Inspection on 07/09/06 for Vulcan Square

This inspection was carried out on 7th September 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vulcan Square 23/07/08

Vulcan Square 09/01/08

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 09/07/2008.

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 7th September 2006 11:00 Vulcan Square DS0000010308.V310336.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.V310336.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.V310336.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 0207 537 0411 0207 987 3917 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) www.mencap.org.uk Royal Mencap Society Ms Dorinda Maclean Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 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. Following the dismissal earlier in the year of the Registered Manager a new Manager has been appointed and is currently undergoing the registration process. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors fourth inspection of this home. The Inspection occurred over the course of a day and was conducted by one inspector. The inspection addressed examined key National Minimum Standards. A member of support staff and the manager were spoken to by the Inspector, as was one service user. The Inspector also sampled service users personal files, staff personnel files and other relevant documentation. This is a report about Vulcan Square Care Home. An Inspector visited the home and spoke to people who live and work there. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 6 What the service does well: The home manager is experienced and has professional qualifications. You told the Inspector that you like the staff and that they are friendly and helpful. The home asks other people for information about you to help decide whether this is the best place for you to live. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 7 You have your own plan that says what you do well and what you need help with. The home helps you to take part in lots of different activities. The home meets the needs of service users from different sexes, cultures and religions. The home helps you to stay in contact with your family and friends. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 8 Staffs ask you how you want to be helped with bathing, washing and dressing. You know how to make a complaint and know that the home will keep you safe. You have regular meetings where you get to have your say about the home. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 9 What has improved since the last inspection? All of your important records are kept in just one place. The home keeps one list of your medication and all of your medicines are written on this. Broken furniture in your bedroom has been swapped and the things that were being stored under the stairs have been moved. Staffs carry out weekly fire alarm tests and sometimes help you to practise leaving the building in an emergency. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 10 What they could do better: 5 things have still not been sorted out by the home. The home must keep records of all the meetings you have with your doctor, nurse, dentist, optician and hospital. Your care plan should be looked at every six months to make sure it is still what you need. If you need help to look after your money this should be written in your care plan. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 11 The home needs to follow their policy when they give you medicines. The home must tell us what they find out when they carry out any investigation. The home must carry out some repairs and store cleaning things in a locked cupboard. The home must tell you about the smoking and drinking policy in the contract you have with them. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 12 Staff at the home need to study for qualifications. The home must carry out checks on staff before they start work and help them settle into the home. The manager must talk to staff about the work they do every few months. The home needs to ask you and your family what you think the home does well and what they could do better. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 13 The home must keep its records in good order. Staff must make sure that the fridge and freezer are kept at the right setting. 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. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 14 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.V310336.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Potential service users have their needs assessed. EVIDENCE: The home has had no new admissions since the last inspection. The Inspector sampled the personal file for the mostly recently joined service user. This evidenced that the home had obtained copies of assessments carried out by other professionals as part of the decision making process. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has developed and implemented a risk assessment procedure to safeguard service users. However it must ensure that individual plans address support with personal finances and are regularly reviewed. EVIDENCE: The Inspector sampled the personal files for two service users. These evidenced that the home develops and agrees individual plans with each service user that address their personal, social and healthcare needs. One of the service users sampled was evidenced as having their plan reviewed every six months. However, this was not evidenced by the second service users plan that was dated June 2003 and was evidenced as last being reviewed in June 2004. The individual plan for one service user included information on their strengths, things they would like to do and things they need help with. There was also a detailed support plan that addressed personal care needs including shaving, oral hygiene and bathing. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 17 The Manager advised the Inspector that service users at the home receive support in managing their finances. One of the individual plans seen by the Inspector identified the need for “full support”. The nature of the support was not however detailed in the plan. The home completes a range of risk assessments for service users including travelling to and involvement with community activities, handling food and using kitchen equipment and opening the front door. It was evidenced that risk assessments had been reviewed in September 2005. The Inspector viewed the minutes of service users meetings. These were evidenced as occurring at least bi-monthly and are recorded using pictures and plain English to support service users understanding. Each service user identified things about the home they would like to discuss in the meeting, and recent discussions were evidenced as covering holidays, maintenance, cleaning rota and activities. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 18 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 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 the service. The home supports service users to engage in a range of occupational, educational and community activities. EVIDENCE: The Manager advised the Inspector that five service users attend various day centres within the borough and that one service user has been attending college and will resume their studies after the summer break. In addition service users are also supported to attend local community based services at the Bromley Centre and “Poetry in the Park”. Service users are supported to engage in community activities including trips to local shopping centres and day trips to Greenwich and a trip on a riverboat. The home is applying for funding to purchase a mini bus to increase the number of outings it offers to service users. Earlier in the summer service users had identified Spain as a holiday location and had been supported by staff to spend a seven-day vacation there. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 19 Service users are from a variety of cultural backgrounds and the home aims to meet their individual needs by using a specialist hairdresser for one service user and supporting another to visit an Asian shopping area. Service users also choose the meals appearing on the homes menu plan. Service users are supported where appropriate to maintain contact with their families, and the home has recently assisted one service user in re-establishing contact with estranged family members. A previous inspection had recommended that the home revise its contract with service users to include information on the homes alcohol and smoking policies. During the course of the inspection the Inspector noted that service users choose when to be alone or join in an activity and that staff interact with service users. A house rota has been developed that identifies domestic tasks for each service user to assist with. The Inspector viewed the homes log of meals offered. This evidenced that a range of nutritious meals are provided. Feedback from service users evidenced that they are satisfied with food provided and that meals reflect the varying cultural backgrounds of service users. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 20 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 the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home supports service users with personal care in the way that they need and prefer. However the home must promote service users wellbeing by maintaining a record of all healthcare appointments and follow their medication policy when administering controlled drugs. EVIDENCE: The Inspector noted that service users choose their own clothes and hairstyles and that these reflect their personalities. The Manager advised the Inspector that two service users require assistance with their personal care. Sampling of one of these service users personal file evidenced that their individual plan detailed the nature of the support required and how the service user preferred to receive it. The staff member spoken to by the Inspector demonstrated a good understanding and awareness of how to promote service users dignity and respect whilst providing personal care. The Inspector sampled the personal files for two service users. One of these was found to contain a health checklist with a record of their recent healthcare appointments and the outcome including visits to the GP, dentist and Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 21 audiologist. The Inspector was unable to locate a record of healthcare appointments for the second service user. The home implements a corporate Mencap control and use of medicines policy. This includes guidance on the storage, administration and disposal of medicines. It also addresses self-medication and recognises the need for this to occur within a risk assessment framework. At present all service users receive assistance with their medication. The Inspector sampled the Medication Administration Record (MAR) and the medication available for two service users. This evidenced that all current medication including “as required (PRN)” medication is listed on the MAR. The MAR had been completed to evidence that all medication had been administered in accordance with its prescription. One of the service users sampled is currently taking a controlled medication. This is appropriately stored in a separate locked compartment within the medicine cabinet. The Inspector noted that the homes medication policy states that all controlled drugs must be signed and countersigned on the MAR. There were however several occasions when only one staff member signed off the controlled drug. The Manager advised the Inspector that this occurred on regular occasions when there was only one staff member on duty, with no second worker available to sign. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 22 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 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 the service. The home listens to the views of service users and acts upon adult protection concerns. However, the home must make the findings and outcome of adult protection investigations available to the Commission for Social Care Inspection. EVIDENCE: The home implements a corporate Mencap adult protection policy. This includes definitions of the types of abuse vulnerable adults can experience and a step-by-step guide for staff on their responsibilities. The policy also makes appropriate reference to local multi agency adult protection procedures. The Manager advised the Inspector that since the last inspection all care staff have received adult protection training and that the Manager and Deputy are due to attend adult protection training in October 2006. The member of staff spoken to by the Inspector demonstrated a good understanding and awareness of adult protection issues and their responsibilities. Since the last inspection the home have notified the Commission for Social Care Inspection of two adult protection issues. The first relates the theft of service users monies whilst staff and service users were away from the home on holiday. The Manager advised the Inspector that Mencap had refunded these monies to service users. The Manager also advised that an investigation had failed to identify the perpetrator of this theft, but that the home had reviewed and tightened its procedures in managing service users monies. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 23 A second incident relates to allegations by two service users that a staff member had shouted at them. These allegations were referred to Senior Mencap staff that carried out an investigation with the outcome that the staff member transferred to another home. The local authority adult protection officer was also notified. However, the Inspector noted that a summary of the investigation and findings in both situations had not been supplied to the Commission. The Inspector viewed the homes complaints log. The most recent entry was in May 2006, and relates to one of the incidents detailed above. It also notes that all information relating to the investigation is kept at Mencap head offices. The Inspector viewed the homes complaints procedure. This is another corporate Mencap policy. The home have summarised the main points and illustrated them with pictures to make the policy more accessible to service users. The policy includes information on how to make a complaint, the timescales involved and contact details for the Commission for Social Care Inspection. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 24 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 the following standard(s): 24, 26, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a range of comfortable and homely accommodation that is generally well maintained. EVIDENCE: Vulcan Square care home is made up of two modern terraced homes that are joined together by a shared garden. One house accommodates female service users and the other male service users. Each house has three service users bedrooms and a bathroom on the first floor. One house has a staff sleep in room and the other a staff office that are also accommodated on the first floor. On the ground floor each house has a lounge diner, large kitchen and WC. Since the last inspection the homes rear garden has been renovated and now provides a pleasant courtyard for service users to sit out in. Since the last inspection the lounge area in the men’s house has also been redecorated and new flooring installed. The Inspector saw four service users bedrooms. These had been personalised with service users mementos and reflect their individual tastes and interests. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 25 The Inspector noted that several minor repairs and maintenance issues need attention and these are listed in the requirements section of this report. In addition the Inspector noted that a new chest of draws had been purchased to replace a broken set in one service users bedroom. The Inspector also noted that the under stairs area in both houses had been cleared and is no longer used for storage. The Inspector found the home to be generally clean, free from odour and maintained to a good standard. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 26 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staffs are able to meet service users needs. However, staff must be supported to obtain qualifications and receive regular supervision. EVIDENCE: Discussion with staff and service users evidenced that staff develop a relationship with service users and are able to meet their needs. The service user spoken to by the Inspector described staff as “friendly and helpful”. In addition to the Manager and Deputy five care staff are employed within the home. No care staffs have yet commenced studies for NVQ2, although the Manager stated that two staffs plan to enrol this autumn. During the course of the inspection the Inspector observed care staff being accessible to and approachable by service users. The home operates a corporate Mencap recruitment policy and procedure. There is a centralised personnel Department that retains recruitment and pre employment check information. Photocopies of this information are held locally, as is personnel summary sheet. The Inspector sampled two local personnel files held within the home. One of these was found not to contain any information confirming that two satisfactory references and proof of identity had been obtained. The second was found to contain a Criminal Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 27 Records Bureau (CRB) check from previous employment, but did not evidence that Mencap had obtained a CRB. Of the two files sampled only one was found to contain a completed induction record. The Inspector also sampled supervision records for two staff members. One of these had commenced employment in January 2006 and was evidenced as having received three supervision sessions in the intervening period. A second staff member was evidenced as receiving only two supervision sessions in the last twelve months. The Inspector viewed the homes staff training and development file. This records the type and date of training undertaken by all staff members. The Manager advised the Inspector that training needs are discussed and reviewed in supervision sessions. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 28 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home benefits from an experienced and professionally qualified Manager. However, the home must implement its newly developed quality assurance and maintain all required health and safety records appropriately. EVIDENCE: The Manager advised the Inspector that they are in the process of registering with the Commission for Social Care Inspection. The Manager has previously worked as a Registered Manager in another Mencap home and has obtained NVQ level 4 and the Registered Managers Award. Since the last inspection the home has been developing its quality assurance processes. A questionnaire to obtain service users feedback is currently being drafted and the home also plans to obtain feedback from service users families and day services. The Manager told the Inspector that when implemented the Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 29 results of the questionnaires would be collated and the outcomes published in a service user-friendly format. Whilst sampling service users personal files the Inspector noted that one of these was not in good order. Documents were not stored in a logical order and many were obscured behind photographs or other documents. The Inspector also sampled some of the homes health and safety records. These evidenced that the home carries out weekly fire alarm tests and regular evacuation drills have been recorded with times. The record of fridge and freezer temperatures states that the fridge must be maintained at five degrees or below. On two occasions on the 7th and 15th June the temperature was recorded as seven degrees, with no record of the action taken to restore the temperature to the stated limit. No temperature had been recorded at all on the 8th June 2006. During the site inspection the Inspector found that a potentially hazardous cleaning materials were being stored in an open cupboard in the kitchen. The Inspector also sampled the homes accident and incident logs and found these to be in order. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 30 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 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 3 X 2 X 1 2 X Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 31 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 & 17 Requirement Service users individual plans must be reviewed at least every six months or as their needs change. This is a restated requirement. The previous target of the 31/03/06 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. This is a restated requirement. Previous targets of the 30/11/05 and 31/03/06 were not met. The home must maintain a record of all healthcare appointments attended by service users and their outcome. The home must comply with its own policy when administering controlled drugs. The findings and outcome of any adult protection investigation must be forwarded to the Commission for Social Care Inspection. DS0000010308.V310336.R01.S.doc Timescale for action 30/12/06 2. YA7 15 30/12/06 3. YA19 13 30/12/06 4. 5. YA20 YA23 13(2) 13(6) 30/12/06 30/12/06 Vulcan Square Version 5.2 Page 32 6. YA24 13, 23 & 39 In the women’s house the following repairs and maintenance must be attended to: The first floor bathroom toilet seat must be replaced. (ii) The missing light pull in this bathroom must also be replaced. (iii) The home must ensure that the sinks in each service users bedrooms are cleaned to a good standard. (iv) Each service users bedroom window must be fitted with curtains or a blind. The home must ensure that sufficient staff are supported to study for and obtain NVQ level qualifications in line with National Minimum Standards. The home must evidence that appropriate pre employment checks are carried out including: Obtaining two satisfactory references. (ii) Obtaining a Criminal Records Bureau check. (iii) Obtaining proofs of identity. The home must evidence that new members of staff complete an induction programme. (i) (i) 30/12/06 7. YA32 12 & 18 30/12/06 8. YA34 19 & Sch 2 30/12/06 9. YA35 18(c) 30/12/06 10. YA36 18 This is a restated requirement. The previous target of the 31/03/06 was not met. Staff must have regular, 30/12/06 recorded supervision meetings at DS0000010308.V310336.R01.S.doc Version 5.2 Page 33 Vulcan Square least six times per year. This is a restated requirement. Previous targets of the 30/11/05 and 30/06/06 were not met. The home must develop and implement a quality assurance procedure to gather the views of service users and other stakeholders. The results of this should be evaluated and made available to interested parties. This is a restated requirement. The previous target of the 30/06/06 was not met. Service users personal files must be maintained in good order. Fridge and Freezer temperatures must be maintained within stated parameters. Potentially hazardous cleaning materials must be stored in a locked cupboard. 10. YA39 24 30/12/06 11 12. YA41 YA42 17 12 & 23(4) 30/12/06 30/12/06 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 YA16 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. Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London IG1 4PU 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 Vulcan Square DS0000010308.V310336.R01.S.doc Version 5.2 Page 35 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!