Inspection on 14/06/07 for Trumpington Road 130

This inspection was carried out on 14th June 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trumpington Road 130 05/05/09

Trumpington Road 130 06/05/08

Trumpington Road 130 29/07/06

Trumpington Road 130 20/11/05

Trumpington Road 130 11/08/05

Trumpington Road 130 15/02/05

Trumpington Road 130 02/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Trumpington Road 130 130 Trumpington Road Forest Gate London E7 9EQ Lead Inspector Robert Sobotka Unannounced Inspection 14th June 2007 10:50 Trumpington Road 130 DS0000036677.V340092.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 Trumpington Road 130 DS0000036677.V340092.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. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trumpington Road 130 Address 130 Trumpington Road Forest Gate London E7 9EQ 0208 496 1440 0208 496 1442 irene.luton01@walthamforest.gov.uk 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) London Borough of Waltham Forest Mrs Irene Luton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2006 Brief Description of the Service: Trumpington Road is a purpose built 15-bed respite unit managed by the London Borough of Waltham Forest. The design of the building is different from others in the locality and sets users apart from neighbours in adjacent domestic properties. The home is divided into four units. One of the units can accommodate people with physical disabilities. At present there are still some service users that have been staying in the home for an extended period whilst attempts are made to find appropriate alternative accommodation. The service caters for people with a wide range of learning disabilities and a wide range of support needs. The length of stay also varies. The establishment does not provide nursing services. Trumpington Road 130 DS0000036677.V340092.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 was unannounced. As part of this visit, the inspector spoke to some of the service users staying at the respite service, several staff working in the home, and three of the deputy managers and the registered manager. The inspector also conducted a tour of the premises and viewed various records. The aim of this unannounced visit was to check the home’s progress towards full compliance with the National Minimum Standards and the Care Homes Regulations. The inspector would like to thank all service users and staff who contributed to this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the registered manager has ensured that all food is labelled when opened. There was also evidence that appropriate checks are now undertaken on all staff prior to commencing employment in the home. The registered manager has obtained the relevant qualification in management, as previously required. All but three staff have received training in working with service users with challenging needs. There has been an improvement in ensuring that record of food offered to service users was kept. There has also been an improvement in ensuring that all complaints received by the home are appropriately investigated and that outcome of any investigations is recorded. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 6 The registered manager was able to evidence that all portable electrical appliances have been tested since the last inspection. The recommendation that all bathrooms and shower rooms are made less institutional in keeping with the homely environment has also been met, as all bathrooms have been redecorated since the last visit. What they could do better: There were four requirements, which remain outstanding from the last inspection. These include: - It is required that service users are weighed on a regular basis. Where it is not possible to monitor weight (due to refusals from a service user), this must also be recorded. - The registered manager must ensure that all parts of the home are kept clean and reasonably decorated. - The registered manager must ensure that an offensive odour in one of the rooms in Unit C is eliminated. - The responsible person must ensure that monthly unannounced visits take place and that reports from those are forwarded to the home and to the Commission without delay. In addition, the following 11 requirements and 3 good practice recommendations were made during this inspection visit: - It is required that an assessment in undertaken by the service users’ social worker to review the current placement and to identify more suitable placement for that service user. - The registered manager must ensure that all care plans are reviewed on a regular basis and any action identified within care plans is carried out. - The registered manager must ensure that care plans are drawn up with the involvement of the service user together with family, friends and/or advocates as appropriate, and relevant agencies/specialists. - The registered manager must ensure that all care plans; risk assessments and healthcare plans are signed and dated by their author. - The registered manager must ensure that appropriate risk management strategies are in place in relation to each service user and that risk assessments are drawn up where necessary. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 7 - The registered manager must ensure that the main kitchen is adequately ventilated at all times. - The registered manager must ensure that each person has an up-to-date and fully completed health action plan, which reflects the healthcare needs of that service user. - When medication is administered to people who use the service it must be clearly recorded, to ensure that people receive the correct levels of medication. - The registered manager must ensure that any medication no longer required by a service user is disposed of without any delay. - The registered manager must ensure that accurate records of any medication entering the home and disposed of are maintained. - The registered manager must ensure that any events that adversely affect the wellbeing of a service user are reported to the appropriate authorities, including the Commission for Social Care Inspection. - The registered manager must ensure that the home’s fire risk assessment is reviewed on a regular basis. - It is recommended that food products be bought from local retailers with service users’ involvement instead of making bulk purchases. - It is recommended that the Criminal Records Bureau checks be undertaken every 3 years. - It is recommended that the views of family, friends and advocates and stakeholders in the community be sought on how the home is achieving goals for service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate admission process was in place. Further work is required to ensure that the assessed needs of those who use the project are fully met. EVIDENCE: The registered manager