Inspection on 03/05/05 for Vartry Road, 18

This inspection was carried out on 3rd May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Vartry Road, 18 06/09/07

Vartry Road, 18 07/08/06

Vartry Road, 18 17/10/05

Vartry Road, 18 05/10/04

Vartry Road, 18 29/04/04

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 18 VARTRY ROAD South Tottenham London N15 6PT Lead Inspector Karen M Malcolm Unannounced 3 May 2005 @ 10:20 am 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. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Vartry Road Address 18 Vartry Road South Tottenham LONDON N15 6PT 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 8802 8700 Mr Charan Singh & Mrs Margaret Badu of Choice Support Acting Team Manager Ms Lousie Njie PC Care Home 4 Category(ies) of Learning disabilities registration, with number of places 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 October 2004 Brief Description of the Service: 18 Vartry Road is registered as a care home providing personal care for service users between the ages of 18 and 64 who have learning disabilities. Choice Support has recently taken over as the registered provider. The home provides accommodation and support for four service users. It is situated in a residential area of Haringey and close to shops and transport facilities along Seven Sisters’ Road. St. Ann’s Hospital is about a mile away.The stated aim of the home is to ensure for service users: presence in mainstream community life, choice, competence, participation, respect, individuality, flexibility, co-ordination with other agencies and racial, cultural and religious sensitivity. The premises consist of a two-storey terrace house with three single bedrooms on the first floor and one single bedroom on the ground floor. One of the bedrooms has en suite facilities while the rest are provided with washbasins. The kitchen and dining room / lounge are on the ground floor. There is and a private back garden. There is also a sleeping in room/office. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 10.20 am and 3.30 pm. The newly appointed acting team manager and the acting assistant service manager assisted the inspector during the inspection. On shift were the acting manager and one support worker was on shift at the time of the inspection. One service user was in the home. The other three service users were at their allocated day centre. The home supports four service users with learning disabilities. At present there are no vacancies. All the service users have lived in the home for a number of years, one of the service users has lived in the home since it opened. The acting manager informed the inspector that she is leaving Vartry Road to pursue a career in social worker soon. The inspector had the opportunity to speak to one service user, however interaction was limited due to the nature of user’s learning and communication disabilities. The inspector was also able to speak with one member of staff, which was positive and informative. What the service does well: What has improved since the last inspection? What they could do better: As identified above there are thirty-four areas for improvements and one recommendation. While it is evident that although the staff are experienced and competent working in the care home, the home has failed to ensure that service users changes in care and health needs are recorded, reviewed or monitored appropriately. Systems in place to monitor these processes are not 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 6 being followed through. The registered person is required to submit an action plan, which describes how they will address these matters. The action plan must describe how the registered person addresses and ensure that the Statement of Purpose is amended, service users healthcare needs are addressed appropriately, care plans are reviewed monthly by the key worker and six monthly with the service user, their representative and the social worker, a number of maintenance issues to be addressed, ensuring care staff personal information is kept in the home, the rota is to reflect actual shift the acting service manager works, ensure the at water temperatures are checked and the registered persons to appoint a registered team manager for 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. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 5 Service users were confident that their needs, prior to moving into the home were assessed appropriately, which results in service user receiving a good standard of car. The home’s Statement of Purpose does not provide accurate information for prospective service users to make a choice about whether or not they might wish to live in the home. The home has failed to ensure that all service users who reside in the home have the opportunity to understand and agree the statement of terms and conditions provided by the home. EVIDENCE: A copy of the home’s Statement of Purpose was on file. However it was evident that the name and address referred to on the document was the address of another care home within Choice Support. It was advised that the home’s Statement of Purpose must refer to Vartry Road, the services it’s provides and the user group they support. It was also advised due to the communication difficulties of service users living at Varty Road the Statement of Purpose should be produced in a pictorial format. A requirement has been made relating to this. The home’s policies and procedures indicate that there is a clear and comprehensive admission policy in place. All the service users who reside at Varty Road have live there for a number of years. One user has lived in the home since it opened. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 9 Three care plans were examined. It was evident that all care plans had a copy of an assured tenancy agreement with Sanctuary Housing, the placing authorities agreement with regards to the placement and a contract of terms and conditions with the home. Within the exception of one, service users contracts with the home were signed and dated by the service users or the representative on their behalf. A requirement has been made relating to this. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users are able to take risks with appropriately support. The home has failed to ensure that service users six-monthly reviews are updated to reflect changing needs and agreed changes are recorded and actioned. The absence of this information potentially puts service users at risks of their needs not being met. The home’s system for handling service users personal monies is poor. This places service users at risk of service users of financial abuse. EVIDENCE: Three service users care plans were examined. All care plans have a clear index in place and a detailed personal profile with a current picture on the front of the file. It was evident that each care plan has been developed and agreed with the service users or their representative on their behalf. On examining the care plans it was evident that a number of reviews have not been completed, for example one service user’s care plan was last completed in May 2004. It was advised that care plans are to be reviewed six-monthly. The acting manager showed the inspector new formats for individual personal planning and assessing individual’s health care needs. The inspector commended this, however, it was evident that only one service user health care needs had been completed. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 11 The acting manager stated that all service users have their own individual bank accounts. Benefits for individuals are paid into their own accounts. The inspector was informed that at present the Service Manager for London Borough of Haringey is the only signatory for each of the service users, this is due to the number of changes in the management structure since the previous inspection. Each of the service users has a named key worker. It was evident that each key worker completes monthly summaries. However, it was evident that this was not consistent. Detailed risk assessments are in place on each of the service users file. The care plans are kept securely in the office. However, a number of petty cash tins were observed on the desk in the office. The acting team manager stated that the reason for this was that she was completing some accounts from the night before whilst on her sleep-in duty. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 & 17 Service users engage and benefit from a full active social and leisure lifestyle. Service users are offered a wide range of various meals. However, there are serious concerns that these choices are not always balanced or nutritional to meet individual’s needs. EVIDENCE: The inspector saw a comprehensive programme of activities for each service user. This is displayed on the office wall. There was documented evidence that service users regularly engage in a range of activities appropriate to their interests and abilities. Activities documented in service user plans included painting and art sessions, walking, watching TV, reading magazines, listening to music and various trips out of the home. Three service users have five-day placements at Ermine Road, a specialist day centre for people with learning disabilities, and one user is scheduled to attend three times each week, although he sometimes makes the choice to attend less often. Service users also take part in various activities including going shopping and for walks in the park. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 13 The kitchen was adequately stocked and there was a record of food served including individual variations as required. Records of menu plans are recorded on the newly devised daily log sheets. The daily log sheets give clear guidance to care staff on what information is needed. However, these were not completed consistently by care staff or monitored by the acting team manager. The information provided on a number of sheets examined, were brief or not filled in. One service user’s daily log sheets examined, recorded in the section for breakfast was ‘custard and tea.’ This was consistently recorded on different days. The acting manager stated that this specific service user had recently been admitted into hospital a week before the inspection with abdominal complications. This has been addressed in the section for ‘Personal and Healthcare Support.’ It was evident from the discussion with the acting team manager and one of the care staff separately, that choice is used to established individual’s needs within the home. The example given was that a tin of custard and Weetabix is shown to the individual to make their choice at breakfast. It was evident from the discussion with staff that informed positive choice was not being used in a positive way around mealtimes. A number of requirements relating to this are made. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Healthcare needs of service users are addressed. This is not always consistent, monitored or reviewed when any changes occur to individual health. Medication policies and procedures are comprehensive and clear. The home has failed to ensure that service users medication reviews are monitored. EVIDENCE: Service users health care needs are recorded on file. However, it was evident that this was not consistent. A number of care plans did not have records of service users current optician, dental or chiropody. One service user who has epilepsy did not have in place a record of his up-to-date seizure, although recorded in the incidents/accident file were a number of seizure recorded. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 15 The home has made a referral for the same specific service user to the learning disabilities team in Haringey for physiotherapist input. This is due to the user’s mobility become unsteady, causing him to have a number of serious falls. These have resulted in the user either being taken to hospital, or an appointment being made with the GP. During the tour of the building, it was evident that the same specific service user has a baby monitoring devise in his room. This is to monitor the user during the night in case he has a seizure. The baby alarm is linked to one of the sleeping-in staff rooms. This was discussed with the acting manager and was deemed intrusive. The manager stated that other devices have been used but these were deemed unsuitable. However, there were no records of this on file. At the previous but one inspection a requirement was made with regards to the registered person producing a policy on the use of restraint and limitation to service users freedom/ privacy to include guidelines