Inspection on 06/05/08 for Trumpington Road 130

This inspection was carried out on 6th May 2008.

CSCI found this care home to be providing an Adequate service.

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 10 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 14/06/07

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 28/09/2008.

CARE HOME ADULTS 18-65 Trumpington Road 130 130 Trumpington Road Forest Gate London E7 9EQ Lead Inspector Robert Sobotka Unannounced Inspection 6th May 2008 10:40 Trumpington Road 130 DS0000036677.V363188.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.V363188.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.V363188.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 myrtlebrown02@walthamforst.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 Position vacant Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2008 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.V363188.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place over one day and was unannounced. The inspector spoke to some of the staff working in the home, including the home manager and he spent some time with the service users talking with them and observing the way they were supported by staff within the home environment. He also conducted a tour of the premises guided by one of the people who used the service and a member of staff and he viewed various records. Prior to this inspection the home was asked to complete the Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. The aim of this announced inspection was to check the home’s progress towards full compliance with the National Minimum Standards for Younger Adults (18-65) and the Care Homes Regulations. The inspector would like to thank everyone who contributed to this inspection. What the service does well: What has improved since the last inspection? Since the last inspection, the home has got a new manager. She has previously worked in the home as a deputy manager. Since the last visit, she has ensured that service users are weighed on a regular basis, as previously required. The home manager was able to demonstrate that some progress has been made to ensure that one of the service users has received their assessment to review the current placement and to identify a more suitable placement for that service user. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 6 There has been an ongoing problem with ventilation in the main kitchen. Since the last inspection, the manager has obtained quotes for building works, which have now been approved and work to improve ventilation was due to start soon. Random check of service users’ files evidenced that each person who used the service had an up-to-date health action plan in place. Improvements have been noted in the way that staff recorded medication administered to the people who used the service. Appropriate clinical waste disposal systems were now in place to control the spread of infections. It appeared that Criminal Bureau Checks were being undertaken every three years, as previously recommended. What they could do better: The inspector remains concerned that very limited progress has been made since the last inspection visit to ensure that all outstanding statutory requirements and recommendations have been met. As a result, a referral has been made to the Regional Enforcement Team within the Commission in order to secure compliance with the law in relation to the home’s care planning and risk management systems. In addition, the following statutory requirements remained unmet at the time of this inspection: - 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 the main kitchen is adequately ventilated at all times. - It is required that an application for the home manager to become a registered manager is submitted to the Commission. The following requirements were made following this inspection visit: - The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people competent to do so and with consultation with a service user. For individuals referred through Care Management, the registered manager must obtain a summary of the single Care Management assessment and a copy of the single Care Plan. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 7 - The registered person must ensure that staff record dates of any medication opened by them, so that they follow manufacturer’s instructions in relation to its safe storage and shelf life and that any expired/unused medication is discarded/returned to the pharmacist as required. - It is required that staff are offered a refresher training on adult protection issues, including “whistleblowing”, so that they were aware of the Public Interest Disclosure Act 1998 and the Department of Health guidance “No Secrets”. - The registered person must ensure that all parts of the home are kept clean and reasonably decorated. - The registered person must ensure that carpets are been replaced throughout the building, in order to maintain a safe, pleasant and hygienic environment. - It is required that visits by the registered provider are carried out in accordance with Regulation 26 of the Care Homes Regulations. A copy from each visit should be made available to the home and to the Commission following each visit on a monthly basis. - The registered manager must ensure that the home’s registration certificate is displayed in the home at all times. There were also two good practice recommendations that remain unmet and have therefore been repeated: - 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 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.V363188.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.V363188.