Inspection on 31/08/07 for Therese Care Home

This inspection was carried out on 31st August 2007.

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

Other inspections for this house

Therese Care Home 16/03/07

Therese Care Home 28/11/06

Therese Care Home 27/06/06

Therese Care Home 16/01/06

Therese Care Home 28/06/05

Therese Care Home 09/12/04

Therese Care Home 29/07/04

Therese Care Home 03/12/03

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 Therese Care Home 144 Gassiot Road London SW17 8LE Lead Inspector Davina McLaverty Unannounced Inspection 31 August 2007 10:00 st Therese Care Home DS0000010231.V346461.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 Therese Care Home DS0000010231.V346461.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. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Therese Care Home Address 144 Gassiot Road London SW17 8LE 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) 020 8767 5407 Ms Iolenta Castelino Ms Iolenta Castelino Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide accommodation and care for one named service user over the age of 65. The category MD(E) must be removed once this service user is no longer accommodated. 16 March 2007 Date of last inspection Brief Description of the Service: Therese Care Home accommodates three residents with a mental disorder. The home is a two-storey terrace house with a small garden to the front, and larger garden to the rear of the home. It is situated close to the busy shopping centre of Tooting Broadway and so within easy access of the public amenities and transport links served by the area. The home is owned and managed by Ms Iolenta Castelino, the Registered Person. The weekly fee charged is £350 per week. Therese Care Home DS0000010231.V346461.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 and included a visit to the service by a Regulation Inspector on the 31st August 2007. Prior to the site visit we wrote to the manager to complete a quality self-assessment, which was returned to the Commission. When we visited we spoke to two of the three people who live at the home. We also spoke to the staff member on duty and the manager by telephone during and at the end of the inspection. We also looked at records, observed what was going on and looked at the environment. At the end of the inspection questionnaires were left at the home for staff and residents to complete. We also sent questionnaires to six health care professionals. Following the inspection the inspector met at the Commissions office with the home’s manager. Questionnaires were received from one person who lived at the home and two health care professional. Information from all these sources has been used to help inform the judgements in this report. What the service does well: What has improved since the last inspection? There have been some improvements in the record keeping generally within the home although there is still room for improvement. Files were seen to be better organised and therefore accessible during the inspection. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide sets out basic information about the home. The Service user guide requires some amendments. An assessment procedure is in place to ensure that the home can meet the residents assessed needs. EVIDENCE: The home has a Statement of Purpose and Service Users Guide. The Service user guide requires minor amendment to fully comply with the regulations e.g. stating the organisation’s rule that the kitchen is locked at night. This is still outstanding from the previous inspection. The people living at the home have all lived there for several years and copies of their original assessments are on file. The home has an admission procedure and the manager is fully aware that any new person must only be admitted after a comprehensive assessment has been carried out, which will involve the views of all professionals involved with the person, as well as the person them self. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 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. 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. Care plans and risk assessments are in place but could be more ‘person centred’, stating how people’s individual needs are to be met. Evidence of reviews and residents involvement was seen. EVIDENCE: Two care plans were examined. The inspector observed little change in them since the previous inspection. One person spoken to said that they were aware of their care plan and involved in various meetings regarding it. This person had signed their care plan and there was evidence of the plan being reviewed by the care manager. The staff member on duty when spoken to, was aware of the care plans, but stated that the manager wrote and reviewed them. One Social Worker in their questionnaire stated in response to the question “Does the home work in partnership with you when required?” by stating, “ Yes e.g. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 10 joint visit with manager and client and myself to day care provider. We worked together to maintain the client in day care”. The inspector’s view, as stated at the previous inspection, is that the care plans were still quite basic and lacked detail. However, the inspector notes that the feedback from professionals involved with their clients is that their outcomes are being met and that the care provided is good and meets the persons assessed need. Also, the person themself stated that they felt well supported. The inspector noted that one plan focused on the person’s physical disabilities, which included social, cognitive, emotional and skills, as well as their individual needs, wishes and desires, but did not state how their needs were to met by staff. A current enhanced health and social care plan was in place, as well as a Care Plan Approach (CPA) Risk Assessment. The inspector noted that decisions made at the Care Plan Approach were not seen to have been integrated into the home’s care plan. The manager reported that due to the size of the home, staff are aware of these review meetings and their outcomes, which are discussed at staff meetings. The staff member on duty