Inspection on 03/08/05 for Vulcan Square

This inspection was carried out on 3rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Vulcan Square 23/07/08

Vulcan Square 09/01/08

Vulcan Square 07/09/06

Vulcan Square 26/01/06

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 09/07/2008.

CARE HOME ADULTS 18-65 32-33 Vulcan Square Westferry Road Isle of Dogs London E14 3RJ Lead Inspector Lea Alexander Unannounced Inspection 3rd August 2005 at 2.30 pm 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. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 32-33 Vulcan Square Address 32-33 Vulcan Square, Westferry Road, Isle of Dogs, London, E14 3RJ 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 7537 0411 020 7987 3917 h3055@mencap.org.uk Mencap Ms Dorinda Maclean Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 22nd February 2005 Brief Description of the Service: Vulcan Square comprises of two adjoining houses set in a small square of similar residential properties. Each house comprises of a lounge, kitchen diner and a ground floor wc and handbasin. On the first floor there are three service users bedrooms in each house and a small box room which 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. At present two female service users reside in one house and three male service users in the other. The buildings are the responsibility of East Living, and the management and staff are employed 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. The home has experience some changes since the last inspection. The Manager, Deputy Manager and one support worker are currently suspended and undergoing investigation. A temporary Manager and Deputy have been appointed. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of an afternoon and evening. The Inspector individually interviewed three service users and one permanent staff member. The Inspector also spoke with the Deputy Manager. Personal files relating to service users and staff personnel files were sampled. The homes policies and procedures were also reviewed along with other relevant documentation. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection twelve previously identified requirements are restated and a further twenty-seven are made. Service users personal information is stored in a number of files and theses were found to be disorganized and out of date. Service user planning and review occurs irregularly and not all areas of need were recorded on the plans available. Risk assessments were inadequate. Neither these or individual plans are being regularly reviewed. Assessments and care plans did not 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 6 address health care needs. There is poor practise in recording and following up on healthcare appointments. Not all available medications were listed on the Medication Administration Record, and different lists of medication did not match up. Out of date medications had not been disposed of. Regular service users meetings are not being held. Poor cleaning practises were noted in one service users bedroom. Maintenance issues from previous inspections remain outstanding, and additional maintenance was identified as a result of this inspection. Key policies and procedures and one personnel file were not available on site. The fire evacuation record, accident and incident log and complaints log were poorly maintained. A number of staff training needs have been identified including adult protection and epilepsy training. Staff supervision and staff meetings have not occurred in many months. As a result of the number of shortfalls identified as a result of this inspection and as a significant number of these have been restated over time, the Commission for Social Care Inspection may now be minded to consider enforcement action. 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. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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) 2. There have been no new admissions since the last inspection. EVIDENCE: The Deputy manager advised that there continues to be a vacancy for one service user in the women’s house. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 9 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, 8, 9 & 10. Service users personal files, individual care plans and risk assessments were found to be in a disorganised state. It was not evidenced that the individual plans or risk assessments completed accurately reflected service users needs or that these documents are systematically or regularly reviewed. EVIDENCE: The Inspector sampled several service users personal files and noted that information continues to be stored in two ring binders and several other smaller folders and some loose leaves kept in a rack. Some of these files contained little information or were empty. Others contain information duplicated elsewhere. Correspondence that would be appropriately filed together, for example correspondence relating to finances was spread over a number of files. A previous requirement to review and rationalise the service user file system remains outstanding. The files sampled were of a poor quality. The Inspector noted that a statement of support and action plan had been completed on one of the service users sampled. This was annotated as being drawn up in June 2003 and being reviewed in June 2004. The service user and support staff had signed this. There was no evidence of any subsequent review. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 10 The Inspector noted that a separate detailed care plan for this service user relating to supporting this service user with their hair care was on file, but this was not related or referred to in the support and action plan. On this same service users personal file the Inspector found minutes of a placement review meeting dated October 2004 and noted that these were comprehensive and addressed area’s such as physical and emotional wellbeing, personal hygiene, domestic skills and social and leisure activities. The recording of this meeting was comprehensive and appears to have been user focused with many direct comments recorded from the service user. It was not clear from the documents viewed how this review meeting related to or informed the support and action plan or the individual care plan relating to hair care. The Inspector noted that in one section of the service users personal file headed “Residents Information”, confidential information relating to all service users was recorded. The home must ensure that