Inspection on 23/07/08 for Vulcan Square

This inspection was carried out on 23rd July 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

Vulcan Square 09/01/08

Vulcan Square 07/09/06

Vulcan Square 26/01/06

Vulcan Square 03/08/05

Vulcan Square 22/02/05

Vulcan Square 13/07/04

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 09/11/2008.

CARE HOME ADULTS 18-65 Vulcan Square 32-33 Vulcan Square Westferry Road Isle Of Dogs London E14 3RJ Lead Inspector Lea Alexander Unannounced Inspection 23rd July 2008 1:15 Vulcan Square DS0000010308.V367726.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 Vulcan Square DS0000010308.V367726.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. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vulcan Square Address 32-33 Vulcan Square Westferry Road Isle Of Dogs London E14 3RJ 020 7537 0411 020 7987 3917 h3053@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Vulcan Square DS0000010308.V367726.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: Vulcan Square comprises two adjoining houses set in a small square of similar residential properties. Each house has lounge, kitchen diner and a ground floor wc and hand basin. On the first floor there are three service users bedrooms in each house and a small box room that accommodates the staff sleepover room in one house and the staff office in the other. The two houses have the same layout and are connected by a shared garden. Three female service users reside in one house and three male service users in the other. The buildings are owned and maintained by East Living. The home is staffed and managed by Mencap. The home is set in the heart of Docklands on the Isle of Dogs. There are local shops and amenities nearby. Behind the development there is access to the River Thames. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector visited the home over the course of two days. They had inspected the home on several occasions previously. During the course of the inspection we spoke to the manager and to the care staff on duty. Two people who use the service were on holiday, but we did speak privately to the four other residents who live there. We also looked at a range of records relating to the day-to-day running of the home and the manager completed an Annual Quality Assurance Assessment (AQAA) that we also looked at. The quality rating for this service is * stars. This means the people who use the service experience adequate quality outcomes. What the service does well: The home meets the needs of a diverse group of men and women of differing ages, cultures and abilities. The staff group are reflective of the people who use the service and the local community. People who use the service told us that they liked living at the home and that staff were friendly and helpful. Residents are supported to manage their finances. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 6 People who live at the home take part in a range of community, leisure and occupational activities. The home is comfortable and residents choose their own meals. People who use the service are supported to manage their medication and to attend healthcare appointments. Residents stay in contact with their families and friends. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? The home listens to residents and keeps them safe. The home properly vets potential staff. Staffs receive regular supervision and support to study for NVQ qualifications. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 8 What they could do better: As residents needs change their care plans and risk assessments must be updated. Residents should be involved in making decisions about the home. Confidential information must be kept securely. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 9 Some repairs are needed and home should smell nice. The manager must apply for registration and the homes quality assurance exercise must be published. All necessary health and safety checks must be carried out. 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. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 10 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 Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has developed a statement of purpose and service users guide and assesses potential residents prior to their moving in. EVIDENCE: The manager told us that no residents had been admitted to the home since the previous inspection. We looked at the personal files for two people, but could not find evidence of an initial assessment. We spoke to the manager who told us that they had looked through archived documents but had not been able to locate these. The manager assured us however that the home does have an established assessment process including a written assessment that all potential residents participate in. Previous inspections have evidenced that the home has produced a statement of purpose and service users guide. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service understands the rights of residents to take control of their own lives. Residents are also evidenced as participating in some of the decisionmaking processes of the home. Each resident has individual plans and risk assessments but these are not always comprehensive or updated when there is a change. EVIDENCE: We looked at the care plans for two residents and found that they addressed a range of health, social and personal care needs. For each person there was evidence of the home including life story work in the plans. These plans were also person centred. However, for one resident discussion with care staff and sampling of daily records evidenced that they had become increasingly incontinent, but this was not reflected in their care plan. A document in this Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 13 residents file also referred to guidelines and triggers for challenging behaviours but we could not find this document. Discussion with people who use the service, with the manager and with staff evidenced