CARE HOME ADULTS 18-65
1b Vale Road 1b Vale Road Forest Gate London E7 Lead Inspector
Sharon Lewis Announced Inspection 30 August 2005 at 10:00am
th 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 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 Stationary 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. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 1b Vale Road Address 1b Vale Road, Forest Gate, London E7 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8471 3545 020 8471 3545 Heritage Care Ms Europa Durning Care Home Six (6) Category(ies) of Learning Disability (6), Learning Disability over registration, with number 65 years of age (6) of places 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 20th October 2004 Brief Description of the Service: 1B Vale Road is a registered care home which provides 24 hour residential care for 6 people with learning disabilities. The registered provider is Heritage Care, and the property is owned by London & Quadrant, who also provide housing services. It is situated on the ground floor and is specially designed to accommodate people with mobility difficulties, with most areas being fully wheelchair accessible. All service users have single bedrooms with washbasin facilities. The home has a communal lounge and kitchen/dining areas. The lounge overlooks the communal garden that includes a patio area with garden furniture and lawn area with flowerbeds. Vale Road is situated off Upton Lane, in Forest Gate. Buses 25 and 86 run along the Romford Road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of culturally diverse shops, services and amenities are situated on Upton Lane, Romford Road and Woodgrange Road. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Announced Inspection was undertaken on a Tuesday and lasted approximately eight hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. The Inspector spoke to all service users currently living at the home. Individual discussions were also held with the Acting Manager and three Support Workers. Service users files and daily logs, medication and medication administration records, all health and safety records and other relevant documentation were examined. A tour of the premises was also undertaken. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well:
All service users were comfortable in their surroundings and indicated that they were happy living at the home. Service users benefit from residing in a warm, family atmosphere where their individuality and independence is promoted. Person centered planning is at the centre of the home’s philosophy. Quality of care is service user led. The home focuses on service users unique histories, individual needs and personal preferences. Personal activity and care plans are then developed which reflects their individuality. The home is commended for the production of pictorial individual ‘My Life’ life story files. Service users had built up good relationships with staff. Service users benefit from a stable, competent staff team. Service users are able to take part in age, peer and culturally appropriate activities. The home demonstrated that service users engage positively in their local community and are attending relevant classes and social groups.
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 6 This included visiting their local pub, café, hairdresser, tea dances, flower arranging, pensioner’s group, sauna, swimming and accessing a range of local amenities. During the Inspection two service users went out for lunch. Service users have opportunities for personal development within the home. Service users are able to attend a Women’s Group and music therapy. Spiritual needs were addressed through regular church attendance. Service users benefit from a range of in-house activities that included pampering sessions, aromatherapy, foot massage, facials, art and music/sing songs. Independent living skills are actively encouraged. During the Inspection service users were observed participating in individual cooking sessions. Service users additionally assist with gardening, meal preparation, clearing the table, shopping, housework and their laundry. Each bedroom was individualised with its own colour scheme and washbasin facilities. Service users bedrooms had a range of personalised items that reflected their individuality, hobbies and interests. What has improved since the last inspection?
Service users benefit from an increased security system, daily patrols by the local Police and management liaison with the community team and council departments. The home now has CCTV surveillance for the external areas and there are plans to install a security gate. Service users reviews now include the involvement of respective local authorities. Service users are now assured that their changing needs are regularly reviewed with significant professionals. A refurbishment and maintenance programme is in progress. During the Inspection a new bathroom was in the process of being fitted. Efforts have been made to promote service users political activity and encouragement to vote. A ‘Right to Vote’ information pack had been obtained from the Disability Rights Commission. Service users benefit from a permanent staff team. The organisation has managed to recruit to the majority of vacant positions. Continuity of care has been achieved through bank staff being recruited to permanent positions. A pictorial service user contract has been developed, which enables service users to have greater understanding of the home’s terms and conditions.
