that service users are protected from harm while being supported to go out and live as independent lives as possible. Staff at the home keep trying to find different ways to communicate with service users and find out what they want. They give service users the information they need to make as many decisions they can and have as much choice as possible. EVIDENCE: The inspector looked through two service user files and found detailed guidance around how to support service users and risk assessments in place with staff action to manage or minimise risks. Reviews take place every six months to look at setting goals for the service users for the next six-month period and longer-term goals. The reviews showed that the home takes action Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 11 to make sure that the last meetings goals are met b the following meeting. There are plans in place called Training in Systematic Programmes (TSIs) to help service user develop skills and become more independent. The only problem with the information in the files was that the support guidelines had not been reviewed since 08/05 or in some cases 01/05. The registered manager said that they are reviewed after every six-monthly meeting but that they have not been recorded. (See Requirement 1) The registered manager talked about the different systems in place to ensure that service users are part of the home and make their own decisions as far as possible. As mentioned earlier the home is doing creative work with video and other media to communicate with service users and find out what they want. Staff are trained in Makaton and learn new signs every week. All service users have the same advocate, a woman from a local agency but they do not have advocates who share some of the same disabilities or, in some cases their ethnic and cultural background. (See Requirement 2) There are a number of incidents that are sent through to the Commission at this home but from discussion and from looking through files the inspector was satisfied that these incidents were due to the conditions and behaviours of the service users and the staff at the home are doing they can to manage or minimise the risks and incidents. There are clear procedures in place for staff to follow when incidents take place. Therapia Road, 26 DS0000060225.V294922.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, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to go out during the day and in the evenings. They have individual programmes in place that develop their skills and aim to make them as independent as possible. Service users are supported to keep in touch with their families and visit them as often as possible. Service users are offered healthy and varied meals. EVIDENCE: As mentioned earlier there are TSIs in place that allow staff to support service users to develop their skills. These have been put in place following specialist advice from external professionals. The registered manager talked about the work that the home is doing around communication issues in order for service users to get more from their experiences in the home and outside of it. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 13 Each service user has an individual weekly plan that shows that they attend day centres and go out in the local community during the day and in the evening and weekends. There are activities that take place in the home. The registered manager talked about how they are introducing an exercise programme where staff offer 1:1 support every day with each service user to go for a walk or do some other physical activity. The registered manager has some concerns about the level of staffing at the home and how it does not allow service users to do all they could do. This issue is discussed further under Standard 33. The activity programmes showed that service users have a varied and fulfilling programme. Service users are supported to visit and keep in contact with their families and friends. There are weekly menus kept at the home that showed a variety of meals being offered. The registered manager talked about how the home has introduced a programme of five portions of fruit or vegetables every day and is working on taking photographs of food and meals so that service users have more meaningful choices with their menus. Therapia Road, 26 DS0000060225.V294922.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff at the home support service users with their personal care as they choose and service users are taken to regular GP and clinic appointments to make sure that they stay as healthy as possible. Specialist professionals in the community treat particular conditions that the service users have. Although service users at this home could not take their own medication, staff give them their medication safely and record that they have done this properly. EVIDENCE: The inspector looked through files, medication records and stocks of medication held in the home and found no problems with any of the systems that are in place to support service users with personal, health care and medication issues. Detailed plans are in place to tell staff how to support service users in the way they choose and service users are regularly taken to the GP for appointments. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 15 Reviews state that the organisation is currently drawing up Health Action Plans for service users in line with government guidance. This issue will be assessed at the next inspection. Therapia Road, 26 DS0000060225.V294922.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 judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and recorded so that they can be looked at every few months to make sure that the home is improving in ways that service users want. The procedures that are in place in the borough for protecting vulnerable adults have not been followed properly recently and staff are not fully trained in the issues around abuse. This could mean that service users are not fully protected from harm. EVIDENCE: The inspector examined the complaints book and found that complaints are recorded and taken seriously. However one issue had been dealt with as a complaint when in fact it was an allegation made against a member of staff. The registered manager had been told to investigate the issue by her line manager and it had all been recorded in the complaints book instead of a confidential file. No contact had been made with the borough’s adult protection services. The inspector spoke with line manager who said that generally they understood the need to contact social services but in this instance had made a mistake. (See Requirement 3, 4 & 5) There was a previous recommendation that the Registered Manager should ensure that the complaints records show whether the complainant was satisfied with the outcome of the complaints investigation. This is not yet being done. Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 17 Staff have not attended training around abuse or protection of vulnerable adults although three people have done some of it as part of their induction training. (See Requirement 6) The staff team had discussed the organisation’s adult protection policy in their last team meeting. The registered manager has recently reminded staff that the procedure when finding and unexplained bruise or mark on a service user is to take them to the GP who will decide what it has been caused by. Therapia Road, 26 DS0000060225.V294922.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is some decoration that is planned to take place soon but other than that the home is comfortable and clean throughout with service users being involved in how the place is decorated and which furniture is bought. The garden at the back of the house is large and well taken care of. EVIDENCE: There was a previous requirement that the Registered Provider must ensure that all repairs and decoration to the premises are completed within reasonable timescales. There has been a significant amount of work done on the home since the last inspection. The decking in the garden has been replaced, as have the worktops in the kitchen. The bathroom that had previously been difficult to use because of being too small has been knocked through into the toilet next to it making a much larger bathroom and there has been some decoration of communal areas and service users’ rooms. There is still work needed in the hallway and communal areas but the registered manager said she had put this off as it would have meant the service users moving out of the home and this Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 19 needed to be planned well. Although the home is still in need of general decoration the registered manager felt that she had been given the money she needed in her budget and had already started getting quotes for the work. On the tour of the building the home as clean and hygienic and there were no major problems. The home is comfortable throughout and service users’ rooms have been decorated in the way they choose unless there is some practical reason why they cannot have what they want e.g. one service user has had specially made wardrobes and sink area fitted to ensure their safety. Therapia Road, 26 DS0000060225.V294922.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): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and all have the qualifications they need to do the work at the home. This means that service users are cared for by people who understand what they need and know how to support them. It is not entirely clear whether there are enough staff at this home to meet all of service users’ needs. The organisation must do more work to provide the Commission with more evidence. EVIDENCE: All staff either hold or are undertaking the NVQ 2 or 3 in Care with one newer member of staff having just applied for it. The deputy manager is doing the Level 4 and the registered manager hold the NVQ Level 4 in Management and Care and is currently undertaking the Assessors qualification. There was a previous requirement that the Registered Individuals must ensure that staffing levels at the home are increased to ensure that service users are at all times provided with sufficient care and support to maintain their own health, safety and welfare (both in and outside of the home) and that all service users are protected from physical harm from other service users. This had been met shortly after the last inspection and the inspector was no longer Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 21 concerned that service users are at risk from other service users due to insufficient staffing levels. As mentioned earlier the registered manager believes that there are not enough staff to fully support service users. Currently the rota allows for two staff on duty at all times with five shifts a week being three members of staff. The registered manager stated that she believes there should be three members of staff on duty at all times to fully meet the needs of service users given that two service users need 1:1 support as stated in their care plans. The inspector spoke with the line manager of the service who stated that compared to other service the level of activities that service users at this home take part in is a lot higher. The formula that the Commission uses as a guide to staffing shows that the home would benefit from an increase in staffing. (See Requirement 7) The organisations’ recruitment records are not held in the homes and the inspector will be going to their head office to assess the records for all the homes at a later date. The Commission now has a form that has to be held on file for all staff which is a form of checklist for recruitment records and which is signed by one of the Registered Individuals. (See Requirement 8) The registered manager talked about the recent management training that all managers in Odyssey undertook which was very useful for them. Staff at the home have recently all done (or are about to do) equalities and diversity training and the managers will be attending training around management of those issues. Staff have also recently done training around risk assessment, accountability and duty of care as well as receiving training around legislation and medication training from the local pharmacist. Therapia Road, 26 DS0000060225.V294922.