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): 2, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to the way any prospective people who use the service are assessed, so that their needs can be fully met. EVIDENCE: Due to the nature of the project, majority of the service users begin using this service following emergency admission, such breakdown in usual care arrangements, for example illness or death of the main carer or breakdown of another placement. As part of this visit the inspector viewed care plans of two of the people who have recently been admitted to the project following a breakdown of their previous placements. There was evidence that the project had obtained relevant information in respect of one service user. It was noted however that the service had very little information in respect on the second service user, even though they have been using the service for approximately six months. There was no evidence of any correspondence between the service and the person’s allocated social worker. The inspector was concerned that due to lack of information about this person, staff had very little knowledge as to how this person’s needs should be met and what risk management systems should be implemented in order to protect this person from potential abuse. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 10 The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people competent to do so. For individuals referred through Care Management, the registered manager must obtain a summary of the single Care Management assessment and a copy of the single Care Plan. 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 some of the service users. It was identified at the previous inspections that staff working in the home were struggling to appropriately meet the needs of another service user, who has been living in the project for a number of years and whose needs have changed significantly in the last couple of years. Several staff who spoke with the inspector felt that due to the changes in behaviour and needs of that 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. At the last inspection a statutory requirement was made that an assessment should be undertaken by the service users’ social worker to review the current placement and to identify a more suitable placement for that service user. During this visit, the inspector was informed that the assessment process was underway in order to ensure that a more suitable placement is found for the service user. Many of the people 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.V363188.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Very limited progress has been made to ensure that the service user’s care plans and risk assessments are up-to-date and kept under review, so that staff working in the home can appropriately support each person who uses the service. This adversely affects the quality of care provided to the people using the service. EVIDENCE: As part of this visit, the inspector checked 5 care plans, which were chosen at random. The inspector was concerned that very limited progress was made to ensure that all care plans are reviewed on a regular basis and that any action identified within the care plans is carried out. One service user’s care plan was very basic and incomplete. It contained very little information as to how this service user’s needs were going to be met and/or what this person’s needs were. There was no information about what emotional support would be offered to the service in relation to dealing with some relationship issues. Some areas of the care plan were felt incomplete. A care plan of another person, who was of a white British origin, did not include Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 12 any information as to how the service was going to address any cultural needs of this person. It included an entry “not applicable” instead. This issue was highlighted at the previous random inspection, which took place in January 2008 and the home was unable to evidence that even though this person’s care plan has been reviewed since the last inspection visit, no amendments have been made to address this issue. Another person’s care plan was found to be incomplete. File of another person who used this service on a regular basis was not available in the home at the time of this visit. Some of the care plans viewed were not signed and/or dated by their author. Due to the ongoing concerns in relation to the home’s care planning systems; this matter has been referred to the Commission’s Regional Enforcement Team in order to secure compliance with the legislation. 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 inspector was also concerned that very limited progress has been made since the last inspection to ensure that appropriate risk management strategies are in place in relation to each service user and that risk assessments are drawn up where necessary. At the time of this visit, a care plan file of one of the service user did not include any risk assessments, even though some potential risks have been clearly described in the pre-admission documentation supplied by this person’s social worker. During the review of care plans and other supporting documentation, the inspector identified other areas where risk assessments were required, but were not in place. This included risk assessments in relation to going out independently, going missing and being at risk of financial exploitation. This matter has now been referred to the Regional Enforcement Team and a statutory enforcement notice will be issued to the home in order to ensure that improvements are made to the home’s risk assessment systems. Trumpington Road 130 DS0000036677.V363188.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 good. 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 provider. 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, most of those service users have moved to more suitable projects in the community. Service users visit cinemas, local pubs, go to shows and go out for lunch. One of the service users told the inspector that he goes out independently and that he also has a part-time cleaning job. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 14 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, daily logbooks and visitor’s book evidenced that the home supports service users to maintain family contacts. Visitors are welcome in the project. The people who use the service confirmed this. 