Inspection on 24/10/06 for Touchsky

This inspection was carried out on 24th October 2006.

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

Other inspections for this house

Touchsky 20/05/08

Touchsky 19/04/07

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 24th October 2006 10:00 Touchsky DS0000007250.V316916.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.V316916.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.V316916.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 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.V316916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 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.V316916.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 on the 24/10/06 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. The inspection also included an examination of some documents and records, and a tour of the premises. Overall, the inspector was disappointed to note that there has been only very limited improvement to the home since the previous inspection, and a total of thirty two requirements have been set at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Key documents were not available for inspection, and the homes admission procedure needs to be amended. EVIDENCE: The inspector arrived at the home at 10am. Two care staff were on duty, as per the homes staffing rota. The inspector asked to see the homes Service User Guide, and the homes Statement of Purpose. Neither of these documents could be located by the staff in the home. The staff informed the inspector that they believed these documents would be in the homes office, and that this was kept locked. The inspector was informed that only the homes manager, deputy manager and administrator had access to the office. None of these staff were on the staff rota for the day of inspection, and none of them came to the house during the course of the inspection. Throughout the course of the inspection, the inspector was repeatedly told that key documents were kept in this office, and the inspector was therefore unable to test several standards on this occasion. However, requirements that were set at the last inspection have been repeated in this report, where the inspector was unable to verify if they have been met or not. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 8 At the last inspection requirements were made around the Statement of Purpose and the Service User Guide, both of these are repeated. The inspector was unable to check service users contracts/statement of terms and conditions. There have been no new admissions to the home since the previous inspection, therefore pre admission assessments were not tested as part of this inspection. The inspector did however check the homes admission procedure. This stated that service users will be able to visit the home before making a decision as to move in or not, and that service users will initially move in on a trial basis. However, the procedure also stated that “The majority of referrals will be under the age of 65 and suffering from dementia”. But the home is not registered to provide care to people with dementia, and it is required that the homes admission procedure accurately reflects the actual admissions practice within the home. Touchsky DS0000007250.V316916.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): 7,8 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Carer plans and risk assessments were not readily available to staff and service users in the home, and their was no evidence that service users are involved in the day to day running of the home. EVIDENCE: The inspector was very disappointed to note that both care plans and risk assessments were not available to view in the home. Not only should these documents be available for inspection at all times by persons so authorised to do so, but it is crucial that staff have access to these documents as a matter of course at all times. Clear and comprehensive care plans and risk assessments are essential tools in ensuring that service users needs are met in a comprehensive and consistent manner, and risk assessments are equally important documents, helping to ensure that any risks are managed and Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 10 therefore reduced as much as possible. At the last inspection a requirement was made around care plans, and this is repeated in this report. One service user has bed rails fitted to the side of their bed. The inspector was unable to verify if a risk assessment was in place around this. A CSCI Regulation Manager spoke with the homes manager by telephone the day after the inspection, and was informed that there was not a risk assessment in place around this, and this must be addressed. Through observation and discussion there was evidence that service users have control over their daily lives. Service users are able to get up and go to bed as they wish, and were observed to be consulted over what they had for dinner on the day of inspection. One service user was seen to ask staff if they would support them to go the shops, and this was arranged. Service users are given keys to their bedrooms and the homes front door as appropriate. Staff informed the inspector that service users were involved in the day to day running of the home. However, there was no evidence of this. It is required that service users are given the opportunity of been involved in the day to day running of the home, and that this involvement is clearly recorded. The homes policies and procedures were available for inspection, however, there was no evidence of a policy in place around confidentiality, and this must be addressed. Further, as stated, service users do not have access to records pertaining to themselves, and it is required that service users have access to their own records as appropriate. Touchsky DS0000007250.V316916.