informed the inspector that there have been no revisions to the project’s statement of purpose since the last inspection. Due to the nature of the project, majority of the service users begin using this service following emergency admission, such breakdown in usual care arrangement, for example illness or death of the main carer or breakdown of another placement. As part of this visit the inspector viewed care plan of one of the service users who was recently admitted to the project following a breakdown of previous placement. There was evidence that the project had obtained relevant information in respect of the service user to ensure that his needs would be met. Following the discussion with staff working in the home, as well as direct and indirect observation, the inspector was satisfied that the project was able to meet the needs of most of the service users. It was however evident that staff working in the home were struggling to appropriately meet the needs of one of the service users, who has been living in the project for a number of years and Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 10 whose needs have changed significantly. Several staff who spoke with the inspector felt that due to the changes in behaviour and needs of the service user, the current placement was no longer suitable for this person and it was adversely affecting the wellbeing of other people who were using the service. The inspector was of the same opinion. It is required that an assessment in undertaken by the service users’ social worker to review the current placement and to identify more suitable placement for that service user. Many of the service users using Trumpington Road are referred to the project as an emergency, which means that is some cases it may not be possible to arrange trial visits. Each of the care plans viewed contained a costed contract, which included terms and conditions of the placement. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 11 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, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure that service users care plans are brought up-to-date and reviewed on regular basis. Further work was also required to ensure that all appropriate risk assessments are in place and that service users are involved in their care planning process. Confidentiality was maintained. EVIDENCE: As part of this visit, the inspector checked 5 care plans, which were chosen at random. The inspector noted that some of the care plans were not being reviewed on a regular basis. Some care plans were basic. The care plan of the newly admitted service user drawn up by the home was inconsistent with the information obtained prior to the admission to the project and provided by the previous care provider. This included information relating to emotional and healthcare needs of the service user. Some areas of the care plan were felt incomplete. The registered manager must ensure that all care plans are reviewed on regular basis and any action identified within the care plans is carried out. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 12 Some of the care plans viewed were not signed and/or dated by their author. This required improvement. In addition there was no evidence that service users were involved in the care planning process, even though some appeared to be capable of making decisions relating to their stay at Trumpington Road. The registered manager must ensure that care plans are drawn up with the involvement of the service user together with family, friends and/or advocates as appropriate, and relevant agencies/specialists. The majority of risk assessments were in place, however the inspector identified that there were no risk assessments on file for the newly admitted service user, even though there were clear areas of risk identified. In one instance the risk assessment was reviewed following an incident, but no amendments were made in the service user’s care plan to reflect this. The registered manager must ensure that appropriate risk management strategies are in place in relation to each service user and that risk assessments are drawn up where necessary. Confidentiality was being maintained. All information relating to service users is kept in the staff and/or manager’s office. Staff working in the home were sharing information on need-to-know basis. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Appropriate leisure activities were provided by the project. Ventilation in the kitchen premises required improvement. Further thought should be given to allow service users to be able to purchase food products from shops, as opposed to food products being ordered by the home in bulk. EVIDENCE: Trumpington Road is a respite unit and therefore the primary responsibility for finding employment and education does not lie with the service providers. Those who have lived in the home for a considerable length of time were receiving support in moving onto other projects. Since the last inspection, the majority of service users have been moved to more suitable projects in the community. One of the service users who spoke with the inspector during this visit stated that he was supported to attend any pre-arranged activities in the local Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 14 community. Service users visit cinemas, local pubs, go to shows and go out for lunch. The home has got a recreation area. The inspector saw this area being utilised on the day of the inspection. As previously mentioned, the project is a respite unit and the majority of the service users live with their parents/relatives. Documents viewed, such as care plans and visitor’s book evidenced that the home supports service users to maintain family contacts. Visitors are welcome in the project. One of the service users who spoke to the inspector confirmed that he was allowed to bring his friends to the project and it was explained to him that no visitors were allowed after 9 pm. Breakfast and lunch meals are prepared in the individual units. The evening meal is prepared in the main kitchen by the cook and is taken to the units in heated trolleys. There were appropriate food supplies in the home on the day of this unannounced inspection. The inspector visited kitchen premises, which were kept clean, however they were very hot. The registered manager must ensure that the kitchen premises are adequately ventilated at all times. The inspector was informed that all food products in the home are purchased in bulk. The chef working in the kitchen at the time of this visit felt that fresher and better quality food could be bought on a twice weekly or even more regular basis from local retailers. In addition the inspector felt that this practice would enable service users to take an active part in planning and purchasing food of their choice and thus enabling them to learn new skills. It is recommended that food products be bought from local retailers with service users’ involvement instead of making bulk purchases. There has been an improvement in the recording of food offered to service users. Service users spoken to stated that they were happy with the food that was offered to them. The inspector was invited to have lunch with two of the service users in one of the units. The food was attractively presented and nutritionally balanced. Special diets are catered for. Fridge/freezer temperatures were taken and recorded daily. It was noted that all perishable food was now being labelled, as previously required. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Limited progress has been made to ensure that the healthcare needs of those who use the service are being met. Improvements are required in relation to the project’s medication systems. EVIDENCE: The inspector was informed that female service users were supported by female staff and when required all female units were arranged. Times for getting up and going to bed were flexible. Appropriate personal care guidelines were in place. Trumpington Road is a respite unit and the primary responsibility for healthcare remains with the primary carers. Longer stay residents are registered with the local GP and are supported by staff to attend appointments and check ups. Each person using the service has a health action plan in place, however it was noted that these were not always completed and in some cases did not fully reflect the assessed healthcare needs of the service users. This required improvement. The registered manager must ensure that each person has an Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 16 up-to-date and fully completed health action plan, which reflects the healthcare needs of that service user. The inspector was concerned to learn that a requirement from the previous inspection, which states that service users are weighed on a regular basis, remains unmet. It has therefore been repeated and must be met without any delay. Further non-compliance will result in the Commission issuing an enforcement notice. As part of this visit, medication stocks on two out of four units were checked. Medication administration records evidenced that staff did not always sign for medication given to service users. In addition staff were using symbol “o” without giving any explanation as to what it meant. When medication is administered to people who use the service it must be clearly recorded, to ensure that people receive the correct levels of medication. In addition a record of medication received in the home and disposed of required improvement. The registered manager must ensure that any medication no longer required by a service user is disposed of without any delay. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Appropriate complaint systems were in place. Not all significant events were being reported to the appropriate authorities. EVIDENCE: There have been no complaints made directly to the project since the last inspection. There has been one complaint about the project made directly to the social services department, which was being investigated at the time of this inspection. The inspector was satisfied that all outstanding complaints have been resolved, as previously required. Appropriate complaints system was in place. One of the service users who spoke with the inspector said that he would bring any concerns to the home manager and he felt confident that his complaint would be appropriately investigated and resolved. The home had a copy of the CSCI adult protection protocol and there was evidence that staff have received adult protection training. Records of accidents and incidents was maintained and showed that appropriate action was taken to prevent further accidents/incidents, however it was noted that some incidents were not always reported to the appropriate authorities, such as the service users’ social worker/placing authority and the Commission for Social Care Inspection, in line with Regulation 37 of the Care Homes Regulation. The registered manager must ensure that any events that adversely affect the wellbeing of a service user are reported to the appropriate authorities, including the Commission for Social Care Inspection. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 18 Records of finances kept on behalf of service users were appropriately maintained. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The premises were generally meeting the needs of those using the service, however some areas required attention. EVIDENCE: The home was purpose built 15 years ago and is different in design and not in keeping with other houses in the street. The home is close to local shops, amenities and transport. There are four separate units each with a lounge, dining and small kitchen areas. The home is accessible for people with physical disabilities and one unit has specialised bathing facilities and special beds to provide accommodation to those with physical disabilities. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 20 Twelve of the bedrooms are approximately 7 sq.m in size. The three bedrooms in the unit designed for people with physical disabilities are approximately 10 sq.m. The rooms are all small and therefore the amount of furniture is limited as is the space for service users to move around their rooms. However the room sizes are now acceptable under the revised National Minimum Standards for Younger Adults. Each unit has a bathroom and a shower room and there are appropriate facilities to meet the needs of people with physical disabilities. The toilet and bathing facilities are adequate in numbers. Since the last inspection all bathrooms and shower rooms have been upgraded and they provided a pleasant environment for service users. Some parts of the premises required cleaning and tidying up. The requirement, which states that an offensive odour in one of the service users’ bedrooms in Unit C is eliminated remains outstanding and has been repeated. Some of the carpets required cleaning/replacing. One of the bedrooms on Unit A required repainting. The registered manager must ensure that all parts of the home are kept clean and reasonably decorated. This is a repeated requirement and must be met without any further delay. Appropriate laundry and clinical waste facilities were in place. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been noted in the project’s recruitment processes. EVIDENCE: During the course of this visit, the inspector spoke to several care staff and three deputy managers. Staff who spoke with the inspector felt that the home was appropriately managed. Duty rosters were maintained. They showed that appropriate staffing levels were in place. This was also confirmed by staff working in the home, who stated that their workload was manageable. The ratio of staff is determined by the number and needs of the service users accommodated in the project. The inspector checked personnel files of three staff employed in the home. All three files contained information listed in Schedule 2 of the Care Homes Regulations. It was noted though that some of the Criminal Record Disclosures were more than 3 years old. It is recommended that the Criminal Records Bureau checks be undertaken every 3 years. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 22 The registered manager informed the inspector that all but 3 staff have received training in challenging behaviour, as required at the last inspection visit. According to the Annual Quality Assurance Assessment, which was completed by the registered manager, the majority of permanent staff have obtained NVQ Level 2 in Care or above. Staff supervision and appraisal records were not checked during this inspection visit. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 23 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, 41, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was appropriately managed, however further improvements were required to ensure that all National Minimum Standards are met. The project’s quality assurance systems and record keeping required improvement. EVIDENCE: The registered manager informed the inspector that she has obtained the NVQ Level 4 Registered Managers Award, as previously required. In addition she is a qualified Social Worker. Frequency of the monthly unannounced visits from the responsible person still requires improvement, as at the time of this inspection there was no evidence that these were taking place on a regular basis. The requirement in relation to the visits from the responsible individual has therefore been repeated. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 24 It is also recommended that the views of family, friends and advocates and stakeholders in the community be sought on how the home is achieving goals for service users. As previously mentioned, some of the documents must be updated/improved. This included care plans and risk assessments, record of weight of service users, and records relating to the medication in the project. Appropriate health and safety checks were in place. There was evidence that all portable appliances have been tested since the last inspection (in September 2006), as previously required. Landlord’s Gas Safety Certificate was issued in May 2007. Fire alarms were tested on a regular basis and fire drills were also carried out. The home’s fire risk assessment was last updated in October 2005 and it required review. The registered manager must ensure that the home’s fire risk assessment is reviewed on a regular basis. The project was appropriately insured for its stated purpose. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 2 26 x 27 2 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x 2 2 x Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA18 Regulation 17(2) Requirement It is required that service users are weighed on a regular basis. Where it is not possible to monitor weight (due to refusals from a service user), this must also be recorded. (Previous timescales of 31/12/05 and 29/08/06 were not met.) The registered manager must ensure that all parts of the home are kept clean and reasonably decorated. (Previous timescale of 01/10/06 was not met.) The registered manager must ensure that an offensive odour in one of the rooms in Unit C is eliminated. (Previous timescale of 15/09/06 was not met.) The responsible person must ensure that monthly unannounced visits take place and that reports from those are forwarded to the home and to the Commission without delay. (Previous timescale of 01/10/06 was not met.) It is required that an assessment in undertaken by the service users’ social worker to review the current placement and to DS0000036677.V340092.R01.S.doc Timescale for action 01/08/07 2. YA30 23(2)(d) 01/09/07 3. YA30 23(2)(p) 01/10/07 4. YA39 26 01/09/07 5. YA3 14(2)(b) 01/09/07 Trumpington Road 130 Version 5.2 Page 27 6. YA6 15(2)(b) 7. YA6 YA7 15(1) 8. YA41 YA6 YA9 17(3)(a) 9. YA9 13(4)(c) 10. YA24 23(2)(p) 11. YA19 15(1), 13(1) 12. YA20 13(2) 13. YA20 13(2) 13. YA20 13(2) identify more suitable placement for that service user. The registered manager must ensure that all care plans are reviewed on a regular basis and any action identified within the care plans is carried out. The registered manager must ensure that care plans are drawn up with the involvement of the service user together with family, friends and/or advocates as appropriate, and relevant agencies/specialists. The registered manager must ensure that all care plans; risk assessments and healthcare plans are signed and dated by their author. The registered manager must ensure that appropriate risk management strategies are in place in relation to each service user and that risk assessments are drawn up where necessary. The registered manager must ensure that the main kitchen is adequately ventilated at all times. The registered manager must ensure that each person has an up-to-date and fully completed health action plan, which reflects the healthcare needs of that service user. When medication is administered to people who use the service it must be clearly recorded, to ensure that people receive the correct levels of medication. The registered manager must ensure that any medication no longer required by a service user is disposed of without any delay. The registered manager must ensure that accurate records of any medication entering the home and disposed of are DS0000036677.V340092.R01.S.doc 15/08/07 15/08/07 15/08/07 15/08/07 01/09/07 15/08/07 01/08/07 01/08/07 01/08/07 Trumpington Road 130 Version 5.2 Page 28 maintained. 14. YA23 37 The registered manager must ensure that any events that adversely affect the wellbeing of a service user are reported to the appropriate authorities, including the Commission for Social Care Inspection. The registered manager must ensure that the home’s fire risk assessment is reviewed on a regular basis. 15/07/07 15. YA42 13(4)(c) 15/08/07 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. 2. 3. Refer to Standard YA17 YA34 YA39 Good Practice Recommendations It is recommended that food products be bought from local retailers with service users’ involvement instead of making bulk purchases. It is recommended that the Criminal Records Bureau checks be undertaken every 3 years. It is recommended that the views of family, friends and advocates and stakeholders in the community be sought on how the home is achieving goals for service users. Trumpington Road 130 DS0000036677.V340092.R01.S.doc Version 5.2 Page 29 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. 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