confirmed this to be the case. Both the Care Plan and the CPA were signed by the resident. As stated above, people living in the home sign their care plans and have agreed to various house rules. e.g. medication being given by staff, the kitchen being locked at night and staff supporting them to manage their money. In previous discussion with the manager she has stated that these restrictions in place are as a result of health and safety and are to prevent self –harm or self neglect and ultimately, have benefited the people who live there. Risk assessments are in place, but they are basic and mainly focus on keeping people who use the service safe, rather than encouraging a degree of risk to be taken. There was no written change in their risk assessment since 2003. One person said to the inspector that they would like to go out more either on their own, or to more groups. However, staff and his social worker did not feel that this was something he should do and although he clearly had mixed feelings about the restrictions placed on him, he had decided not to pursue it further. The person said that they liked living at the home and got on well with all the staff and the other two residents and would not want to move. The person was aware of his rights to complain and has seen the home’s complaints procedure. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff continue to be aware of the need to support the people who live there to develop their skills, including social, emotional, communication, and independent living skills, however, the process could be improved. Residents must be further encouraged and supported to access the community. Opportunities are available for residents to be involved in the shopping and the preparation of meals, however, a record must be made of all meals prepared. EVIDENCE: The inspector met two of the people living in the home both of whom were appropriately dressed. A relaxed atmosphere was apparent with warm exchanges taking place between staff and residents. One person was watching television and said that they liked to spend all day watching TV. The other person was drawing, which they said they enjoyed and would often go up to Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 12 their room to listen to music. The back room was adequately furnished with three comfortable chairs, dining table and chairs, a television and music equipment. The inspector spoke to both persons together. Both residents were positive about the staff and their interaction with them. One person appeared more contented at the home than the other, but overall both said that they liked living in the home. One resident said he spent the day watching television. In discussion with the staff member on duty they also confirmed that numerous attempts are made to encourage the resident to do other things, but they were not interested, stating that his choice must be respected. The other resident said he wanted to go out more but realised that it was difficult, as staff did not allow him to go out on his own unless it was to his therapy group when a cab picked him up and dropped him back. The person confirmed that staff do take him out occasionally. Record of this was seen in his care plan and daily log. He stated that he also goes out shopping with the manager for personal belongings as well as household items. This resident completed a questionnaire and raised no concerns. In discussion with him, he said that he liked the home. He currently spends a lot of time drawing in the home and several of his pictures were on the walls. The inspector was informed that the third resident at the home attended mass daily and does not return home until teatime. This is a regular occurrence for this resident who is able to go out to known places. Residents appeared to disagree as to whether they had access to the lounge next door, one said they did, the other said it was a staff room. The staff on duty reported that residents could go in there if they wished and that it is a quiet area for the residents, but does double up as the sleep - in room for staff. One persons living at the home said that visitors are welcomed and one person said that they occasionally received visitors. People living in the home said that they could help themselves to drinks in the kitchen, although one said that he never did, as staff always offered him. Meals tended to be prepared by staff, although one person said that they could access the kitchen when they wanted during the day to prepare snacks of their choice. A record of meals prepared is made. The record showed that all three residents tend to eat the same meal. In discussion with the staff member on duty she stated that this is not always the case. All meals cooked should be recorded in the menu book. The kitchen remains locked at night. A risk assessment dated October 2003, states that this is due to ‘health and safety regulations’, due to absent staff; however, the home is now staffed at night. There is no evidence that this has been reviewed since 2003, or what the health and safety reasons are. There was also no evidence in the care files that any resident would be at risk if the kitchen were not locked. However, the inspector noted that people resident in Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 13 the home have agreed to this practice. One person said that they had no need for anything from the kitchen at night. This practice should be included in the home’s Statement of Purpose and Service User Guide. Both care professionals were very positive about the home and how they worked with the people who lived there. One stated the following, “staff are very good at providing a high level of support without being intrusive and are also able to be empowering to clients. Staff advocate well on behalf of the client. The client thrives in the “normalising” setting of a small care home that feels like a “normal “ home to him.” The other stated, “ empathy and understanding of this persons need. The ability to work with him to help himself where other hostels have found it impossible”. Therese Care Home DS0000010231.V346461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to health