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 7 What they could do better:
During this Inspection fourteen legal requirements were highlighted and three recommendations. The Statement of Purpose and Service User Guide must be further developed. The Statement of Purpose must be updated to include the Acting Manager’s qualifications and experience. The Statement of Purpose and the Service User’s Guide must also include the Commission for Social Care Inspection details in regards to complaints. Service users and their relatives must have adequate up-to-date information regarding the home. The service user contract should be signed by the service user, their next-ofkin or representative. Each service user must have an appropriate written contract which details the terms and conditions within the home. The home must hold regular service users meetings. A creative system must be devised which ensures service users consultation in all aspects of the home. Health and safety and general maintenance must be further addressed. The damp/plastering damage in the hallway must be addressed. The hallway additionally requires redecoration. The paintwork in the identified bedroom must also be retouched in the necessary areas. The radiator must also be repaired and dusted in this room. The missing tap cover must be replaced in the identified room. The chest of drawers handle must also be replaced in the identified bedroom. A suitable lock must also be fitted on the rear bathroom door. Service users must reside in a well maintained, homely environment. Weekly fire alarm tests must be undertaken. The home must record everyone involved in each fire drill and any other comments. The fire risk assessment for the building must also be updated. Service users must be protected by the home’s fire safety practices. Fridge and freezer temperatures must be recorded on a daily basis. Service users health must be protected by the home’s food hygiene practices. When available the home must obtain a copy of Newham’s Adult Protection procedure, in order to better protect service users from abuse, neglect or selfharm. The home must provide appropriate bedding for service users. Service users should not be purchasing their own bedding unless they wish to upgrade to a
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 8 more expensive range. Service users finances must be safeguarded by the home’s financial practices. Service users must be protected by more robust recruitment practices. Required personnel information must be available on staff files in accordance with Schedule 2, The Care Homes Regulations 2001. This is an outstanding requirement from the previous two Inspections. Staff must receive regular supervision and a appraisal system must be introduced. Team meetings should also be held more frequently. The person who records the staff team meeting minutes must be identified to ensure accountability. Service users must benefit from a well-supported staff team. A staff training plan must be produced. Service users individual and collective needs must be met by an appropriately trained staff team. The Acting Manager must submit a manager registration application form to the Commission for Social Care Inspection. The Acting Manager must additionally enrol on a level 4 NVQ in both management and care. Service users must benefit from qualified management. A quality assurance survey should be conducted and information sought from service user family friends, advocates and other stakeholders within the community such as outside professionals. A record should also be kept of all compliments. Service users and their representatives views should underpin the self-monitoring, review and development of the home. 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. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5 Vale Road demonstrated the ability to meet service users needs. Documentation must be further developed to inform service users choice and promote their rights. EVIDENCE: All service users were comfortable in their surroundings and indicated that they were happy living at the home. Service users benefit from residing in a warm, family atmosphere where their individuality and independence is promoted. This Inspection evidenced the home’s ability to meet the individual and collective needs of service users. The Statement of Purpose and Service User Guide must be further developed. The Statement of Purpose must be updated to include the Acting Manager’s qualifications and experience. The Statement of Purpose and the Service User’s Guide must also include the Commission for Social Care Inspection details in regards to complaints. Service users and their relatives must have adequate up-to-date information regarding the home. A pictorial service user contract has been developed, which enables service users to have greater understanding of the home’s terms and conditions.