service users personal files contain only information that relates to them. This remains an outstanding requirement from the previous inspection. The home must review its service user planning procedure and documentation. To benefit service users this should be a systematic process and individual plans should address the areas of service user need required by regulation. Written plans and records should support and enhance this process. Shortfalls in the homes service user planning process were identified at the previous inspection and these have yet to be addressed. The Inspector noted that the support and action plan for one service user did evidence that they were independent in choosing their own clothes. From viewing the accident and incident logs the Inspector found out that one service user is being supported to develop independence in their finances. An incident when the service user lost money is recorded in the accident and incident log, and the Inspector noted that there is no mention of this programme in the services personal file or individual plan and no risk assessment. The Inspector met privately with three service users. They all stated that they were happy living at the home. One service user told the Inspector that they had been involved in choosing their housemate and the decision as to who should move in. The Inspector requested to see minutes of service user meetings and was advised that these had not occurred “recently” and no minutes were able to be located. Service user meetings are an important forum to offer service users opportunities to participate in the day to day running of the home and should be held regularly and minuted. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 11 From the service user files sampled it was not evidenced that a risk assessment and management framework is being implemented as part of the care planning process. One service users personal file contained a risk assessment related to using an electric toothbrush. A risk assessment regarding their hair care routine is referred to but was not found on the personal file. The support plan documentation states that this service user requires assistance with using the cooker and microwave but no risk assessment for this activity was located. The Inspector viewed the homes procedure for unexplained absences and found this to be comprehensive. The Inspector did note however that this was filed in a folder labelled “house information” that contained only this procedure. The Inspector was concerned that staff might not easily locate this policy. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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) 12, 13, 15, 16 & 17. Service users are engaged in a range of educational, community and social activities and supported to maintain significant personal relationships. There is a choice of meals served at flexible times. EVIDENCE: From discussion with service users it was evidenced that they are attending a range of local occupational activities including Tower Hamlets College for literacy and numeracy classes, the Coburn Project day service, Poetry in Wood wood carving project and an evening social group. In addition several service users told the Inspector that they enjoy their weekly visit to the local pub. Another service user told the Inspector that he liked to watch videos in his room and chose videos from the local shop. This service user also told the Inspector that he likes the routine at the home and enjoys carrying out the household chores with staff support. From discussion with service users and from records in their personal files it was evidenced that the home supports service users to maintain contact with their families and friends. This included supporting them to send cards on 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 13 birthdays and special occasions. One service user told the Inspector that a friend who lives locally sometimes calls to visit them at the home. Another service user says their brother visits them regularly. The Inspector noted that one service users family lives overseas and staffs send regular copies of review meeting to the family who respond and give feedback on their perception of the service users needs. The Inspector viewed the homes contract with each service user. Whilst the home uses an excellent pictorial format to facilitate service users understanding, it was noted that a previous recommendation to include information on the alcohol and smoking policies remains outstanding. During the course of the inspection the Inspector noted that staff talk and interact with service users. The Inspector noted that service users were able to choose whether to sit together or to be alone. Each service user has their own front door key. The Inspector noted that a pictorial rota in each house identified the domestic chores that each service user has responsibility for. The Inspector was present during the evening meal and observed that service users were offered a choice of suitable meals that respected their individual preferences. Service users were able to choose where to eat and whether to eat alone or with other service users and staff members. The evening meal appeared relaxed unrushed and flexible to suit service users needs. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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. The Inspector was not satisfied that the homes current practise ensures that the healthcare needs of service users are met. The home must ensure that it take adequate steps, and keeps adequate records to address service users healthcare needs. The home must address its medication handling and recording as current documentation is contradictory and inaccurate. EVIDENCE: The Inspector noted that on service users personal files two different documents were being used to record healthcare appointments. The information recorded on each did not tally. On one service users personal file the dates recorded as being the due date for the next appt had expired on the appointment matrix without being updated. An appointment had been recorded as due, but with no record as to whether it had been kept or the outcome. The Inspector was particularly concerned regarding notifications received for both female service users for smear testing. One service user had received a letter in January 2005 stating that a smear test was overdue. Review notes from 2004 on the personal file identify the service users anxiety regarding this test. There is no record in any of the paperwork seen of work done with the service user to facilitate their being able to undergo the test or of any test being booked. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 15 A smear test reminder letter for the second service user dated May 2005 was pinned to the staff office notice board with no evidence of any appointment being booked. The Inspector further noted that an unfiled letter in the loose documents for one service user stated that another attendee at their day service had been diagnosed with TB and that medical follow up may be required for all service users. No other information regarding this could be located in the service users personal file. It is not clear whether any follow up was required or whether this occurred. The Inspector viewed the homes medication administration folder and noted that each service user has a section within this. Each section contains the medication administration record (MAR), a medication list and a medication pen picture. The Inspector noted that the lists of medication on these three sheets did not match up. The Inspector found that several available medications were not listed on the MAR and no reference was made to them anywhere in the medication file. One service user takes only “as required (PRN)” medication. Whilst this is listed on the MAR sheet the opening pages of their section in the medication file state that this service user takes no medication. An out of date medication for one service user had not been disposed of. The Inspector viewed the homes controlled drugs and found these to be in order. The Inspector was advised that no service users are currently selfmedicating. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 16 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. It was not evidenced that the home has a current, fully implemented complaints policy and procedure as required by regulation and previous inspections. To promote service user wellbeing all staff should receive initial and refresher adult protection training. EVIDENCE: The Inspector requested to view the homes complaints policy. Staff on duty could only locate a summary of this in the service user guide. The Inspector noted that the home continue to use an excellent pictorial version of the complaints procedure that is contained within the service user guide and displayed in the homes hallways. This has not however been revised to include a time limit not exceeding 28 days to deal with a complaint or contain up to date contact details for the Commission for Social Care Inspection as previous inspections have required. The Inspector asked to view the complaints log and was presented with a book whose last entry was in 1998. One of the service users spoken to by the Inspector was able to refer unprompted to the pictorial complaints procedure displayed within the home and also told the Inspector that they would tell someone who worked in the home if they had a problem or were not happy. The Inspector viewed the homes adult protection policy and noted that this was a corporate MENCAP nationwide policy. The member of staff spoken to at the time of the inspection had a knowledge and understanding of adult protection issues but the inspector noted that they had not adult protection training from their employer and required some prompting to identify different types of abuse and the situations abuse may occur in. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 17 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, 25, 26, 27, 28, 29 & 30. The premises have a homely feel and are representative of the service users who live there. Whilst the premises are generally clean, attention must be given to supporting service users to maintain their own bedrooms. Issues regarding the maintenance and upkeep of the premises have been identified over several inspections and this remains ongoing. EVIDENCE: The Inspector noted that the premises are comfortable, cheerful and free from offensive odours. Furnishings and fittings are of a domestic nature. The lounge and hallway carpets in both houses have recently been replaced. The communal areas in both houses are comfortable and representative of service users with their photographs displayed. Each lounge area includes a sofa, armchairs, dining table, TV and stereo. The furniture and décor differs in each house that gives a more homely feel. There are a number of outstanding maintenance and repair issues that have been identified over several inspections. These have yet to be addressed and include: a replacement patio door, potential trip hazards presented by the steps leading to the garden area, potential trip hazards in the garden and 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 18 replacement of chests of draws in each service users bedroom with items suitable for the purpose. In addition a number of new requirements regarding the maintenance and upkeep of the property are made and these are listed at the end of this report. The under stairs area of the men’s house is currently being used to store several chairs and some boxes. Each service user has their own bedroom they are able to lock their bedroom doors and retain their own keys. Several service users showed the Inspector their bedrooms and it was noted that these contained a single bed, chests of draws and shelving units. The Inspector noted that service users had been able to choose their own decoration and had used photos, posters and other items to personalise their rooms. Each house contains a downstairs WC and hand basin and upstairs bathroom with mixer tap shower over the bath, hand basin and WC. Bathtubs had also been fitted with bathing seats. Whilst inspecting one service users bedroom the Inspector noted that the curtains were not property hung, causing them to sag down. The quilt cover had not been properly fitted over the duvet. The pillowcase was noted to be extremely soiled and dirty. The premises were otherwise noted to be clean and free from offensive odours. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 19 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, 33, 34, 35 & 36. The ongoing suspension and investigation of three staff members has been disruptive to service users and other staff members. Key policies and documents relating to recruitment and individual staff members could not be located at the home. Staff meetings and supervision have not occurred for many months. EVIDENCE: During the course of the inspection the Inspector observed staff being accessible to, approachable by and comfortable with service users. Since the last inspection the registered manager, deputy manager and a support worker have been suspended are the subjects to ongoing investigation. A part time temporary manager and deputy manager have been bought into the home and a permanent support worker has recently taken up post. Discussions with service users indicated that they had found this upheaval unsettling and distressing. Whilst awaiting current staff appointments the home was reliant upon relief workers to meet staffing needs. The Inspector noted that there had been no recent staff meetings and formed the view that recent events had also proved unsettling to staff members. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 20 The Inspector asked to view, and the staffs were unable to locate the recruitment policy. The Inspector asked to view the personnel file for the recently appointed staff member and was advised that this could not be located, and that the acting manager may have taken it home to work on it. The Inspector did view personnel files for two staff members and noted that the individual development plan on one was incomplete and blank on the other. The Inspector noted that a previous requirement for staff to receive epilepsy training remains outstanding. From inspection of staff supervision records and discussion with staff, the Inspector was not able to evidence that supervision of staff had occurred since February 2005. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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) 38, 40, 41 & 42. As previously stated the registered manager, deputy manager and one support worker are currently suspended. The Inspector has concerns regarding the management of the home. Key policies and procedures were not able to be located and the home is not complying with many areas of National Minimum Standards. The Inspector notes that a significant number of shortfalls in complying with National Minimum Standards have occurred over several inspections. EVIDENCE: As previously stated that current registered manager is under suspension and a manager from another MENCAP home is working at Vulcan Square several days per week. In addition a temporary deputy manager has also been appointed for 30 hours per week. East Living is responsible for the upkeep, maintenance and replacement of the buildings, fixtures and fittings. A series of inspections have noted that the quality of repairs, maintenance and replacement of items appear inadequate for the proper needs of the service being provided. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 22 The Inspector asked to view the record of visits made under Regulation 26 by the responsible individual. The file produced whilst labelled as containing these reports actually contained a copy of a service users complaint and quarterly reports completed by the Registered Manager. The requirement for the responsible individual to visit the home on a monthly basis and provide reports on this to the Commission for Social Care Inspection has been restated over several inspections. The Inspector noted that staffs on duty at the time of the inspection were unable to locate significant policies including the medication, complaints and recruitment policy and procedure. Other areas of this report have highlighted significant shortfalls in the homes record keeping practises particularly regarding the maintenance of service users personal files and records of healthcare appointments. The Inspector also noted that staff personnel files are being kept in a filing cabinet with a broken lock, in an open office. The Inspector viewed the homes health and safety file. Many of the documents within it were misfiled. The Inspector looked for a fire evacuation record to evidence recent evacuation drills and time taken to evacuate the building. No such record was found under the section of the health and safety file labelled “Fire Evacuation Practice”. Although misfiled the Inspector was able to locate the records of fridge and freezer temperatures and found that these were within acceptable limits. During the site inspection the Inspector noted that in both fridges packets of opened sliced meat had been labelled with the wrong end date in relation to the recorded start date and the items storage instructions. Opened packages of cheese had not been labelled with a start date. Prepared foodstuffs in one fridge were being stored in a cup with no labelling. The Inspector noted that there was a good range of foodstuffs available in each house. Potentially hazardous cleaning substances were securely stored in locked cupboards. The Inspector viewed the homes accident and incident log. The last accident entry was undated. Two different format accident books were being stored inside the accident/incident log, and a third format of form was being used to record accidents. Some staff members were not using any of these forms and instead had filed handwritten accident reports of their own devising. The Inspector also noted that some accidents, for example a service user cutting their finger had been recorded as an incident. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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 x N/A x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 1 1 1 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 2 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 2 1 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 32-33 Vulcan Square Score x 1 2 x Standard No 37 38 39 40 41 42 43 Score x 2 x 1 1 1 x G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 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 6 Regulation 17(1)(a) & 17(3)(a) Requirement The current service user file system should be reviewed and rationalised. This is a restated requirement. The previous target of the 22/07/05 was not met. The homes service user planning documentation must be reviewed and rationalised. This is a restated requirement. The previous target of the 22/07/05 was not met. Each service users personal file must only contain information that relates to them. This is a restated requirement. The previous target of the 31/03/05 was not met. Reviews of the service user plan must be held regularly. This is a restated requirement. The previous target of the 22/07/05 was not met. Where support and tuition are needed in assisting service users to manage their own finances the reasons for this and manner of support must be documented and recorded. Regular service user meetings must be convened to faciliate Timescale for action 30/11/05 2. 