that residents each have their own bank account. All residents receive support in managing their finances, and with their agreement monies are held in the staff office and withdrawn as required. Residents have an individual locked box that contains their money. A separate log detailing the date and nature of any withdrawal or deposit is recorded and signed by staff. We talked to people who use the service and looked at the minutes of residents meetings. These evidenced that meetings take place each month, and that many aspects of the day-to-day running of the home are discussed. Topics discussed at recent meetings included holidays and day trips, household chores and maintenance. However, prior to this inspection the manager had contacted us to discuss plans for a change in use to one of the homes lounges. We noted that discussions with people who use the service or the available records did not evidence that these plans had been discussed or agreed with residents, and that part of the plan to install a PC for staff use had already been implemented. We looked at the risk assessments for two residents who use the service. Whilst some risk assessments relating to the care plan were available, some gaps were identified. For example one resident was identified as having increased episodes of challenging behaviour. Another resident was identified from records as having episodes of aggressive behaviour. Neither of these potential risks had been assessed. The relocation of a PC and staff mail slots to the residents lounge raises issues of confidentiality. We asked the manager how confidential information that might be displayed on screen in a public area, or put in an unattended staff mail slot would be protected, and were advised that procedures to address these issues were being developed. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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. 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. Residents are involved in meaningful occupational, leisure and community activities of their choice, according to their individual interests, needs and capabilities. People who use the service are supported to maintain important relationships and to develop daily living skills. EVIDENCE: Discussion with people who use the service, with the manager, with staff and sampling of records evidenced that people who use the service are supported to engage in a range of activities. The residents we spoke to told us that they got to choose what activities they participate in and enjoyed their daily routines. Some of the residents told us they particularly enjoyed the holidays and day trips the home had supported them to access. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 15 Each resident has an individual programme for between 4 – 5 days per week at either day services, community projects, and college or work experience. In addition residents are supported individually to attend local shops, hairdressers, social clubs and the swimming pool. Residents are supported to maintain contact with their families in the way that they choose. Some have visits from family members whilst others are supported to maintain telephone contact with overseas relatives. One resident is supported to maintain a friendship with a resident in another Mencap home. People who use the service told us that they choose when to join in with activities or to spend time with other residents. Residents told us that the meals provided were “okay”. During the course of our visit we observed one resident preparing their meal. A menu is drawn up each week and residents participate in the selection of meals. Staff and residents told us that an alternative is available if residents do not want to eat the meal identified on the menu. We looked at the homes planned menus for a five-week period. The meals offered were generally nutritious and varied. However, we noted that the home does not maintain a record of the meals actually taken by residents, particularly when an alternative to the planned meal is taken. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare services and personal care is responsive and varied according to individual needs. The home has good medication storage, recording and administration practises. EVIDENCE: We were told that the majority of residents require prompts or reminders to attend to their personal care, but that some residents do need assistance. We spoke with a member of care staff who was able to describe the steps they take to ensure that residents dignity and respect is promoted during personal care, for example covering parts of the body not being attended to, seeking permission and encouraging the resident to do what they can for themselves. The residents we met were dressed in clothes of their choice that reflected their personalities. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 17 The home maintains records of healthcare appointments attended by residents and their outcome. We looked at the records for two residents and these evidenced recent GP, Dental, Podiatry and Psychiatric appointments. The Manager and staff told us that none of the residents are self-medicating. One resident is prescribed a controlled drug. The home operates a corporate Mencap medication policy that complies with National Minimum Standards. We compared the actual medication available for two residents with what was listed on their Medication Administration Record (MAR). The two were found to correspond. We also noted that the MAR sheet was properly completed. Controlled medication was stored securely in accordance pharmacy guidance and a controlled drug register maintained. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home displays an easy to read complaints procedure, and residents are aware of how to make a complaint. The home has developed safeguarding policies and procedures and care staffs demonstrate an understanding of safeguarding issues and their responsibilities. EVIDENCE: The home operates corporate Mencap complaints and safeguarding policy and procedures that comply with National Minimum Standards. An easy to read summary of the complaints procedure is prominently displayed within the home. The residents we spoke to told us that they felt comfortable telling staff if there was anything they were unhappy about. We looked at the homes complaints log. The manager told us that the homes previous complaints log had been misplaced, and showed us the new log that had replaced it. This evidenced that one complaint had been received since the previous inspection and that this had been passed to a Senior Manager for investigation and response. Prior to this inspection the manager had informed us of an incident of challenging behaviour by one resident upon another. The incident had been fully documented and reported to relevant professionals involved in their care. A plan to manage any further potential incidents had also been developed and Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 19 implemented. However, we noted that the care plans and risk assessments of the two residents concerned had not been updated to reflect the potential behaviour or risks. We had received a notification from the home relating to the outcome of an adult protection matter identified at an earlier inspection, and we were satisfied that the matter had been dealt with in accordance with the homes policy and procedure. No other safeguarding issues were identified. The member of care staff we spoke to demonstrated a good understanding of safeguarding matters. They were able to identify a range of abuses vulnerable adults may experience and their responsibilities should they have any concerns. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a range of comfortable communal and private space, and residents have their own bedroom that they can personalise. However, during our visit there were some unpleasant smells and a number of repairs and maintenance issues were identified. EVIDENCE: The home is located in two four-bedroom houses in a residential location in Tower Hamlets. One house accommodates male residents, and the other female. The houses have a shared rear garden and staff and service users move between the two houses using patio doors onto the garden from each lounge. The houses are similarly laid out with lounge dining areas and separate kitchens. Each house has a ground floor WC and access to the first floor and Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 21 all bedrooms is via a staircase. In the women’s house the fourth bedroom is used as an office and in men’s house this room is used as a staff sleep in room. The houses are generally well maintained, and are comfortable and homely. Pictures of people who use the service decorate the communal areas, and residents are able to personalise their own bedrooms with pictures and other items. Residents told us they have a key to their own room and can choose whether they want to keep their bedroom locked. Several residents showed us their bedrooms. Each had been supported to personalise their room so that it reflected their personalities and important life events. Several minor repairs identified at an earlier inspection had been completed, however some new maintenance works were identified and these are detailed in the requirements section of this report. The manager advised that the majority of identified maintenance issues had already been reported for repair. We did also note that the open area’s underneath the stairs were being used for storage of some bulky items including flat pack furniture boxes and unused office materials, which was unsightly. Whilst we were inspecting the premises we noticed a musty smell in one of the bathrooms and a smell of urine in one residents bedroom. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have confidence in the staffs that care for them. Staff members undertake external qualifications beyond basic requirements, and sufficient staff is employed and rostered on duty by the home. The home has sound recruitment procedures and appropriately supervises care staff. EVIDENCE: The manager told us that there has been no new staffs join the home since the last inspection, but that one staff member had transferred to a different Mencap home. We were informed that the home currently employs five permanent care staff and also uses bank staff. Discussions with the manager and care staff evidenced that since the last inspection four-care staff have completed NVQ level 3 and are awaiting the outcome of their final assessment. At the time of this inspection two care staff were on duty during the day and a waking and a sleeping worker were on duty at night. We looked at the current staffing rota and found that it accurately reflected the situation found in the home. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 23 The residents we spoke to told us that staffs were friendly and that they felt relaxed with them. People who use the service also commented that staffs were supportive and helpful. We looked at the personnel information available at the home for two members of staff. This evidenced that for each two references and an enhanced Criminal Records Bureau (CRB) check had been obtained. However, the CRB for one member of staff was dated January 2004 and it was not evidenced that a more recent CRB had been obtained. New members of staff joining the home receive a corporate induction to the Mencap organisation. Sampling of personnel records, discussion with the manager and care staff evidenced that since January 2008 a range of training had been provided to staff including dementia, safeguarding, epilepsy and professional development. We looked at the supervision records for two members of staff. These evidenced that one staff member had received five supervision sessions in the current year and a second had received three. The manager advised that further supervision sessions had been scheduled and we were satisfied that both staff members would receive a minimum of six supervision sessions in the course of the year. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A manager has been appointed to the home, but they have yet to start the registration process with the Commission. A completed Annual Quality Assurance Assessment was received from the home. Some important health and safety checks, such as fire alarms are not being carried out regularly. EVIDENCE: A new manager was appointed to the home in March 2008. They told us that they had not yet applied to the Commission for Social Care Inspection for registration. The manager told us that they had commenced their NVQ level 4 studies and hoped to complete them by the end of 2008. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 25 The manager told us that a development plan was in place for the home and that a member of staff was currently reviewing and updating this document to include feedback from people who use the service in residents meetings and reviews. In addition the home has distributed feedback surveys to family members to seek their views on the service provided. The development plan and surveys were not available for us to look at during this inspection. The Manager told us that copies of all Mencap corporate policies and policies are available on the internal intranet, and that all permanent members of staff are able to access these online at the home. However, residents and bank staff are not able to access them, and the manager told us that they are exploring ways to address this. The home maintains a log of fridge and freezer temperatures. We looked at these and found that the temperatures were checked and recorded daily. The recorded temperatures were within acceptable limits. We looked in the fridge and freezer for both houses and found that some started processed food items had not been date labelled to ensure their consumption within the manufacturers stated timescales. We looked at the homes fire system records. These records evidenced that the home is not carrying out weekly fire alarm tests. The records for house number 33 evidenced that the most recent test had been carried out on the 7th July with another test carried out several days earlier on the 1st July. However, the two tests prior to this had been carried out on the 23rd June and 26th May 2008. In house number 32 the most recent test had been carried out on the 20th July 2008 with earlier tests being carried out on the 17th June and 7th May 2008. The records evidenced that regular evacuation drills are carried out. We also looked at the homes log of water temperatures and accident and incident reports and found these to be in order. The home displays a current insurance certificate with sufficient cover. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 2 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 3 X 2 X 2 2 X 1 X Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement The home must ensure that care plans are updated and reviewed, as a resident needs change. Guidance referred to in care plans must be available on the personal file. The home must evidence that residents are involved in the decision-making processes of the home. Risk assessments must be updated to reflect current potential risks and the plans to manage them. The home must ensure that confidential information is kept securely at all times. The home must maintain a record of the meals eaten by residents. In the men’s house the following repairs and maintenance must be carried out: (i) The mouldy grout in the men’s house upstairs bathroom and the damaged bath panel must be Version 5.2 Page 28 Timescale for action 20/10/08 2. YA8 24 20/10/08 3. YA9 13 & 14 20/10/08 4. 5. 6. YA10 YA17 YA24 17 13 & 16 13 & 23 20/10/08 20/10/08 30/12/08 Vulcan Square DS0000010308.V367726.R01.S.doc replaced. This is a restated requirement. The previous target of the 30/06/08 was not met. (ii) Damaged walls in the hallways and kitchen must be repaired. Dirty walls in the kitchen must be cleaned. Broken and damaged furniture in resident’s bedrooms must be repaired or replaced. In the bathroom the damaged bath, mouldy grout, damaged tiles and corroded radiator must be repaired or replaced. The missing cistern lid and missing light switch handle must also be replaced. In the downstairs WC the ceiling must be redecorated and the rusty extractor fan repaired or replaced. Mouldy grout by the WC and the missing cistern lid must also be replaced. (iii) (iv) (v) (vi) (vii) (viii) In the women’s house the following repairs and maintenance issues must be attended to: (i) The commode must be removed from the lounge. Version 5.2 Page 29 Vulcan Square DS0000010308.V367726.R01.S.doc (ii) (iii) (iv) (v) In the downstairs WC mouldy grout and the discoloured mirror must be replaced. The hallway should not be used to store unused office materials. In the bathroom the extractor fan must be cleaned and the toilet seat repaired or replaced. The damaged bath panel and missing light pull handle must be replaced. 7. 8. 9. YA30 YA37 YA39 13 & 16 8&9 24 10. YA42 12 & 37 Discarded items of office furniture must be removed from the garden and properly disposed of. The home must be free from offensive odours. The manager must apply for registration. Once collated the outcomes of the homes quality assurance exercise should be made available to interested parties. Started processed foods must be date labelled. The home must carry out and record weekly fire alarm checks. These are restated requirements. The previous target of the 30/05/08 was not met. 20/10/08 20/10/08 30/12/08 20/10/08 Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 30 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 YA34 Good Practice Recommendations The home should develop and implement a policy addressing timescales for the renewal of CRB’s. Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 31 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 Vulcan Square DS0000010308.V367726.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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