for the use of monitoring equipment. However, this was not in place. A requirement is made. It was also evident that the same service user has a fear of injection and has refused on a number of occasions not to have a blood test. The user’s GP was not happy with care staff decision not to restraint the user during a visit for a routine blood test and the consequences of this resulted in a complaint by the GP. Following this a multidisciplinary meeting was held. The outcome was a ‘management of risk strategies’ report. A copy of this was on file in the home. During the inspection the inspector was advised that this specific service user has a blood test appointment coming up and the acting team manager stated that an appointment has been made with the GP to prescribe a mild sedative for the service user. This was discussed with the acting team manager and it was advised that if there are any changes to the ‘management of risk strategies’ this is to be referred back to the multidisciplinary team, with evidence why before this decision is changed. The home has a clear and comprehensive medication policy in place. Medication supplied to the home is in blister packs. It was evident on the MAR charts examined that one service users takes daily one dosage of evening primrose as a recommendation from the learning disabilities consultant. However, the medication it not prescribed and is brought by the user. The acting team manager stated that this specific user has been taken this medication for many years due to the recommendation. It was advised that evening primrose should be prescribed by the GP, but the inspector was informed that the GP has refused to prescribe the evening primrose as a long-term medication. On examining the specific service users healthcare records, no record was made relating to this. The inspector was informed that one service user was admitted to hospital for one day, a week before this inspection. A copy of the report was submitted to the CSCI. However, it was evident from a discussion with the acting team manager that the specific service user was admitted to hospital with abdominal 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 16 complication. This problem has been an ongoing medical problem, which has now become serious. The manager explained that the specific service user’s health condition is related to dietary needs. It was evident that no report regarding this issue was on file, no hospital admission details, no up dated risk assessment or what action is now with regards to the user’s dietary care needs. This was discussed with the acting team manager and the care staff member, who escorted the user to hospital on the day. During the inspection the staff member completed a brief report and a Regulation 37 was submitted to the inspector after the inspection. A requirement regarding this is made. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users know that their views are listened to and appropriate policies and procedures are in place to protect service user from abuse, neglect and selfharm. EVIDENCE: Although at the previous inspection it was identified that the complaint policy should be in pictorial form to guide service users to complaint, this was not in place. There were no records of any complaints having been received. The home has a policy and procedure to guide staff on how to respond to allegations or evidence of abuse from service users. As recommended all staff working in the home had signed to indicate that they have read and understood and agreed to abide by the adult protection and whistle blowing policies. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, & 30 The standard of décor is satisfactory therefore providing service users with pleasant environment which to live. The home has failed to ensure that service users environment is maintained inside and out when repairs or improvements are needed for the home. EVIDENCE: The house is located near to local amenities such as public transport and local shops and is comfortable and on a domestic scale. The home has a lounge/dining room on the ground floor, a spacious kitchen. The home has four single bedrooms. There is one bedroom that has quite limited useable space as it is below 9.3 sq metres. This bedroom had compensatory space in the form of additional communal space. During the tour of the home the inspector noted that the bedrooms that were seen were comfortable and well furnished and had been personalised to suit the personalities and interests of their occupants. However, one bedroom had a number of nails sticking out of the wall these were deemed dangerous and must be removed. The vanity sink unit cupboard door in the same service user’s bedroom was broken. These were addressed with the acting team manager. A requirement relating to this made. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 19 It was also evident during the tour of the building that the kitchen units were broken and needed replacing and the grill glass oven door was broken and was taped up. The acting manager stated that this has been reported to the housing association last year however, in the maintenance logbook examined there was no record of this. The service manager stated that the housing manager is aware of this, as he has visited the home recently. During the tour of the building it was evident one of the armchairs in the lounge was blocking one of the fire doors in the room, this chair was also worn and old. The manager stated that this is being replaced. The bin in the kitchen had no lid on it, two lampshades were needed in the sleeping-in room and in the hallway, the towel dispenser in the kitchen had no towels, the back door to the garden did not lock properly and the grassed area in the garden needed cutting. The manager stated that service users are able to access the garden at anytime and one service user spends a lot of time in the garden from time to time. It was also recorded in the maintenance book and reported to the housing association the day before the inspection, that there were a number of cockroaches found in the kitchen area. The acting team manager also stated that over the past year the home has had mice, ants and now this. It was advised that the home should consult with the local authority environmental office with regards to this. It was also required at the previous inspection that the registered person is to provide proper storage cupboards in the downstairs hall or cease this area for storage. During the tour of the building this area was still being used as a storage area by the home. This requirement has been restated in this report. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 & 35 The home has failed to ensure that service users are protected and supported by sufficient permanent competent and qualified staff. EVIDENCE: At present the staff team consist of three full-time care staff and this includes the acting team manager and two part time care staff. It was evident that there are a number of vacant posts and that bank staff covers these. At the previous inspection the registered persons were required to ensure that a personnel file is kept in the home for all staff that work regularly in the home and that all files include the necessary identification in each staff members’ files. Whereas this has been addressed for most staff, new staff members’ personnel files do not include the necessary information. This is not to say that the registered providers have not undertaken adequate checks prior to staff commencing work in the home. The home has clear and thorough policy and procedures in place regarding recruitment. However the appropriate information has not been provided to the home by the central personnel department of the organisation. This information must be available in the home and as this requirement is not fully met it is restated in this report. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 42 & 43 Service users health, safety, welfare and the future are being regularly reviewed and monitored. The registered provider has failed to ensure that the there is a manager in post to ensure that the service users benefit from a well run and managed home. EVIDENCE: Prior to the inspection a letter was submitted to the inspector stating the manager of the home is now acting as the assistant service manager for the organisation and one of the support workers is acting up as the team manager. During the inspection the acting team manager and acting service manager was present and they informed the inspector that one day a week the acting service manager completes a shift within the home to support the acting team manager. However, on the rota shown to the inspector this was not reflected. A requirement is made relating to this The acting team manager also stated that she is leaving the organisation to pursue a career in social work. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 22 The health and safety certificates were in place. However, the water temperatures checks were checked by the home on a monthly basis. On examining the records it was evident that only the kitchen and the office water temperatures were checked. It was advised that the water temperatures should consist of all the baths and sinks in the home and this should be completed weekly. The fire drills are completed quarterly and checks are completed weekly. The new format introduced for recording fire drills did not have a specific section to record the names of the users & staff present in the home, at the time of the drill, however, the old format did. The home’s financial business plan was in place. It was also evident that the fax machine was not working on the day. This was addressed with the acting team manager. It was also evident that the registered persons had not completed ‘person in control’ visits since the last inspection. This was addressed with the acting service manager. Prior to this report being completed copies of the home’s Regulation 26 visits were submitted to the CSCI. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 2 Standard No 31 32 33 34 35 36 Score x 2 x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 18 VARTRY ROAD Score x 1 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 3 G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The registered persons must compile in relation to the care home a written Statement of Purpose which consisit of the aims and objectives of the care home, the facilities and services which are provided for the service user group who reside in the home. This need to be updated accordingly. The registered persons must ensure that all terms and conditions in respect of the accomodation to be provided for service users are to be signed and dated by all parties. This is to include the service user, their representative and the manager. The registered persons must ensure that service users care plans are reviewed at least sixmonthly with the service user, their representative and the manager. To reflect changing need and agreed changes are recorded and actioned. A record of this is to be kept on each of the service users care plan file. The registered persons must ensure that monthly summary Timescale for action 30 June 2005 2. 5 5(1)(b) 30 June 2005 3. 6 15(2)(b) 30 July 2005 And from then on 4. 6 15 (2)(b) 30 July 2005 Page 25 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 5. 7 17(2) Schedule 4.9 6. 6 15(1) 7. 17 16(2)(i) 15(2)(b) 8. 17 17(2) Schedule 4.13 9. 19 12(1) reports, completed by care staff on behalf of the service users are completed monthly and these are monitoried and reviewed. The registered persons must ensure that service users cash tins are kept securely. Guidance notes for care staff are to be put in place. These procedures are to include checking and storing of service users cash tins. The registered persons must ensure that each service users daily log sheets are completed after each shift by a care staff. The daily log sheets are to be completed in full, detailing all the events, activities, incidents that required on the sheet. The registered person is to monitor and review the daily log sheets to ensure they are being completed. The registered persons must ensure that service users with communicational difficulties are given informed positive choices at meal times. Written step-bystep guidance notes on how this is appropriately communicated to each service user is to be on file. This is to be reviewed and monitored by the registered person. The registered persons must ensure records of food provided for service users in sufficient detail to enable any person inspecting the records to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diet prepared for individual service users. The registered persons must ensure the specific service user who was admitted to hospital with a complication health issue And from then on 30 June 2005 And from then on 30 June 2005 And from then on 30 July 2005 And from then on 30 June 2005 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 26 10. 