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 11 The service user contract should be signed by the service user, their next-ofkin or representative. Each service user must have an appropriate written contract which details the terms and conditions within the home. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 - 10 Service users individual needs and choices are generally promoted at Vale Road. Service user consultation must be developed. EVIDENCE: Person centered planning is at the centre of the home’s philosophy. Quality of care is service users led. The home focuses on service users unique histories, individual needs and personal preferences. Personal activity and care plans are then developed which reflects their individuality. All service user files were examined during this Inspection. Service users assessed and changing needs and personal goals, are reflected in their individual care plan. The home is commended for comprehensively, documenting service users needs. This included their social, health, emotional, communication, care and where appropriate sexual needs. The home is commended for the production of pictorial individual ‘My Life’ life story files for service users. These intertwined service users personal histories with world history events, included photo’s, pictures, collages, service users dreams, likes and dislikes. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 13 Care plans are subject to regularly reviews. Service users reviews now include the involvement of respective local authorities. Service users are now assured that their changing needs are regularly reviewed with significant professionals. Observation, discussion and examination of documentation, evidenced that service users exercised choice in their daily lives. Service users were observed engaging in different activities and choose whether to be alone or socialise with others. The Acting Manager explained that consultation meetings were not held, due to the communication needs of service users. The majority of service users communicate non-verbally. It was explained that the home must hold regular service users meetings. A creative system must be devised which ensures service users consultation in all aspects of the home. Service users are supported to take risks as part of an independent lifestyle. Risk assessments have been developed for all service users. Service users’ files were securely stored. The home evidenced through documentation, discussion and observation that service users are treated with respect and dignity. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 - 16 Service users lifestyle needs are individually promoted at Vale Road. EVIDENCE: Service users have opportunities for personal development within the home. Service users are able to attend a Women’s Group and music therapy. Spiritual needs were addressed through regular church attendance. It was good to service users involvement in the Person Centered Planning presentation. Service users are able to take part in age, peer and culturally appropriate activities. The home demonstrated that service users engage positively in their local community and are attending relevant classes and social groups. This included visiting their local pub, café, hairdresser, tea dances, flower arranging, pensioner’s group, sauna, swimming and accessing a range of local amenities. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 15 Service users benefit from a range of in-house activities that included pampering sessions, aromatherapy, foot massage, facials, art and music/sing songs. The home has a large video collection and staff related that service users particularly enjoyed watching musicals. During the Inspection service users were engaged in a range of activities which included reading magazines, cooking, exercising, listening to music, dancing, watching television, sitting in the garden, doing artwork, having a foot spa, going shopping and two service users also went out for lunch. Each service user has an individualised activity plan, which is subject to review. Activity plans were varied and incorporated the particular needs and interests of each service user. Currently the Activity Co-ordinator post is vacant and the Acting Manager is temporarily covering this position. This vacancy did not infringe on service users daily lives. All service users were engaged in meaningful activity. Discussion with staff and documentation evidenced that service users maintain family and personal relationships. This included visits by family and friends. Efforts have been made to promote service users political activity and encouragement to vote. A ‘Right to Vote’ information pack had been obtained from the Disability Rights Commission. Independent living skills are actively encouraged. During the Inspection service users were observed participating in individual cooking sessions. Service users additionally assist with gardening, meal preparation, clearing the table, shopping, housework and their laundry. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 - 20 Service users personal and health needs are promoted at Vale Road. EVIDENCE: Service users receive personal support in the way they prefer and require. Times for getting up/going to bed, baths, meals and other activities are flexible and dependent on service users needs and preferences. Service users choose their own clothes and their overall appearance reflects their individual personalities. Service users visited the hairdresser and barber regularly. Pampering sessions are part of the home’s activity plan and the majority of female service users had manicured nails. Documentation evidenced that service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Evidence was seen that service users have been referred to a speech and language therapist, clinical psychologist and specialist check-ups. Service users benefit from regular optician, chiropodist, dentist, psychiatric and district nurse support. The home promotes a healthy lifestyle through exercise. During the Inspection service users were observed using their exercise bike.