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and the managers know what they are doing and how staff should meet service users’ needs. This means that staff are clear about what they have to do and service users are well cared for. Although the organisation does undertake reviews of care and aims to include the goals of service users in their development plans for the home, the home does not make sure that service users views (or the views of their families) are part of all development at the home. There is not a complete system in place that makes sure that all areas of work at the home are assessed regularly and then plans put in place to make things better for service users. The health, safety and welfare of service users are being protected by the effective use of procedures and regular monitoring at the home. EVIDENCE: Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 23 The registered manager has been at this home for fifteen years and has all the necessary qualifications to undertake the post. She continues to do training to expand her knowledge and throughout the inspection showed her awareness of issues that affect service users and how the staff should meet their needs. As mentioned in the summary of this report service users’ families were very happy with the manager. There is about to be a difficult period in the home soon in that both the registered manager and the long-term deputy manager will be leaving at around the same time. The registered manager talked about how she is trying now to make sure that staff are aware of all the systems in place so that they can run them effectively while new managers settle. The inspector will be talking with the line manager of this service to find out how they intend to manage this potential problem. The registered manager spent some time discussing equalities issues within the home and how they bring those issues into discussions with staff and plans to meet service users needs. The inspector was satisfied that the registered manager was able to make sure that these issues are brought up and addressed throughout the home. There was a previous requirement that the Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan with a previous recommendation that the Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. The home does not currently have in place a system that makes sure the home can monitor and develop all areas of the work. The organisation does have a system in operation that looks at service users goals and feeds those into a quarterly action plan but that is yet sufficient to be called the comprehensive quality assurance system that meets this standard. The organisation does conduct the monthly visits to the service by an external manager or service manager but the Commissions records showed that these have not been sent through to the Commission as required for the previous few months. A survey about what people think of the home is about to be sent out to service users’ families and other professionals who work with the home. (See Requirements and 9, 10 & 11 and Recommendation 2) There was also a previous recommendation that the Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home, which is repeated here. The home states that they tell relatives about the Commission’s inspections but two relatives said that they are not made aware when there has been an Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 24 inspection of the service by the Commission and are not told when the reports are available. (See Requirement 12) Two relatives said that although generally communication was good between them and the home, they didn’t always get told about things that happened to their relatives quickly enough. They said that they did get information but sometimes it was two or three days after the event when they used to be told about things in writing within twenty-four hours of the event. (See Requirement 13) The inspector checked through all the health and safety document and systems and found all the required documents to be in place and all checks to be carried out as required apart from the fact that some weekly fire tests had been missed over the past few months. (See Requirement 14) Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 25 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 2 X X 2 X Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 (2) Requirement The Registered Manager must ensure that support guidelines are reviewed at least every six months or as service users’ needs change. The Registered manager must ensue that staff research agencies and individuals who can advocate or offer peer support for service users and who share some of the same culture, heritage and disabilities. The Registered Individuals must ensure that the borough’s adult protection procedures are followed every time an allegation of potential abuse is made. The Registered Individuals must ensure that a separate record of allegations of abuse and any investigations is held and stored confidentially. The Registered Individual must ensure that the Commission is informed of any allegations of potential abuse. The Registered Individuals must ensure that all staff undertake training around abuse and protection of vulnerable adults. DS0000060225.V294922.R01.S.doc Timescale for action 31/07/06 2. YA7 12 (b) 30/09/06 3. YA23 13 (6) 30/06/06 4. YA23 13 (6) 30/06/06 5. YA23 13 (6) 30/06/06 6. YA23 13 (6) & 18 (1) (c) (i) 30/09/06 Therapia Road, 26 Version 5.2 Page 27 7. YA33 18 (1) (a) 8. YA34 19 (1) (b) 9. YA39 12 (3) 10. YA39 24 11. YA39 26 12. YA39 24 13. YA39 24 The Registered Individual must conduct a full assessment of staffing levels at the home which includes detailed analysis of the number of hours service users need at particular times of the day to establish staffing levels necessary at the home to meet all service users needs. The results of this assessment must be sent to the Commission. The Registered Individuals must ensure that the Commission’s recruitment form is completed for all staff and held on file at the home. The Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan. Unmet requirement: Previous timescale 31/03/06 The Registered Individuals must ensure that an effective quality assurance system, based on seeking the views of service users, their families and others is in place in the home. The Registered individuals must ensure that the monthly visits carried out by senior managers are sent thought to the Commission as required. The Registered Manager must ensure that all relatives are told when there had been an inspection of the service and are told when the reports are available. The Registered Manager must ensure that relatives are made aware of incidents involving their relatives in a timely manner, usually within twenty-four hours DS0000060225.V294922.R01.S.doc 31/08/06 31/08/06 30/09/06 30/09/06 30/06/06 30/06/06 30/06/06 Therapia Road, 26 Version 5.2 Page 28 of the event. 14. YA42 23 (4) (c) The Registered Manager must ensure that the weekly fire system tests are carried out as required. 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The Registered Manager should ensure that the complaints records show whether the complainant was satisfied with the outcome of the complaints investigation. Previous recommendation. The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Previous recommendation. 2. YA39 Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 29 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 Therapia Road, 26 DS0000060225.V294922.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!