care services both within the home and in the local community. A medication procedure with guidelines for administration in place, although closer monitoring is needed. EVIDENCE: The care plans indicate that the residents generally attend to their personal care needs, although prompting e.g. personal hygiene is given. The staff member stated that residents have access to baths when they wanted and appropriate encouragement would be given where residents were seen to be neglecting their personal care. A record is kept of appointments with GPS, dentists and CPN’s, and care managers. Both residents reported that staff would accompany them on Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 15 appointments to health professionals. One GP in his questionnaire stated, “ Staff are very aware of persons particular health need and social needs.” “ very aware of this persons disability and very appropriate in their management”. Comments also made included “ I cannot emphasize strongly enough how beneficial this placement has been”. The other professional stated that in their view the home meets their clients health and social care needs “ the client is well maintained at the home” “good communication –I am phoned regularly about any problems or changes”. The home has a medication policy. Medication Administration sheets (MAR) with the exception of a day’s gap on one resident MAR sheet where it was not clear whether the medication had been dispensed. On checking the daily log confirmation was seen that the medication had been given but that the staff member had omitted to sign the sheet. Prescribed cream seen in the medication cabinet for one resident was not being given but on checking the medication record was due to be returned to the pharmacy as it was no longer required. Staff receive external training in dispensing and the administration of medication. The home must ensure that a system is put in place where gaps are identified, that appropriate action is taken and that medication due to be returned to the pharmacy is clearly labelled. Therese Care Home DS0000010231.V346461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure at the home. Safeguarding of adults guidelines have been updated to ensure that appropriate action will be taken in the event of abuse being identified or alleged. EVIDENCE: The home has a complaints policy that provides suggestions of different people to whom a resident can complain, such as the home manager, social worker or the CSCI and then states the steps that will be taken. No complaints had been made since the previous inspection. Staff had all received training in protection of vulnerable adults and evidence of this was seen on staff files examined. Wandsworth Inter - agency guidelines were available in the home. There is no policy or procedure at the home to detail the practices regarding resident’s monies and financial affairs. The current arrangement for one resident is that his personal allowance is paid into the Managers account and she provides him with a daily allowance. However, despite the resident agreeing with this practice, this should be reviewed with the resident and his social worker and an account opened in the resident’s name. The staff member on duty stated that the manager deals with resident’s money. The other two residents have their own accounts and are sole signatories. The Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 17 manager looks after their bank books. Again, both residents have signed a statement to state that they are in agreement with this arrangement. The Social Worker of one resident is also aware of this and maintains that this is practical given the needs of their client. In discussion with the home’s manager she stated that the resident personal allowance, which goes into her bank account is because the resident cannot open a bank account in their name due to a lack of documentation e.g. birth certificate or passport to open an account. She also stated that the resident’s brother is happy with this arrangement as is the social worker and resident. However, this arrangement musty be reviewed and clearly stated on the persons file with all people involved signing their agreement to this arrangement if it is to continue. Therese Care Home DS0000010231.V346461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and well decorated throughout. EVIDENCE: The home is well decorated, bright and clean. Residents stated that on the whole they were satisfied with their bedrooms. Each bedroom was observed to be adequately maintained, and varied in degree of personalisation. Both staff stated that staff respect their privacy when in they are in their room and will knock/ call them if they want them. Whilst inspecting the premises the inspector noted that mice poison had been put down in the front lounge. The staff member said that there were field mice in the garden and that one had got into the house. The staff member stated Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 19 that this was some time ago and that the tray of poison was a precautionary step as the back door is often left open. The inspector noted that one of the floor tiles in the kitchen was cracked and loose and should be replaced. At the previous inspection a new door had been installed in the rear lounge. This was observed to have a crack in the glass. This door was also wedged open, as were all doors throughout the home. The manager was informed that door wedges must be removed and consideration given to installing magnetic doorstops. The Registered Person stated that the fire officer had agreed to using the type of door wedge at the home. Therese Care Home DS0000010231.V346461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment checks are in place. Staff development and training have improved. EVIDENCE: Criminal Bureau checks were seen to have been carried out for all staff. References for the newest staff member was brief and included a character reference. A job description was seen and an employment contract was in place as well as a photograph of the staff member. A staff training programme was seen to be in place and the inspector noted that more effective