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): 11,12,13,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Food was found to be of a satisfactory standard, and there was evidence that service users have access to the community, and that visitors are welcome. However, the home must ensure that service users are offered appropriate and sufficient 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. Staff informed the inspector that service users are involved in in-house programmes to help develop independence, for example around cooking and laundry skills. At the last inspection it was required that the home have guidelines in place around these programmes within service users care plans. As the inspector was unable to test this, this requirement has been repeated in this report. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 12 Service users have access to the local community. On the day of inspection one service user went out for lunch, another visited local shops. Service users have their own bank accounts, and visit the bank to withdraw money. Service users use public transport, including busses and mini cabs. No service users visit a place of worship, but a priest visits the home on occasions. As at the last inspection, the inspector had concerns about the level of community based social and leisure activities available to service users. One service user informed the inspector that they enjoyed going to the pub, restaurants and to the cinema, and an activities chart on the wall indicated that they were supposed to go the cinema weekly. Yet daily logs indicated that in the past month, this service user had been to a café once, and for occasional walks, and had not been given the opportunity of visiting pubs or the cinema. Daily records for two other service users indicated that they had even less access to community based social and leisure activities over the same period. It is a repeat requirement that service users have access to regular community based social and leisure activities, in line with their assessed needs and stated preferences. In-house service users have access to TV, video, music and the home holds occasional parties. Friends and relatives are welcome at any reasonable time, and can see service users in private if they so wish. Since the last inspection the home now has a phone which service users can access, and service users are given their own mail to open. Records are kept of menus, and since the previous inspection any change to the menu is now also recorded. Service users informed the inspector that they are involved in planning menus, and in food preparation. Menus indicated that service users are offered a varied, balanced and nutritious diet. Since the last inspection the home now keeps records of fridge and freezer temperatures. The kitchen was clean and tidy, and food was stored appropriately. At the last inspection a requirement was set that all staff involved in food preparation undertake appropriate training in food hygiene. The inspector was unable to check training records during this inspection, and this requirement is therefore repeated. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was generally satisfied that the home is meeting the health care needs of service users. Service users have access to health care professionals, and the handling of medications in the home has improved since the last inspection. EVIDENCE: At the last inspection, requirements were set that full information is maintained of interventions to support service users with specific diagnoses, and that the home must ensure that details of action to be taken in the event of a sudden death are both accurately and consistently available. The inspector was unable to check documentation relating to these two requirements during the course of the inspection, and they are therefore both repeated in this report. All service users are registered with a GP. Staff informed the inspector that service users see health professionals as appropriate, and that records are maintained of any appointments. These records were however locked in the Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 14 office, and unavailable for inspection. One service user uses continence products, staff informed the inspector that used continence products were disposed of along with the rest of the household waste in the homes regular dustbin. It is required that the home disposes of used continence products as appropriate, to help decrease the risk of the spread of infection. Since the last inspection the home now has a medication policy in place. Indeed, there have been considerable improvements to the handling of medications in the home since the last inspection. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. The inspector carried out an audit of the medications, and records tallied with the actual amounts of medication the home had in store. Medications were stored in a locked cabinet. Medication Administration Record (MAR) charts were maintained, and since the last inspection these are now properly dated, clear and easy to understand. However, there was one instance seen by the inspector were information on the MAR chart had been obscured by the use of correction fluid, and it is required that correction fluid is not used on MAR charts. It was further found that the home did not have any guidelines in place around the administration of medications prescribed on a PRN basis. For example, one service user has been prescribed both LORAZEPAM and CHLOPROMAZINE on a PRN basis, yet there were no guidelines in place for administering these medications. This must be addressed. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 15 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 home has introduced systems to help ensure that service users are protected from abuse, although all staff must undertake training in adult protection issues. EVIDENCE: The home has a complaints log, although staff informed the inspector that the home had not received any complaints since the previous inspection. There was also a complaints procedure, this has been amended since the last inspection, and now includes timescales for responding to any complaints received, along with contact details of the CSCI. However, the procedure is only for service users to make a complaint. The home did not have a procedure for other persons, for example neighbours or social and health care professionals, to make a complaint, and this must be addressed. Further, the procedure was not on display within the home, and it is recommended that it should be. The home has a copy of the Local Authorities adult protection procedures, and also its own adult protection policy. The inspector was pleased to note that this has been revised since the last inspection, and now appears to be in line with current legislation. At the previous inspection a requirement was set that all staff working at the home undertake training around adult protection issues. As the inspector was unable to check training records, this requirement has Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 16 been repeated in this report. However, staff spoken to during the course of the inspection demonstrated a good understanding of the issues involved around adult protection. The home keeps money on behalf of service users in a locked safe. Records and receipts are kept of financial transactions involving service users monies, those checked by the inspector were satisfactory. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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. At the last inspection a requirement was Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 18 set that broken paving stones in the rear garden were repaired. This work was in progress during the course of the inspection. However, the laundry room was found to be left unlocked and unsupervised, even though it contained COSHH products, and it is required that all COSHH products are stored securely The home has two bathroom/toilets and two toilets on their own. Since the previous inspection the two bathrooms have been redecorated, and the standard of cleanliness and hygiene across the bathrooms and toilets was greatly improved since the previous inspection. However, the locks on both of the toilet doors were broken on the day of inspection, and this must be addressed. 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. However, the chest of draws in one of the ground floor bedrooms was in a very poor state of repair, and many of its draws could not be opened. This must be repaired or replaced. 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. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 19 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 and 34. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home is staffed in sufficient numbers, service users would further benefit from having an appropriately trained, qualified and supervised staff team. EVIDENCE: The home provides 24-hour care including a waking night staff and emergency on-call procedure. There was a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. However, it did not indicate who was in charge at any given time, and this must be addressed. Of the nine care staff employed at the home, the inspector was informed that only one has achieved a relevant care qualification, although several other staff are currently working towards such a qualification. It is required that at least 50 of care staff employed at the home have an NVQ Level 2 in care or equivalent qualification. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 20 The home had a policy in place on equal opportunities, but there was no evidence of a policy on recruitment and selection, and this must be addressed. Staffing records were unavailable for inspection during this visit, and will therefore be tested as part of the next inspection. Through observation and discussion there was some evidence that staff have built up good relations with individual service users, and demonstrated a good ability to communicate with service users. At times service users made it clear they wished to be left alone, and staff were seen to respect this. At the previous inspection requirements were set that staff are provided with appropriate job descriptions, that staff receive regular formal supervision and that staff undertake training in epilepsy and statutory health and safety matters. Due to records been locked away in the office, the inspector was unable to test these requirements on this occasions, and these requirements are therefore repeated in this report. There was evidence that the home now holds regular staff meetings. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector believes the homes manager to be suitably qualified and experienced, more attention needs to be paid to several areas within the home, including quality assurance and record keeping. 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. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 22 Several polices required by NMS were either not readily available in the home, for example on recruitment and selection and confidentiality, or were not fully comprehensive, such as the complaints policy and procedure. It is required that the home has all polices in place in line with NMS and the Care Homes Regulations 2001. As stated elsewhere within this report, many of the records kept in the home were not available to staff and service users, and were not available for the purposes of inspection. It is required that all records held in the home are made available at all times to relevant staff and service users, and to any other persons who are authorised to inspect them. At the last inspection a requirement was set that the home introduce a system of seeking service users views on the running of the home, to gain feedback and help inform future planning. Staff informed the inspector that the home had introduced a system of questionnaires that were issued to service users. However, these were not available for inspection on the day, and the requirement is therefore repeated in this report. Copies of inspection reports were available to view in the home. Most of the homes fire extinguishers have been removed from their usual place and are currently been stored in the homes laundry room. Staff informed the inspector this was because one service user on occasions has removed extinguishers from the wall and thrown them. It is required that the home seeks the advice of the Local Fire Authority on this issue, to determine where fire extinguishers should be kept within the home in these circumstances. Fire extinguishers have been serviced since the last inspection, in May 2006. Fire alarms are tested weekly, and were last serviced on the16/12/05. Regular fire drills are held. The home tests hot water temperatures on a weekly basis. In date certificates were in place for PAT, gas safety and electrical installation. The home had in date employer’s liability insurance cover. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 23 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 X 2 X 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 2 X 1 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X 3 3 2 2 1 2 3 Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 24 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 31/08/06 not met) The registered person must ensure that all staff who work in the home receive training in Adult Protection issues. (Timescale 31/08/06 not met) The registered person must ensure that the homes Service User Guide contains all information required by National Minimum Standard 1. (Timescale 31/08/06 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 30/06/06 not met) The registered person must ensure that the home has all necessary policies and procedures in line with National Minimum Standards and current DS0000007250.V316916.R01.S.doc Timescale for action 30/11/06 2. YA23 13 31/01/07 3. YA1 5 30/11/06 4. YA14 16 30/11/06 5. YA40 17 30/11/06 Touchsky Version 5.2 Page 25 6. YA1 1 7. YA19 13 8. YA16 15 9. YA17 13 and 18 10. YA31 18 11. YA32 18 12. YA35 18 13. YA35 13 and 18 legislation. (Timescale 31/08/06 not met) The registered person must ensure that the Statement of Purpose is amended to accurately reflect the services the home can provide. (Timescale 31/08/06 not met) The registered person must ensure that full information is maintained of interventions to support service users with specific medical diagnoses. (Timescale 30/06/06 not met) The registered person must ensure that service users responsibilities for housekeeping tasks are specified in their individual plan. (Timescale 31/08/06 not met) The registered person must ensure that all staff involved in food preparation in the home have undertaken appropriate food hygiene training. The registered person must ensure that all staff are provided with a copy of their job description, and that this job description accurately and clearly reflects the roles and responsibilities of the specific post it relates to. (Timescale 31/08/06 not met) The registered person must ensure that at least 50 of the care staff in the home obtain a relevant qualification in care. (Timescale 31/08/06 not met) The registered person must ensure that all staff employed at the home undertake training in issues around epilepsy as appropriate. (Timescale 31/08/06 not met) The registered person must ensure that all staff employed in the home undertake all DS0000007250.V316916.R01.S.doc 30/11/06 30/11/06 30/11/06 31/01/07 30/11/06 31/01/07 31/01/07 31/01/07 Touchsky Version 5.2 Page 26 14. YA36 18 15. YA39 24 16. YA21 12 17. YA4 14 18. YA8 12 19. YA9 13 20. YA10 12 21. YA10 17 necessary statutory health and safety training as appropriate. (Timescale 31/08/06 not met) The registered person must ensure that all staff receive regular formal supervision, at last six times a year. (Timescale 31/08/06 not met) The registered person must ensure that systems are in place to seek and record the views of service users on the home to help inform future planning. (Timescale 31/08/06 not met) The registered person must ensure that details of action to be taken in the event of sudden death are both accurate and consistently available. (Timescale 30/06/06 not met) The registered person must ensure that the homes admission procedure accurately reflects the homes categories of registration. The registered person must ensure that service users are given the opportunity of been involved in the day to day running of the home, and that this involvement is recorded. The registered person must ensure that a comprehensive risk assessment is carried out and held on file for any instances were bedrails are used. The registered person must ensure that the home has a confidentiality policy in place, and that this policy makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. The registered person must ensure that service users have access to their own records as appropriate. DS0000007250.V316916.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 Touchsky Version 5.2 Page 27 22. YA19 13 23. YA20 13 24. 25. YA20 YA22 13 22 26. YA26 23 27. YA27 23 28. 29. YA30 YA33 13 17 30. YA34 19 31. YA41 17 The registered person must ensure that used continence products are disposed of appropriately in line with good practice as regards infection control. The registered person must ensure that guidelines are in place on the administration of any medications prescribed on a PRN basis. The registered person must ensure that correction fluid is not used on MAR charts. The registered person must ensure that the home has a complaints procedure that is applicable to any persons wishing to make a complaint. The registered person must ensure that the broken chest of draws in the ground floor bedroom is repaired or replaced. The registered person must ensure that all bathrooms and toilets in the home have a working lock fitted, including an emergency override device. The registered person must ensure that all COSHH products in the home are stored securely. The registered person must ensure that the homes staffing rota clearly identifies who is in charge of the home at any given time. The registered person must ensure that the home has a policy in place on the recruitment and selection of staff to the home. The registered person must ensure that all necessary records and documentation are made available for inspection at any time by persons so authorised to do so. DS0000007250.V316916.R01.S.doc 31/01/07 30/11/06 30/11/06 30/11/06 31/01/07 31/01/07 30/11/06 30/11/06 30/11/06 30/11/06 Touchsky Version 5.2 Page 28 32. YA42 13 and 23 The registered person must arrange for a visit to the home by the Local Fire Authority to provide advice on the safe storage of fire extinguishers in the home. 31/01/07 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 It is recommended that a copy of the homes complaints procedure is put on display within the home. Touchsky DS0000007250.V316916.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 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. 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