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 17 Medication was found to be securely stored and records were appropriately maintained. Service users files evidenced their medication was reviewed on a regular basis. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Further developments are needed to ensure service users safety and welfare is promoted, to minimise risk and safeguard them from abuse or harm. EVIDENCE: The home has produced a complaints policy. The complaints book was examined, there have been no service user complaints since 2001. Complaints were documented by staff against other staff members. These were appropriately addressed by management. Adult Protection procedures have been produced. The home had an adult protection flow chart displayed in the main office, which listed steps to take in reporting any incident of adult protection. Discussions with staff evidenced their awareness of the adult protection procedure. Records additionally evidenced protection of vulnerable adult training. The home has obtained a copy of the ‘No Secrets’ document issued by the Department Of Health. When available the home must also obtain a copy of Newham’s Adult Protection procedure, in order to better protect service users from abuse, neglect or selfharm. Service users finances and financial records were examined. Each service user has a record of their income, expenditure with running balances and receipts. All service users additionally had savings account. Records were appropriately maintained, however it was noted that a service user had purchased their own bedding. The home must provide appropriate bedding for service users. Service users should not be purchasing their own bedding unless they wish to
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 19 upgrade to a more expensive range. Service users finances must be safeguarded by the home’s financial practices. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28 & 30 Vale Road provides service users with a homely environment. General maintenance however must be further addressed. EVIDENCE: Vale Road is a purpose built property and all accommodation is on the ground floor. There are 6 single bedrooms all with washbasins and two bathrooms. Although one is currently being refurbished. There is a large kitchen/dining room and a communal lounge, which was comfortable and homely. Service users were noted to be enjoying the patio garden, which had garden furniture. A sensory garden is additionally being developed. Vale Road is situated off Upton Lane, in Forest Gate. Buses 25 and 86 run along the Romford Road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of culturally diverse shops, services and amenities are situated on Upton Lane, Romford Road and Woodgrange Road. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 21 Service users benefit from an increased security system, daily patrols by the local Police and management liaison with the community team and council departments. The home now has CCTV surveillance for the external areas and there are plans to install a security gate. Each bedroom was individualised with its own colour scheme and a washbasin facilities. Service users bedrooms had a range of personalised items that reflected their individuality, hobbies and interests. These included televisions, music system, personal artwork, pictures, exercise bike and other items of importance. The home has a laundry room and the premises was found to be clean and free from offensive odours. A refurbishment and maintenance programme is in progress. During the Inspection a new bathroom was in the process of being fitted. General maintenance must be further addressed. The damp/plastering damage in the hallway must be addressed. The hallway additionally requires redecoration. The paintwork in the identified bedroom must also be retouched in the necessary areas. The radiator must also be repaired and dusted in this room. The missing tap cover must be replaced in the identified room. The chest of drawers handle must also be replaced in the identified bedroom. A suitable lock should also be fitted on the rear bathroom door. Service users must reside in a well maintained homely environment. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 22 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 - 36 The home has adequate staffing however shortfalls must be addressed to ensure service users benefit from an effective staff team. EVIDENCE: Examination of the staffing rota and observations evidenced that the home was sufficiently staffed to meet the individual and collective needs of service users. All staff employed have social care experience. An on-call system is in operation in the event of an emergency. Service users had built up good relationships with staff. Service users benefit from a permanent staff team. The organisation has managed to recruit to the majority of vacant positions. Continuity of care has been achieved through bank staff being recruited to permanent positions. A senior support worker has been recruited and is expected to commence duties by October 2005. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 23 Service users must be protected by more robust recruitment practices. Required personnel information must be available on staff files in accordance with Schedule 2, The Care Homes Regulations 2001. This is an outstanding requirement from the previous two Inspections. NVQ training is in progress and a record of staff training was available. A staff training plan must be produced. Service users needs must be met by an appropriately trained staff team. Staff must receive regular supervision and a appraisal system must be introduced. Service users must benefit from a well-supported staff team. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 24 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 & 42 The home is adequately managed however service users welfare, health and safety must be better promoted. EVIDENCE: Service users benefit from the appointment of new Manager. The Acting Manager has worked for Heritage Care since 1997, has two years experience in a senior capacity and has managed the home since December 2004. The Acting Manager demonstrated the necessary skills and qualities for the role. The Acting Manager had a good rapport with service users and staff and was committed to improving the service to achieve the best outcomes for service users. The Acting Manager must submit a manager registration application form to the Commission for Social Care Inspection. The Acting Manager has a Level 3 NVQ qualification. The Acting Manager must additionally enrol on a level 4
1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 25 NVQ in both management and care. Service users must benefit from qualified management. Evidence was seen that team meetings were held and service users welfare and other pertinent issues were discussed. Team meetings should be held more frequently. The person who records the staff team meeting minutes must also be identified to ensure accountability. A quality assurance survey should be conducted and information sought from service user family friends, advocates and other stakeholders within the community such as outside professionals. A record should also be kept of all compliments. Service users and their representatives views should underpin the self-monitoring, review and development of the home. Weekly fire alarm tests must be undertaken. The home must record everyone involved in each fire drill and any other comments. The fire risk assessment for the building must also be updated. Service users must be protected by the home’s fire safety practices. Fridge and freezer temperatures must be recorded on a daily basis. Service users health must be protected by the home’s food hygiene practices. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 x 3 Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 4 3 2 3 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 3 2 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
1b Vale Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 3 x 3 2 x G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 27 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 1 Regulation 4 (c) Requirement The Statement of Purpose must be updated to include the Acting Manager’s qualifications and experience. The Statement of Purpose must also be amended to include the Commission for Social Care Inspection details in regards to complaints. The Service User’s Guide must be amended to include the Commission for Social Care Inspection details in regards to complaints. The home must hold regular service users meetings. When available the home must obtain a copy of Newham’s Adult Protection procedure. The damp/plastering damage in the hallway must be addressed. The hallway additionally requires redecoration. The paintwork in the identified bedroom must also be retouched in the necessary areas. The radiator must be repaired and dusted in the identified bedroom. The missing tap cover must be replaced in the identified room. Timescale for action 01.12.05 2. 1 5 (1) 01.12.05 3. 4. 5. 8 23 24 12 (2) & (3) 13 (6) 23 (2) (b) & (d) 01.12.05 01.12.05 01.01.06 6. 24 23 (2) (c) (d) & (m) 01.12.05 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 28 7. 8. 27 34 23 (2) (e) & (j) 19 (1) 9. 10. 11. 35 36 37 18 (1) (c) 18 (2) 9 12. 42 23 (4) 13. 14. 42 23 16 (2) (g) 16 (2) (c) The chest of drawers handle must also be replaced in the identified bedroom. A suitable lock must be fitted on the rear bathroom door. Required personnel information must be available on staff files in accordance with Schedule 2, The Care Homes Regulations 2001. (Previous two timescales not met.) A staff training plan must be produced. Staff must receive regular supervision and an appraisal system must be introduced. The Acting Manager must submit a manager registration application form to the Commission for Social Care Inspection. The Acting Manager must additionally enrol on a level 4 NVQ in both management and care. Weekly fire alarm tests must be undertaken. The home must record everyone involved in each fire drill and any other comments. The fire risk assessment for the building must also be updated. Fridge and freezer temperatures must be recorded on a daily basis. The home must provide appropriate bedding for service users. Service users should not be purchasing their own bedding unless they wish to upgrade to a more expensive range. 01.12.05 01.11.05 01.12.05 01.12.05 01.10.05 01.10.05 01.10.05 01.10.05 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 29 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 5 38 39 Good Practice Recommendations The service user contract should be signed by the service user, their next-of-kin or representative. Team meetings should be held more frequently. The person who records the staff team meeting minutes must be identified. A quality assurance survey should be conducted and information sought from service user family friends, advocates and other stakeholders within the community such as outside professionals. A record should also be kept of all compliments. 1b Vale Road G57 G06 S22851 1b Vale Rd V237795 300805 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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