Inspection on 19/04/07 for Touchsky

This inspection was carried out on 19th April 2007.

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

Other inspections for this house

Touchsky 20/05/08

Touchsky 24/10/06

Touchsky 03/05/06

Touchsky 01/09/05

Touchsky 13/04/05

Touchsky 12/08/04

Touchsky 06/04/04

Touchsky 16/03/04

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 Touchsky 240/242 Odessa Road Forest Gate London E7 9DY Lead Inspector Rob Cole Unannounced Inspection 19th April 2007 10:00 Touchsky DS0000007250.V337113.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 Touchsky DS0000007250.V337113.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. Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Touchsky Address 240/242 Odessa Road Forest Gate London E7 9DY 020 8534 0035 020 8926 6560 touchsky8@btinternet.com 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) Mrs Florence Ndiedzei Muyambo Mrs Florence Ndiedzei Muyambo Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 Brief Description of the Service: Touchsky is a care home registered to provide support and accommodation to six adults with mental health issues. The home is situated in a quiet residential area of Forest Gate in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The home is privately run. Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 16/4/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present throughout the inspection. The inspection also included an examination of policies and other records, and a tour of the premisis. Overall, the inspector was pleased to note that there have been considerable improvements to the home since the previous inspection, and service users spoken to informed the inspector that they were happy with the level of care and support provided. There were however some issues that must be addressed, as highlighted within this report. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still some issues that must be addressed. The home must ensure that complaints are recorded and investigated as appropriate, and that care plans and risk assessments are comprehensive. Further, service users must be supported to access regular community based social and leisure activities in line with their assessed needs and stated preference. Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 6 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. Touchsky DS0000007250.V337113.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 Touchsky DS0000007250.V337113.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): 1,3,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users would be able to visit the home before making a decision as to move in or not, although written information about the home, including accurate information on fees payable, must be made available. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English. The Statement included details of the aims and objectives and of the organisational structure of the home. Since the last inspection both of these documents have been subject to review, and dated. However, the Statement of Purpose said that the fees for the home ranged from £500 to £1000 per week, but the contract for one service user said that their fees were £2074 per week, and the manager confirmed that this was the correct figure. It is required that information contained in the homes Statement of Purpose is accurate and up to date. The Service User Guide included details of the homes physical environment and a copy of the complaints procedure, and was in line with National Minimum Standards (NMS). Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 9 Contracts/statements of terms and conditions were in place for all service users. These include details of the rights and responsibilities of both parties and of fees payable. However, they do state what these fees cover, and what is extra, and this must be addressed. There have been no new admissions to the home since the previous inspection. The home did however have an admissions procedure in place. This stated that pre admission assessments would be carried out for any prospective service users, and that they would be given the opportunity of visiting the home before making a decision as to move in or not. Touchsky DS0000007250.V337113.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector believes that service users have control over their daily lives, however, the home must ensure that care plans and risk assessments are comprehensive. EVIDENCE: Individual care plans are in place for all service users. Plans around mental and physical health needs were of a good standard. Needs have been clearly identified, and plans were clear and comprehensive. However, care plans were less detailed around other needs, for example around social and leisure needs, or cultural needs, and it is required that comprehensive care plans are in place for all service users, setting out how the home can meet all their needs. Plans are drawn up with the involvement of the service user, their keyworker and the homes manager. There was evidence that plans are subject to regular review. At the last inspection a requirement was made that care plans include service Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 11 users responsibilities for housekeeping tasks within the home, this has not been met, and is therefore repeated in this report. Where risk assessments for service users are in place, they are of a satisfactory standard. They cover risks associated with smoking and with mental health issues. However, there were significant areas of risk that have been highlighted, that have not been satisfactorily risk assessed. For example, one service user has a history of jumping out in front of moving traffic, but there was no risk assessment in place around this. Further, not all risk assessments have been subject to regular review, and this must be addressed. One service user has a history of violent and aggressive behaviour towards other people. However, there were no guidelines in place around how the home should manage this. It is required that individual guidelines are drawn up for the management of challenging and aggressive behaviours. Through observation and discussion there was evidence that service users have control over their daily lives. For example service users are able to get up and go to bed at a time of their choosing, choose their own clothes to wear etc. On the day of inspection one service user requested staff support to go out, this was seen to be arranged. The inspector was pleased to note that since the previous inspection service users are now involved in the day to day running of the home, and that this involvement is now recorded. For example, the home’s garden has recently been renovated, including a new fountain, which service users chose. Regular service user meetings are held, these evidenced discussions on menus and general house issues. Since the last inspection the home now has a policy in place on confidentiality. This makes clear under what circumstances a confidence may be broken. Confidential records are stored securely, and service users now have access to their own records. Touchsky DS0000007250.V337113.