17 14(2) 11. 19 13(1)(b) 12. 19 13(1)(b) 13. 19 13(1)(b) 14. 19 14(2) 15. 19 13(1)(b) 14(2)(a) is to be referred to a dietican. A record of action/s taken is to be kept on file and reviewed monthly. The registered persons must ensure that the specific service users risk assessment is updated, regarding the users current health issue. The registered persons must ensure 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. The registered persons must ensure all service users are supported to access and attend healthcare needs, such as optican, dental or chiropody. A record of the appointment is on file with a detailed account of the follow-up action being taken. The registered persons must ensure that the specific service users who has epilespy has on his health care notes a detailed account of all siezures. The registered persons must review the baby monitoring device in the specific service users bedroom. This is to include, the purpose for the baby monitoring alarm, a risk assessment with regarding the service users privacy/freedom and when it is to be reviewed. The registered persons must obtain advice and a risk assessment by a occupational therapist with regards to the baby alarm monitoring device in one of the service users bedroom. A copy of the risk assessment is to be on file alongside the OT assessment. 30 June 2005 And from then on 30 June 2005 And from then on 30 June 2005 30 June 2005 30 June 2005 30 August 2005 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 27 16. 19 13(8) 17. 19 13(1)(b) 14(2)(b) 18. 28 23(4) 19. 24 23(2)(b) 20. 21. 24 24 23(2)(b) 13(4) 22. 25 23(2)(b) 23. 24 23(2)(o) 24. 26 13(4) 25. 33 18(1) The registered persons must produce a policy on the use of restraint and limitation to service users freedom/ privacy to include guidelines for the use of monitoring equipment. The registered persons must ensure that the specific service management of risk strategies report is review with the multidiscplinary team before any changes are made. The records of the outcome of the meeting are to be place on file and monitoried monthly. The registered persons must provide proper storage cupboards in the downstairs hall or cease to use it for the purpose of storage. (Previous timescale 1 May 2005 not met.) The registered persons must ensure that the kichen cupboards that are broken are repaired. The registered persons must ensure that the broken oven grill glass door is replaced. The registered persons must rearrange the sitting area in the lounge area to ensure the fire door is not blocked and replace the broken worn armchair. The registered persons must repair the vanity sink unit that is broken in one of the service users bedroom. The registered persons must ensure that the garden grounds is cut and appropriately maintained. The registered persons must remove the nails that are exposed on one of the service user bedroom wall. The registered persons must review the present staffing situation in the home and a 30 July 2005 30 July 2005 16 July 2005 30 July 2005 30 July 2005 30 July 2005 30 July 2005 30 June 2005 And from then on 30 June 2005 30 July 2005 Page 28 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 26. 33 19 Schedule 2 Schedule 4.6 27. 33 19 Schedule 217(2) Schedule 4.6 13(4)(c) 28. 42 29. 37 9 30. 42 23(4)(c) 31. 24 23(2)(c) 32. 24 23(5) report of the outcome must be submitted to the CSCI on completion. The registered persons must ensure that a personnel file is kept in the home for all staff and that all files include the necessary identification in each staff members’ personnel files. (Previous timescale 1 December 2004 not met.) The registered persons must indicate clearly on the rota all staff shift patterns, sickness, annual leave and time on shift as required under 17(2) Schedule 4.7 in the Care Home Regulations 2001 (CHR 2001). The registered persons must obtain a thermostat control on the bath and sink taps in the bathroom to ensure that they do not exceed 43°c. A weekly record of all the sinks and bath temperatures is maintained on file. The registered persons must appoint a registered manager upon appointment an application for registration must be submitted to the CSCI The registered persons must ensure that the records of fire drills in the home include a list of all the staff and service users who were in the building at the time of the drill. The registered persons must obtain two lampshades one for the sleeping-in room and one for the hallway. Paper towels must be made available in the dispenser in the kitchen and a new bin placed in the kitchen. The registered persons must undertake appropriate consultation, with the local authority responsible for 30 July 2005 And from then on 30 July 2005 And from then on 30 June 2005 And from then on 30 August 2005 30 June 2005 And from then on 30 July 2005 And from then on 30 June 2005 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 29 33. 20 13(2) 14(2)(a) 34. 42 16(2)(ii) environmental health for the area with regards to the infestation of the cockroaches found in the kitchen area and appropriate action taken. The registered person must ensure all requests from the LD Consultant with regards the specifc service userss health, is reviewed and used as part of the assessment of needs. The registered person must ensure that the facsimile machine is working. 16 July 2005 30 July 2005 And from then on RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations It is reccomended that the registered persons should consider producing the homes Statement of Purpose for the home in a pictorial format. 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 30 Commission for Social Care Inspection North London Area Office Solar House, 1st Floor 282 Chase Road London N14 6HA National Enquiry Line: 0845 015 0120 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 18 VARTRY ROAD G59 S60634 Vartry Road V215220 03.05.05 (4).doc Version 1.30 Page 31 - 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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