Inspection on 17/08/07 for Wadeville Hostel

This inspection was carried out on 17th August 2007.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wadeville Hostel 20/10/06

Wadeville Hostel 27/02/06

Wadeville Hostel 06/09/05

Wadeville Hostel 10/02/05

Wadeville Hostel 31/08/04

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 Wadeville Hostel 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND Lead Inspector Ms Pauline Lambe Unannounced Inspection 17th August 2007 09:30 Wadeville Hostel DS0000037846.V341611.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 Wadeville Hostel DS0000037846.V341611.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. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wadeville Hostel Address 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND 01322 432998 01322 440663 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) MCCH Society Limited Vacant Care Home 13 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (4) of places Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2006 Brief Description of the Service: In December 2002 this home varied its registration and changes were made to the configuration of the home. The home is now registered for thirteen residents with a learning disability, two of whom may be over 65 years of age. The registered provision provides 24-hour support with a sleep in arrangement and waking night support. The house is split into two separate dwellings, seven residents live in 2a and six in 2b. Each dwelling has a kitchen/dining room, lounge, bedrooms, toilet and bathing facilities. The garden is a shared area for both dwellings and is shared with people in the on site supported living accommodation. Daytime opportunities are provided through the day services previously operated by Bexley Council but now managed by MCCH Society Ltd. The Community Learning Disability Team provide specialist health and social input. Information on the current fees was not accessible on this occasion. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced key inspection was started on 17th August 2007 and completed on 11th September 2007. The manager and staff assisted with the inspection. All of the residents were out at the start of the inspection and were seen later in the day when they returned home. Twelve residents lived in the home and plans were in place to admit a new resident in the near future. The inspection included a review of information held on the service file, a tour of the premises, inspecting records, talking to staff and the manager and reviewing compliance with previous requirements. Satisfaction surveys were sent to residents and relatives. Residents were seen when they returned to the home from day centres in the late afternoon. Not all residents were able to voice their views of the service. Feedback received from relatives and residents about the quality of the service was positive. Residents and relatives were satisfied with the quality of care provided. Staff worked together to ensure the needs of the residents were met and supported and encouraged residents to become independent. The environment was clean and tidy and generally well maintained. Residents were well cared for and had a lifestyle suited to their ability and preferences. A number of requirements have been made mainly in relation to management of the service. What the service does well: What has improved since the last inspection? As the manager had only been in post for a short while at the time of this inspection she was still assessing systems and formulating a work plan. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 6 Staff had an away day to look at ways to improve the service and the manager was preparing an action plan based on the findings of the day. A new care plan format was being introduced. Records were kept to show residents had participated in social and leisure activities. Up to date gas service records were seen. Flat 2a had a new fridge. Accident records seen were fully completed and the fire alarm was tested weekly. What they could do better: 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. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user guide did not include details of fees and charges. Not all resident records seen included a pre-admission assessment of need. Prospective service users were supported to visit the home prior to admission. EVIDENCE: The new manager confirmed that new residents were given a copy of the Service User Guide. This document did not include information about the terms and conditions of occupancy or fees. As the manager had only been in post for eight weeks it was agreed to extend the date to meet this requirement to allow time to review both the service user guide and the statement of purpose. The manager agreed to send a copy of the revised documents to the Commission. Requirement 1. Two residents were admitted since the last inspection. The records for one resident did not include a pre-admission assessment of need. Records for the second resident included a detailed care manager assessment of need. Requirement 2. Staff said that new service users were given an opportunity to spend time in the home, view vacant rooms and get to know the residents and staff before Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 9 making a decision to move in. The manager said that residents received written confirmation that the home was suited to meeting their assessed needs. However none of these letters were seen on the records viewed. Recommendation 1. Staff said that trial visits were arranged new residents prior to admission. The records for one resident admitted since the last inspection showed they had spent time in the home prior to admission. Seven visits had been arranged for the resident including an overnight stay. Plans were in place to admit a new resident and the person had visited the home, met staff and residents and picked the paint colour they wanted for their bedroom. The resident’s family were also involved and planned to provide the bedroom furniture and personalise the room. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual support plans were prepared for residents. Residents were supported to actively participate in the day-to-day running of the home and make personal decision. Care must be taken to ensure resident risk assessments are kept up to date. EVIDENCE: Care records for three residents were viewed. The records seen included assessments, risk assessments and support plans. The individual support plans seen reflected how assessed needs were to be met however these could be more detailed for example in relation to the support needed in relation to personal hygiene. Records seen included future plans for residents with times for achievement and the supporting person identified. Some risk assessment seen had not been reviewed for some time and it was not clear if these were still relevant. Some records seen had not been signed or dated. Staff on duty displayed a wealth of knowledge about the residents, their needs, moods, characters, interests and relative and friend contact. The new manager had Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 11 introduced new care records and staff were given time to change over to the new system. Progress with completing this will be reviewed at the next inspection. Requirement 3. Based on information provided by residents and staff and from reviewing records it was evident that residents were encouraged to play an active role in the running of the home and making personal choices and decisions. Residents helped staff to maintain the garden, do the food shopping, prepare, cook, plan and serve meals, lay and clear tables, wash and iron their own clothing, change their bed linen and play and active role in keeping the communal areas clean. Residents were encouraged to suggest ideas for activities and holidays and to let staff know if they required help to purchase personal items. Individual support plans were prepared with residents so that their preferences were addressed. The new manager introduced weekly resident meetings in the individual units. Meeting minutes seen showed residents were involvement in decision-making. Risk assessments were seen in the care records viewed. For example areas considered included access to the kitchen, participating in cooking, safety when out in the community and safety on the stairs. Some assessments seen had not been reviewed for some time. Requirement 4. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported to take part in appropriate and preferred leisure and social activities, to have an annual holiday and to keep in touch with family and friends. The choice and variety of food provided in the home was good. EVIDENCE: Care records seen included an informative social history of the resident and a weekly activity programme. The activity programme included day centre and other commitments and leisure activity the resident attended. Residents were able to take time off from the day centre if they wished. However staff said they enjoyed going to the centres and only took a day or a half-day off each week to complete personal domestic chores and spend one to one time with their key worker. Residents were supported to access local facilities and leisure activities such as attending club evenings and discos, swimming, pub lunches, cinemas and bus Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 13 rides. Activities such as parties, BBQs and a garden fete were arranged in the home and residents were encouraged to invite family and friends to these events. Residents and staff enjoyed maintaining the lovely rear garden. The garden was very colourful with flowers, plants and shrubs and they were very proud of their tomato crop. Plans were in place to take some residents to the Isle of Wight and to Camber Sands for a holiday. Daily diaries seen showed residents did take part in leisure activities and residents who could comment said they were happy with how they spent their leisure time. Staff welcomed residents on their return home from the day centre and offered or encouraged then to have a hot or cold drink. Residents were free to choose what part of the house they wanted to be in staff gave them the opportunity to discuss their day and the activities they were involved with. Some residents sat in the kitchen, some in the kitchen and some went to their rooms or into the garden. Staff respected resident’s choice and right to privacy. Residents were supported to maintain contact with family and friends. A comment made by one relative was “my relative is doing better at Wadeville than they could living with me”. There were ample supplies of fresh fruit and vegetables seen. Residents had their meals in the dining area and were supported to help themselves to breakfast and lunch at times that suited them. Staff prepared weekly menus with resident input, and residents were encouraged to take part in the food shopping and preparing meals. Menus seen showed residents were provided with a varied diet. Staff prepared the main meal with residents help as appropriate. Some of the residents enjoyed cake making and this was addressed in their care records and a lovely supply of homemade cakes seen which residents and staff enjoyed. Residents did not raise any concerns about the food provided. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff ensured resident’s health can personal care needs were met. The management of medication required some improvements. EVIDENCE: Records seen showed that individual support plans were prepared with residents and included personal preferences. Residents had a named key worker who worked with them to meet individual goals and to make personal choices. Residents were encouraged and supported to attend and be involved with meetings about their care, health and future and to make decisions for themselves together with relatives, advocates and staff as appropriate. A record was kept for each resident of involvement with healthcare professionals such as the GP, dentist, district nurse, psychiatrist, chiropodist and hospital appointments and care advice or guidance provided recorded. A policy and procedure was provided in relation to medicine management. The arrangements for managing medicines were assessed on both units. None of Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 15 the residents managed their own medicines. Records were kept for receipt, administration and disposal of medicines. Boots provided medicines in a monitored dose system, provided printed administration charts and disposed of unused medicines. Medicines were stored in filing cabinets in both units and the senior on duty held the key. The registered person should consider providing a more secure medicine storage cabinet, as a large number of medicines were stored regularly in the home. Medicines were stored in a corridor area in both units and the temperature of this area was not monitored. Staff said the areas did not get very hot at any time of the rear. Homely remedies were not used and no controlled drugs were in stock on this occasion. At the last inspection the need to have suitable storage for controlled drugs was discussed with the Commission pharmacist and the registered person advised to provide this. This advice had not been acted on. Administration charts were generally well maintained but care must be taken to ensure hand written entries made by staff on administration charts are countersigned to ensure accuracy and full instructions for medicine use must be recorded and not labelled ‘as directed’. One resident required medicines to be crushed before administration and this had been agreed with the GP. Medicine records checked for two residents on each unit were found to be accurate. In unit 2a it was noted that a prescribed medicine for two residents had been transferred from the original dispensed container to a small plastic wallet and the pharmacist label re-attached. This is unsafe practice and must cease. Internal and external medicines were being stored together. Requirements 5 and 6 and recommendation 2. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to manage complaints and to safeguard residents and their personal finances. EVIDENCE: The home had a comprehensive complaints procedure, which included a timescale for responding to concerns and contact details for the Commission. The new manager had introduced an easy read version of the complaints procedure with words and pictures for residents. She also included complaints and concerns on the agenda for the resident’s weekly meetings. A system was in place to record complaints made about the service. No complaints had been made about the service to management or the Commission since the last inspection. Management had received two ‘thank you’ cards since the last inspection. A safeguarding adults policy and procedure was provided. Since the last inspection no allegations or suspicions of abuse were reported. Staff spoken with had a good understanding of safeguarding adults and their role in managing this. Safe systems were in place to manage resident’s money. Resident benefits were paid into their own bank or building society accounts and staff supported residents to access their money. The registered person was the appointee for some residents and for these people money was paid to the appointee and suitable arrangements in place to enable residents to access their personal allowance. A safe was provided to store money and records were kept for money received and spent by or on behalf of residents. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained to a satisfactory standard and all parts of the home seen were clean, tidy and odour free. Adequate bathing facilities were provided and bedrooms seen were nicely decorated and personalised. EVIDENCE: The home was maintained to a satisfactory standard and all parts of the home seen were clean, tidy, odour free, homely, welcoming and comfortable. Plans were in place to replace the lounge carpet in both units and the hall carpet in 2b the week after the inspection. The compliance date to have this work done which was 31/12/06 had not been met. At the time of writing this report the a carpet had not been fitted on the date given to the home by the carpet fitter. The manager agreed to inform the Commission in writing when this had been done. Requirement 7. Bedrooms seen were nicely decorated and furnished and many had been nicely personalised. One bedroom in 2a was being redecorated and refurbished for a Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 18 new resident due to be admitted in the near future. The resident was involved in the process and in choosing the décor. Adequate bathing and toilet facilities were provided. Hot water temperatures checked were within safe limits and the manager said all hot water outlets had thermostats fitted. The wall behind the shower room in 2a showed signs of damp and the paint was peeling. The manager said this had been noted and the repairs requested. Requirement 8. A high standard of hygiene was maintained throughout the home. Staff and residents worked together to keep the home clean and tidy. Liquid soap and hand towels were provided in some of the bathrooms and toilets. Care was taken with washing; ironing and storing resident’s personal clothing to ensure residents were always well presented. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training required improvement. The forms held in the home to evidence employee recruitment information were not available for all staff. EVIDENCE: From the information provided nine support staff were employed, four had NVQ 2 or above and three were currently undertaking NVQ 2 qualification. The home continued to work towards meeting the standard set by the Department of Health for 50 of care staff to achieve a vocational qualification in care. Staff rosters seen showed adequate staffing levels were maintained. Three support staff were on duty during the day and two waking staff at night. The manager hours were in addition to the support hours provided. The Organisation’s human resources department managed staff recruitment. The Commission agreed that employee records could be held centrally and a form used to evidence that all of the information and checks required by regulation had been completed and this kept in the home for inspection. There was little evidence in the home to show that staff were recruited in line with regulation. Therefore the acting manager was asked and agreed to bring staff Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 20 files to the Commission office on 10th September 2007 for inspection. Staff records were seen on 11th September 2007. Four files were viewed and were generally well maintained. However some issues did arise including one file had two references from the same referee, three files did not have a recent photo of the employee and there was some confusion about the CRB check for one person. There was a date recorded for receipt of the check but no reference number available. The manager agreed to look into this and said that a new CRB check had been sent for the person as it was the Organisations policy to renew all CRB checks three yearly. In the meantime the manager agreed to arrange for the person to work under supervision. Requirement 9. Staff training needs were identified through supervision. The Organisation’s training department provided a monthly programme and a training directory. The acting manager said that staff training had not been kept up to date and she was addressing this as a priority. A number of training applications were seen and staff spoken with confirmed that training had not been good lately but that the manager was working to improve this. A number of training files were viewed and showed that some staff had received training in the last year including medicine management, moving & handling, risk assessment and personal safety. Staff were expected to attend mandatory training such as medicine management, food hygiene, moving & handling, epilepsy care, first aid and fire warden. However this training was not up to date. A number of staff had not attended three days training in the last year. Requirement 10. A system was in place to provide staff supervision. Staff had a supervision agreement and the acting manager planned to provide supervision every six weeks. Currently the manager supervised all staff. Records were seen for four members of staff and showed that supervision sessions had been held recently. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The support and care provided for residents was good. The service must have a registered manager. Changes had been made to the quality assurance system, which will require assessment at future inspections. More attention was required to fire safety training and holding regular fire drills. EVIDENCE: Since the last inspection there had been some management changes. The manager and one senior support worker had left and the other senior had retired but continued to work as a bank support worker. A new acting manager was in post and had the skills and experience needed to run the service. Residents have had to deal with a number of staff changes but had coped well with this. Other support workers had been in post for some time and provided stability and continuity of care for residents. Residents presented Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 22 as relaxed, comfortable and readily approached staff on duty. Minutes were seen of staff meetings and staff spoken with said they were able to have input into these meetings. Requirement 11. A new quality assurance system was being introduced which involved looking at all aspects of the service over a twelve-month period based on the national minimum standards. The acting manager was working on a satisfaction questionnaire to be used to get feedback on the service from residents, relatives and other relevant people. The plan was that at the end of a year an annual development plan would be developed for the service based on the findings of the audits and feedback received. Manager workshops were held to introduce the quality assurance system and a team away day took place earlier in the year review the service and plan improvements. The new manager was preparing an action plan based on the outcome of the day. Visits were made to the service as required by regulation 26 and some reports were sent to the Commission and some seen in the home. Weekly resident meetings had commenced and these would feed into the quality assurance review. Although a requirement made in relation to quality assurance made at the last inspection was not fully met it was decided not to include a new requirement as steps had been taken to address this area of work. Progress with implementing the new quality assurance system will be reviewed at the next inspection. Health and safety records were viewed including fire safety, gas, electricity, water chlorination and hot water temperature checks. All records seen were up to date. Fire safety records seen showed the alarm system and emergency lights were serviced on 31/07/07 and the system was tested weekly. The fire risk assessment was last reviewed in 2005. A fire drill and full evacuation was held in the morning in January 2007 and comments made on staff and resident response. Management must seek advice from the fire safety department on the frequency of fire drills they should hold. Training records seen showed that only one person had received fire safety training since the last inspection. It was noted at the last inspection also that no fire safety training had been provided for staff over the previous year. Accident records seen were well maintained and showed that following accidents residents received appropriate care. Since the last inspection none of the residents had to receive medical treatment following an accident. Requirement 12. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 2 3 2 4 3 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 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 4 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 5 Requirement The registered person must ensure that the Service Users Guide includes the following information-: the terms and conditions of occupancy including the amount and method of payment of fees and a standard form of contract. A copy of the revised Service Users Guide must be forwarded to the Commission. (Previous timescales were not met). The registered person must ensure residents are admitted to the home based on an assessment of need. The registered person must ensure support plans show how all identified needs will be met and that all records including daily diary entries are signed and dated. The registered person must ensure risk assessments are reviewed and kept up to date. The registered person must ensure that Schedule 3 drugs are stored appropriately. (Timescale of 05/02/07 was not met). The registered person must DS0000037846.V341611.R01.S.doc Timescale for action 19/10/07 2 YA2 14 19/10/07 3 YA6 15 19/10/07 4 5 YA9 YA20 13 13 19/10/07 12/10/07 6 YA20 13 12/10/07 Page 25 Wadeville Hostel Version 5.2 7 YA24 23 8 YA27 23 9 YA34 19 10 YA35 18 11 YA37 8 ensure: • Staff do not transfer medicines from their original dispensed packaging to another container and must not transfer the pharmacist label. • Two staff must sign hand written entries they make on administration charts. • Administration charts include full instructions and not labelled ‘as directed’. • Internal and external medicines must be stored separately. The registered person must replace the carpets in the lounge in 2a and 2b in 2007. (Timescale of 31/12/06 was not met) The Commission must be informed in writing then this has been done. The registered person must ensure the wall behind the toilet pan in the shower room in 2a is repaired. The registered person must ensure that the agreed form used to record recruitment checks is completed in full for all members of staff and kept in the home for inspection. (Timescale of 5/2/07 was not met). The registered person must ensure staff have training relevant to the work they do including medicine management and other training identified though the supervision process. The registered person must comply with regulation and ensure the service has a registered manager. The registered person must keep DS0000037846.V341611.R01.S.doc 19/10/07 19/10/07 19/10/07 02/11/07 19/10/07 Wadeville Hostel Version 5.2 Page 26 12 YA42 23 the Commission informed in writing of the action taken and progress made to meet this requirement. The registered person must ensure that: • Staff receive regular fire safety training updates • That regular fire drills are carried out (Timescale of 5/2/07 was not met). 02/11/07 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 YA3 YA20 Good Practice Recommendations The registered person should ensure a copy of the letter sent to residents as required by regulation 14 is kept on file. The registered person should consider providing a more suitable secure cabinet to store medicines in both units. That a medicine profile is provided for each resident, That there is evidence to show that individual residents have their medicines reviewed by the GP regularly and that staff competency in relation to safe management of medicines is assessed annually and evidence kept to show this has been done. Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Wadeville Hostel DS0000037846.V341611.R01.S.doc Version 5.2 Page 28 - 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!