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users are supported to live valued lives, however, more attention needs to be provided to the provision of community based social and leisure activities. EVIDENCE: No service users are currently involved in any formal employment or educational opportunities. Service users spoken to confirmed that this was in line with their wishes. In house service users have programmes in place around developing daily living skills, such as around laundry and cooking skills, to help develop their independence. As stated, these programmes must be detailed within their care plans. Service users have regular access to the community, visiting local shops, banks and hairdressers etc. Service users use public transport, including buses Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 13 and trains. A priest occasionally visits the home and spends time with service users. The home keeps records of activities, these indicated that service users regularly go for walks, to cafes and shops. However, as at the last inspection, it was found that service users have only limited access to community based social and leisure activities. For example, the homes manager informed the inspector that one service user likes to go swimming, to the theatre, the cinema and on day trips. The service user confirmed this. Yet there was no evidence that any of this has taken place this year. It is required that service users have access to a variety of community based social and leisure activities, in line with their assessed needs and stated preferences. In house service users have access to TV, video and music. The home organises occasional parties, for example to celebrate birthdays, and BBQ’s. Service users are able to maintain contact with their families, and are able to visit them in their own homes. There is a visitors policy in place, and visitors are welcome at any reasonable time. Service users have access to a telephone which they can use in private, and are given their own mail to open. Records are maintained of menus, these evidenced that service users are offered a varied, balanced and nutritious diet. Service users spoken to informed the inspector that they are happy with the food provided, and that they are given a choice of meals, which are served in sufficient quantities. The inspector sampled the food on the day of inspection, which appeared appetizing and nutritious. Fresh fruit was available, and service users were observed to help themselves to drinks and snacks throughout the day. The kitchen was clean and tidy, and food was stored appropriately. Fridge and freezer temperatures and checked daily. Touchsky DS0000007250.V337113.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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is generally able to meet the health and personal care needs of service users. EVIDENCE: The home provides limited personal care to service users as required, and will encourage and prompt service users to manage their own personal care as appropriate. All service users are registered with a GP. The home maintains records of medical appointments, including details of any follow up action required. These evidenced that service users have access to relevant health care professionals as appropriate, including CPN’s, opticians and dentists. The home has a comprehensive medication policy in place, and all staff undertake training before they are able to administer medications. Medications are stored in a locked cabinet. No service users currently self medicate, or are Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 15 on any controlled drugs. Records are kept of medications entering the home and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained, and those seen by the inspector where up to date. However, one service user has been prescribed CHLOPROMAZINE tablets on an as required basis. The MAR charts states take two a day when required, while the medication label states take one a day when required. It is required that instructions on MAR charts are consistent with instructions on medication labels, and that both are in line with the prescribing instructions of the medical practitioner who prescribed the medication. The inspector was informed that all service users have made a will. However, the home has not sought and recorded the views of service users on their wishes on arrangements to be made in the event of their death, and this must be addressed. The manager said that service users would be able to remain in the home with a terminal illness, so long as the home could meet their medical needs. Touchsky DS0000007250.V337113.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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector believes that the home has appropriate policies and procedures in place around complaints and protection, although it must ensure that all complaints are appropriately recorded and investigated. EVIDENCE: The home has a complaints procedure in place, which includes timescales for responding to any complaints, and contact details of the CSCI. It has been developed since the last inspection, and is now designed for anyone wishing to make a complaint, not just service users. A copy of the procedure was on display within the home. The home also has a complaints log. However, this has not been appropriately maintained. For example, since the last inspection of the home, the CSCI received a complaint from a social worker that they were not able to gain appropriate access to a service user. This complaint was passed on to the homes manager, who informed the CSCI that they dealt with this issue, yet their was no record of it in the homes complaints log. It is required that the home keeps a record of any complaints received, including details of any investigation, outcomes and follow up action. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. This appeared to be in line with current legislation. Since the last inspection, all staff have now undertaken training in Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 17 adult protection issues. Staff spoken to demonstrated a good understanding of their responsibilities with regard to adult protection issues. Touchsky DS0000007250.V337113.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): 24,25,26,27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, both internally and externally, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in the Forest Gate area of the London Borough of Waltham Forest. It is in a quiet residential street, close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. The communal areas consist of a kitchen, dining area, sitting room, laundry room, designated smoking room and a garden. Service users were observed to move freely around communal areas. Much work as been done on the garden Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 19 since the last inspection, and it now presents as an attractive space which service users can access, with appropriate garden furniture. The home has two bathroom/toilets and two toilets on their own. Bathrooms were clean, tidy and free from offensive odour. All bathrooms had working locks fitted, which included an emergency override device. All service users have their own bedrooms, these have been decorated to their personal taste, for example with televisions and family photographs. All bedrooms had hand basins fitted. Bedrooms had adequate natural light and ventilation. Bedding, carpets and curtains were domestic in character. Bedrooms had furniture in line with NMS, including tables, chairs, wardrobes and chest of draws. At the last inspection it was found that a chest of draws in one of the bedrooms was badly damaged, this has been appropriately repaired. The home has taken steps to help reduce the risk of infection spreading. Protective clothing such as aprons and gloves are available to staff, and hand washing facilities were situated throughout the home. COSHH products were stored securely. Touchsky DS0000007250.V337113.