6 15(1) 30/11/05 3. 6 17(1)(b) 30/11/05 4. 6 15(2)(b) 30/11/05 5. 7 15(1) & (2) 30/11/05 6. 8 12(2) 30/11/05 Page 25 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 7. 8. 9 9 13(4)b 15(2)(b) 9. 10 17 10. 17 13(4)c 11. 19 13(1)b 12. 13. 14. 15. 20 20 20 22 13(2) 13(2) 13(2) 22(4) & 22(7) their involvement in the day to day running of the home. These meetings must be minuted. Identified elements of the service users plan must be risk assessed. Risk assessments must be regularly reviewed. This is a restated requirement. The previous target of the 22/07/05 was not met. The home must ensure that individual service users records are accurate, secure and confidential. All opened or prepared foods must be appropriately labelled with a start date and finish date that corresponds with storage instructions and good food hygiene practises. This is a restated requirement over several inspections. The most recent target of the 31/03/05 was not met. The registered person must ensure that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. The MAR and other lists of current medication must correspond. All current medication must be listed on the MAR. Out of date medications must be appropriately disposed of. The complaints procedure must state that all complaints will be dealt with within 28 days and give up to date contact details for the Commission for Social Care Inspection. This is a restated requirement over several inspections. The most recent target of the 31/03/05 was not met. 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 26 16. 22 22(3) 17. 18. 23 26 13(6) 16(2)c 19. 28 23(2)(b) & 23(2)(o) 20. 28 12(4)(a) 21. 22. 24 24 23(2)b 16(2)c A record must be kept of all issues raised or complaints made by service users, details of any investigation, action taken, and outcome. This record must be checked at least three monthly. Staff must receive initial and refresher training in adult protection. The home is required to consult with service users to replace the chest of draws in their bedrooms with items suitable for the purpose. This is a restated requirement over several inspections. The most recent target of the 31/03/05 was not met. The home is required to attend the trip hazards in the garden area. (1) The patio doors in the mens house must be replaced. (2) The steps from each house to the garden are too steep and this must be addressed. (3) The protruding remnants of cement posts that originally seperated the garden must be removed. (4) Polypropylene sacking under the garden gravel must be covered. These are restated requirements over several inspections. The most recent targe of 31/03/05 was not met. Service user communal areas should not be used for administrative tasks or storage of papers and documents. This is a restated requirement. The previous target of the 31/03/05 was not met. The gouged wall by the kitchen table in the mens house must be repaired. Appropriate shades should be fitted to the light fittings on both houses upper landings and in the 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 27 womens house lounge. 23. 24. 28 30 23(2)l 23(2)d Items being stored under the stairs must be moved and more appropriately stored. Service users must be properly supported and monitored to maintain appropriate levels of hygiene and cleanliness in their bedrooms. The extractor fans in the down stairs wc s must be cleaned regularly. Marks to the ceilings and wall around the vent must be cleaned or repainted. The home must have a copy of its recruitment policy and procedure available on site. Staff personnel records required by regulation must be available on site. These records must evidence that the necessary checks required by regulation to ensure service users safety have been carried out. The registered person must ensure that an individual training and development assessment and profile is carried out and recorded for each staff member. Staff must receive appropriate training regarding epilepsy. This is a restated requirement. Staff must have regular, recorded supervision meetings at least six times per year. The registered provider must ensure that East Living provides an enviroment that is effective and of a proper standard and that all refurbishment is carried out in consultation with service users and staff. This is a restated requirement over several inspections. The most recent target of the 31/03/05 was not met. 30/11/05 30/11/05 25. 30 23(2)d 30/11/05 26. 27. 34 34 19 19 30/11/05 30/11/05 28. 35 18(c )i 30/11/05 29. 30. 31. 35 36 38 18(a) & 18(c)(i) 18(2) 24 30/11/05 30/11/05 30/11/05 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 28 32. 39 26 33. 41 17 34. 41 17 35. 42 13(4)c 36. 42 23(4) 37. 42 12(1)a 38. 39. 33 40 The responsible individual must visit on a monthly basis and produce a report on the visit that must be copied to the Commission for Social Care Inspection. This is a restated requirement over several inspections. The most recent target of the 31/03/05 was not met. Records required by regulation and for the efficient running of the home must be well maintained, up to date and accurate. Individual and home records must be secure, up to date and in good order and comply regulations and other statutory requirements. The home must develop its food hygiene practises relating to the storage and preparation of foods. Opened package foods and prepared foods must be properly stored with a start date label. All staff and residents must be aware of and practise the evacuation drill in case of fire. Records of the drill including evacuation times must be kept and be available for inspection. Forms used to record accidents must be rationalised and only one format used. Staff must receive training on recording accidents and incidents. Regular, recorded staff meetings must occur at least six times per year. The homes policy and procedures must comply with current legislation and recognised professional standards. Staff must have access to up to date copies, and understand and apply these. 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 Stage 4.doc Version 1.40 Page 29 40. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 16 Good Practice Recommendations The contract with service users should be expanded to include information on the homes alcohol and smoking policies. This is a restated recommendation. 32-33 Vulcan Square G57 G06 S10308 Vulcan Square V241765 010805 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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