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. There has been an ongoing problem with ventilation in the main kitchen. Since the last inspection, the manager had obtained quotes, which have now been approved and work to improve ventilation was due to start soon. The requirement in relation to the ventilation in the main kitchen has therefore been repeated with a new timescale. The inspector was informed that all food products in the home are purchased in bulk. It was previously been recommended that that fresher and better quality food should be bought on a twice weekly or even more regular basis from local retailers with service users’ involvement instead of making bulk purchases. In addition 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. At the time of this visit, this recommendation has not been met and it has therefore been repeated. Fridge/freezer temperatures were taken and recorded daily. Trumpington Road 130 DS0000036677.V363188.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. Improvements have been noted to the way staff support people who use the service in order to meet their personal and healthcare needs. Medication systems were generally well maintained, however staff must follow manufacturer’s directions in relation to storage of medication and its shelf life. 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, where needed. Trumpington Road is a respite unit and the primary responsibility for meeting any healthcare needs of the service users remains with their primary carers. Longer stay residents are registered with the local GP and are supported by staff to attend appointments and check ups. Improvements have been noted since the last inspection and each person had a health action plan in place, which were up-to-date. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 16 The requirement that service users are weighed on a regular basis has now been met and there was evidence to support this on individual service user’s files. The inspector checked medication stocks and these were found be correct. He was satisfied that appropriate records of medication brought into the home, administered to the people who used the service and returned to the pharmacy/primary carers was maintained. Since the last inspection the home had a controlled drugs cabinet installed. The majority of the medication kept in the home was appropriately stored. The inspector noted, however that one of the service users was prescribed medication in a syrup form, which had to be discarded 90 days after it was first opened. At the time of this inspection, staff were not recording when each bottle was opened, hence allowing for this medication to be administered after it has passed its shelf life. The registered person must ensure that staff record dates of any medication opened by them, so that they follow manufacturer’s instructions in relation to its safe storage and shelf life and that any expired/unused medication is discarded/returned to the pharmacist as required. Trumpington Road 130 DS0000036677.V363188.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. Even though appropriate adult protection policies and procedures were in place, not all staff appeared to be aware of the purpose of the whistleblowing procedure. 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. Appropriate complaint systems were in place. Two of the service users who spoke with the inspector said that they would bring any concerns to the home manager and/or their keyworker. As part of this visit, the inspector asked a number of questions in relation to adult protection issues. Service users who spoke with the inspector informed him that they were given information about what to do it they did not feel safe or happy. The inspector also interviewed 3 members of staff working in the home (two members of staff who were directly employed by the London Borough of Waltham Forest and one member of staff who employed by the agency). Whilst staff demonstrated that they knew what to do if they suspected abuse or an allegation was made by a service user, not all staff were aware of the practice of “whistleblowing”. It is therefore required that staff are offered a refresher training on adult protection issues, including “whistleblowing”, so that they were aware of the Public Interest Disclosure Act 1998 and the Department of Health guidance “No Secrets”. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 18 Service users’ finances were not checked on this occasion. Trumpington Road 130 DS0000036677.V363188.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 approximately 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.V363188.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 inspector carried out a tour of the premises. He was taken around the premises by one of the people who used the service and a member of staff working in the home. Some parts of the premises required cleaning and tidying up. It was noted that some of the furniture was becoming to look old and worn and required replacement. An offensive odour in one of the bedrooms has now been eliminated, as previously required. Some of the carpets, especially in communal areas were old and torn and required replacing. The registered person must ensure that all parts of the home are kept clean and reasonably decorated. Appropriate arrangement for safe storage and disposal of clinical waste were now in place, as required at the last inspection visit. Trumpington Road 130 DS0000036677.V363188.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 good. This judgement has been made using available evidence including a visit to this service. Satisfactory staffing levels were in place, however staff would benefit from a refresher course in adult protection issues, especially whistleblowing. EVIDENCE: During the course of this visit, the inspector spoke to several care staff and one deputy manager. 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. Documents viewed contained 2 references and satisfactory enhanced Criminal Records Bureau disclosure, which included checks against the Protection of Vulnerable Adults (POVA) list. The inspector was informed that CRB checks were now being carried out on a three yearly cycle, as previously recommended. Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 22 As previously mentioned, it was identified during this inspection that not all staff were fully aware of the Whistleblowing procedure and would benefit from additional/refresher training. According to the Annual Quality Assurance Assessment, which was completed by the home manager, the majority of permanent staff have obtained NVQ Level 2 in Care or above. Trumpington Road 130 DS0000036677.V363188.