monitoring is taking place to ensure that all staff have undertaken statutory training and refresher courses held. In view of the needs of the residents at the previous inspection it had been required that staff receive additional training in specific areas in relation to residents care needs. The manager stated that she did not feel that staff needed training in the Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 21 identified areas as she maintained that suicide and self- harm was not concern with the current residents. None of the current staff employed hold an NVQ level 2 in care. The manager stated that her staff were not forthcoming in wanting to undertake the NVQ in care qualification, but enjoyed their work and attending one-day courses. However, in view of the national minimum standards and regulations the recommendation made at the previous inspections remains. The staff member spoken to was positive about working at this home and stated that she felt supported by her colleagues as well as by the manager who was hands on and always contactable. This person also stated that she got on well with the residents who she saw as an extension of her own family. Staff meetings were also taking place with a brief record being made. Therese Care Home DS0000010231.V346461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is aware of the need to promote safeguarding and health and safety in the home, however, systems in place were not always seen to be up to date. EVIDENCE: As stated the manager has yet to undertake the ‘Registered Managers Award’, in completing the AQAA. She stated that in her view, she has run the home successfully for seventeen years and maintains that despite changes in legislation, the current service users, their families and health care professionals have collectively found our services at Therese care “ exceptional”. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 23 She also stated that not having the ‘registered managers award’, has not hindered me in doing a through efficient and appropriate management of the home” However, as stated earlier, this requirement still stands due to the regulations and national minimum standards. In discussion with the manager following the inspection, she stated how difficult it is for a small home to embrace all the changes there has been and that she has found it difficult working with numerous inspectors as inspectors have all said slightly different things to her regarding her home. This was noted. The roster seen identified one staff member on duty per shift. On the day of the inspection the roster required amending to reflect the correct name of the person working. Where two staff cover a shift or part of a shift due to a residents needs this should be on the roster along with the name of the staff member who sleeps in. The inspector saw copies of questionnaires completed by residents regarding the services at the home that they receive. The quality assurance should also consider the views of relatives and other stakeholders e.g. care managers and comments incorporated into a brief report concluding with any steps that need to be taken as a result of their comments. Health and safety records were sampled. Hot water checks are not carried out as the manager has stated that residents are not at risk of scalding themselves and have signed to say that they are aware of the risks Regular fire drills were seen to be taking place regularly. The Fire alarm system was last serviced in February 2007 An accurate record must be kept of the fridge and freezer temperatures as this was seen not to be the case on the day of the inspection when both records were inaccurate with the fridge and freezer temperatures seen by the inspector. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4(1)(c) Sched 1 Requirement The Service User guide must detail restriction imposed on residents by the locking of the kitchen door at night. A record must be made and maintained of meals served in the home. The manager must ensure that a system is in place to evidence on the Medication Administration record where medication has not been signed as given. Also medication to be returned to the pharmacist must be kept separately in the medication cabinet. The Registered Manager must undertake the Registered Managers Award or equivalent. (Timescale of 31/03/07 not fully met) Timescale for action 30/10/07 2 3 YA17 YA20 Sch4 (13) 13(2) 20/09/07 30/09/07 5. YA37 9(2)(b)(I) 30/03/08 6. YA39 24 The quality assurance system 30/03/08 must seek the views of relatives and other professionals/stakeholders and be collated detailing any changes to be put in place as a result of the feedback received. DS0000010231.V346461.R01.S.doc Version 5.2 Page 26 Therese Care Home 7. 8 9 10 YA42 YA42 YA33 YA42 13, 23 13(4) (c) 17 17(2) Sch 4 (14) The cracked tile in the kitchen must be replaced. 31/12/08 An accurate record of the fridge 30/09/07 and freezer temperature must be maintained. The roster must reflect 30/09/07 accurately staff working each shift. A comprehensive fire risk 30/10/07 assessment must be put in place to ensure the safety of residents and staff in the event of a fire. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4. 5 6 Refer to Standard YA6 YA13 YA23 YA32 YA42 YA42 Good Practice Recommendations Care plans should be more person centred and relevant to the service and the residents. Residents who wish to participate in the community must be encouraged and supported. A review of resident’s finances with interested parties should be undertaken and clear records maintained. The Registered Person should ensure that all care staff at the home undertake the NVQ level 2 in Care qualification. The cracked pane of glass in the fire door should be replaced. The home should not use door wedges but give consideration to installing an electromagnetic doorstop that is linked to the fire alarm system, which will ensure that fire doors are automatically in the event of a fire. Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Therese Care Home DS0000010231.V346461.R01.S.doc Version 5.2 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. 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