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): 31,32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is staffed in sufficient numbers to meet service users needs, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support including waking night staff and an emergency on-call procedure. During the daytime the home has two care staff on duty. The inspector was satisfied that current staffing levels are adequate to meet service users needs, however, as the home currently has two vacancies, staffing levels would need to be reviewed if their were any further admissions to the home. A staffing rota was on display within the home, and since the previous inspection this now indicates who is in charge of the home at any given time. However, one member of the staff team who has not worked at the home for several weeks was still appearing on the rota as working at the weekend. The manager informed the inspector that this was an oversight, and that these Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 21 shifts had been covered by other staff. It is required that the staffing rota accurately rerecords the hours worked in the home by all staff. Since the previous inspection all staff have now been given a copy of their job description, which is specific to their role. Through observation and discussion their was evidence that staff have built up good relations with individual service users, and were seen to interact with them in a friendly and respectful manner. Staff spoken to demonstrated a good understanding of their roles and responsibilities. The home has a policy on equal opportunities, and since the last inspection now also has a policy on recruitment and selection. The inspector checked several staff employment files at random. These were found to contain all required documentation, including proof of ID and CRB checks. All staff receive regular formal one to one supervision. This is minuted, and staff get a copy of the minutes. Supervision includes discussions on performance and training needs. All staff also have an annual appraisal. Of the nine care staff employed at the home, six have gained a relevant care qualification. The manager informed the inspector that it was the intention of the home that in time all care staff will be given the opportunity of completing such a qualification. Since the last inspection all staff have undertaken training in epilepsy and food hygiene, however, several staff have as yet not had any recent training on fire safety, and this must be addressed. Recent staff training includes adult protection, first aid and moving and handling. Touchsky DS0000007250.V337113.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): 37,38,39,40,41,42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate quality assurance systems in place, and effective management of health and safety. EVIDENCE: The homes manager is a Registered Mental Health Nurse with over ten years experience of managing a care home. They have successfully completed the Registered Managers Award. Staff and service users informed the inspector that they found the manager to be approachable and accessible. Staff supervision and service user meetings contribute to the quality assurance within the home. Copies of previous inspection reports were available to view Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 23 in the home. The manager carries out a six monthly quality assurance audit, this includes the policies and procedures and the homes environment. Since the last inspection the home now issues questionnaires to service users to gain their feedback on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback. The home had policies in place in line with NMS. Those checked by the inspector, including adult protection and recruitment and selection appeared satisfactory. Confidential records were stored securely, staff and service users can access their records as appropriate. At the last inspection it was found that all the homes fire extinguishers were been stored in the homes laundry room. The inspector was informed that this was because one of the service users had on occasions thrown them at people. A requirement was made that the home contact the Local Fire Authority to seek their advice on where extinguishers could be kept. The advice of the Fire Authority was that it would be satisfactory for the extinguishers to remain in the laundry room, but clear signs would need to be put up around the home stating where they were. This has been done. Extinguishers were last serviced in May 2006. Fire exits were clearly signed and free from obstruction. Fire alarms are tested weekly, and the home holds regular fire drills. Fire alarms were last serviced on the 25/1/07. COSHH products were stored securely, and the home tests fridge/freezer and hot water temperatures. The home had in date safety certificates for gas safety, PAT testing and electrical installation. The home had in date employer’s liability insurance cover. Touchsky DS0000007250.V337113.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 X 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 3 3 3 3 3 3 Touchsky DS0000007250.V337113.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 YA6 Regulation 15 Requirement The registered person must ensure that all service users have a comprehensive service user plan in place, and these must be reviewed at least once every six months. (Timescale 30/11/06 not met) The registered person must ensure that service users have access to appropriate community based social and leisure activities in line with their assessed needs and stated preferences. (Timescale 30/11/06 not met) The registered person must ensure that the Statement of Purpose is amended to contain accurate and up to date information. (Timescale 30/11/06 not met) The registered person must ensure that service users responsibilities for housekeeping tasks are specified in their individual plan. (Timescale 30/11/06 not met) The registered person must ensure that all staff employed in the home undertake all necessary statutory health and DS0000007250.V337113.R01.S.doc Timescale for action 31/07/07 2. YA14 16 31/07/07 3. YA1 1 31/07/07 4. YA16 15 31/07/07 5. YA35 13 and 18 31/07/07 Touchsky Version 5.2 Page 26 6. YA5 16 7. YA9 13 8. YA9 13 9. YA20 13 10. YA21 12 11. YA22 22 12. YA31 17 safety training as appropriate, including training on fire safety issues. (Timescale 31/01/07 not met) The registered person must ensure that service users contracts/statement of terms and conditions are in line with National Minimum Standard 5. The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others, and that these assessments are dated and subject to regular review. The registered person must ensure that individual guidelines are in place on the management of any challenging behaviours that service users may exhibit. The registered person must ensure that any instructions on Medication Administration Record charts are consistent with instructions on the medication label, and that both are in line with the instructions of the medical practitioner who prescribed the medication. The registered person must ensure that the home seeks and records the views of service users on their wishes for arrangements to be made in the event of their death. The registered person must ensure that all complaints are recorded and investigated as appropriate. The registered person must ensure that the homes staffing rota accurately records the hours worked in the home by all staff. 31/07/07 31/07/07 31/07/07 31/05/07 31/07/07 31/05/07 31/05/07 Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Touchsky DS0000007250.V337113.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!