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, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to ensure that all National Minimum Standards are met. EVIDENCE: Since the last inspection, the home has got a new manager. The new manager has previously worked in the home as a deputy manager. She is a qualified nurse and holds a relevant managerial qualification. At the time of this visit, the requirement that an application for the manager to become registered with the Commission remained unmet and has therefore been repeated. The inspector remains concerned that very limited progress has been made since the last inspection visit to ensure that all outstanding statutory Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 24 requirements and recommendations have been met. As mentioned in earlier parts of this report, a referral has been made to the Regional Enforcement Team within the Commission in order to secure compliance with the law in relation to the home’s care planning and risk management systems. As part of this visit, the inspector asked to see copies of reports from monthly unannounced visits from the registered provider, which are required by law. The home manager was able to locate 6 out of 12 required reports. Following this inspection, 2 additional reports for the last 12-month period were forwarded to the inspector. It is of concern that monitoring visits from the registered provider are not being undertaken on a monthly basis in line with the Regulation 26 of the Care Homes Regulations and that copies of the reports from such visits are not being forwarded to the home, so that the manager and staff are aware as to what improvements are required. It is required that visits by the registered provider are carried out in accordance with Regulation 26 of the Care Homes Regulations. A copy from each visit should be made available to the home and to the Commission following each visit on a monthly basis. The previously made recommendation that the views of family, friends and advocates and stakeholders in the community are sought on how the home is achieving goals for service users, still remains unmet and has therefore been repeated. Appropriate health and safety checks were in place. The Landlord’s Gas Safety Certificate was issued in May 2007. The care home’s fire alarms were tested on a regular basis and fire drills were also carried out. A fire risk assessment was last updated on 12/09/07. Portable Appliances Testing was overdue, however it was arranged for the following day. At the time of this inspection, the home manager was unable to locate the home’s registration certificate and it was not displayed, which is an offence. The registered manager must ensure that the home’s registration certificate is displayed in the home at all times. Trumpington Road 130 DS0000036677.V363188.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 X 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X 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 3 2 X 2 X 2 X X 3 2 Trumpington Road 130 DS0000036677.V363188.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 YA3 Regulation 14(2)(b) Requirement It is required that an assessment in undertaken by the service users’ social worker to review the current placement and to identify a more suitable placement for that service user. (Previous timescales of 01/09/07 and 01/03/08 were not met.) The registered manager must ensure that the main kitchen is adequately ventilated at all times. (Previous timescales of 01/09/07 and 01/04/08 were not met.) It is required that an application for the home manager to become a registered manager is submitted to the Commission. The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people competent to do so and with consultation with a service user. For individuals referred through Care Management, the registered manager must obtain a summary of the single Care Management assessment and a copy of the single Care Plan. DS0000036677.V363188.R01.S.doc Timescale for action 01/07/08 2. YA24 23(2)(p) 01/08/08 3. YA37 8, Care Standards Act 2000 14(1) 15/06/08 4. YA2 15/06/08 Trumpington Road 130 Version 5.2 Page 27 5. YA20 13(2) 6. YA23 13(6) 7. YA30 23(2)(d) 8. YA24 23(2)(d) 9. YA39 26 10 YA43 Care Standards Act 2000 The registered person must ensure that staff record dates of any medication opened by them, so that they follow manufacturer’s instructions in relation to its safe storage and shelf life and that any expired/unused medication is discarded/returned to the pharmacist as required. It is required that staff are offered a refresher training on adult protection issues, including “whistleblowing”, so that they were aware of the Public Interest Disclosure Act 1998 and the Department of Health guidance “No Secrets”. The registered person must ensure that all parts of the home are kept clean and reasonably decorated. The registered person must ensure that carpets are replaced throughout the building, in order to maintain a safe, pleasant and hygienic environment. It is required that visits by the registered provider are carried out in accordance with Regulation 26 of the Care Homes Regulations. A copy from each visit should be made available to the home and to the Commission following each visit on a monthly basis. The registered manager must ensure that the home’s registration certificate is displayed in the home at all times. 15/06/08 01/08/08 01/07/08 01/08/08 01/07/08 01/07/08 Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA17 YA39 Good Practice Recommendations It is recommended that food products be bought from local retailers with service users’ involvement instead of making bulk purchases. (This is a repeated recommendation.) 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. (This is a repeated recommendation.) Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Trumpington Road 130 DS0000036677.V363188.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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