Inspection on 30/01/08 for Warren The

This inspection was carried out on 30th January 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Warren The 15/01/07

Warren The 19/01/06

Warren The 07/02/05

Warren The 01/07/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Warren The 84 Coombe Road Croydon Surrey CR0 5RA Lead Inspector Janet Pitt Key Unannounced Inspection 30th January 2008 10:45 X10015.doc Version 1.40 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 Warren The DS0000025856.V358546.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 Older People. 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. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warren The Address 84 Coombe Road Croydon Surrey CR0 5RA 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) 020 8688 7022 020 8686 8808 Mr James Emmanuel Kwabena Safo Mrs Bernadette Joan Redmond Care Home 18 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0) of places Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified resident under the age of 65 to be admitted. Date of last inspection Brief Description of the Service: The Warren is situated in a pleasant residential area of Croydon, opposite a Tramlink stop and overlooking Lloyd park. The house itself is well named, with the two double bedrooms being situated in the turret of the home, and the top floor comprising of four single rooms each of intriguing dimensions. The accommodation comprises of the aforementioned two double rooms and fourteen single. There is a large lounge on the ground floor, which leads into the conservatory dining area. Part of the conservatory can be curtained off to provide a more secluded space for meetings. There is a second, smaller conservatory, which serves as the designated smoking lounge. The home has an extremely attractive garden, the feature of which is a large fishpond. The stated aim of the home is for it to be run to a very high standard and to give effective environmental, physical and psychological care for the elderly, incorporating quality job satisfaction and status to the people it employs. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is three stars. This means the people who use this service experience excellent quality outcomes. Two inspectors and an expert by experience undertook this unannounced inspection. A site visit was made, during which time we spoke with the manager, staff and people who live in the home. Staff files, records relating to needs of individuals who live in the home and medication records were examined. A tour of premises was made and the lunchtime meal was observed. The manager, staff and people who live in the home were spoken with during the course of the site visit that lasted five and a quarter hours. The home completed an Annual Quality Assurance Assessment (AQAA); information from this has been included in this report. What the service does well: What has improved since the last inspection? Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 6 A requirement made at the previous inspection relating to fire alarm testing and recording has been met. There has been some improvement in relation to staff files and prospective staff supplying all the necessary information. However, care must be taken with obtaining appropriate references for people. 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. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People can be confident that they will have sufficient information if they chose to live in The Warren. Their needs will be assessed prior to admission and a plan of care drawn up to meet these needs. EVIDENCE: Three people who live in the home confirmed that they were able to bring personal belongings to The Warren when they first moved in, but had no clear recollection of the process, as they had live there for several years. The AQAA indicated that people are provided with Service Users Guide and a contract detailing terms and conditions. No one is admitted to the home unless an assessment of their needs has been carried out. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 9 This ensures that the service can meet the needs of people who use the service. Staff also have information on the needs and wishes of individuals before they arrive at the home. The pre admission assessments are used to set up an initial assessment and care plan detailing what needs a person has. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who live in the home are usually involved in the care planning process. Independence is promoted within a risk-assessed framework, but care needs to be taken to make sure risk assessments are followed through. Appropriate contact is maintained with other health professionals and recorded. End of life care is dealt with in a sensitive manner. EVIDENCE: People’s care plans were examined. The format of the plans was clear and all information was accessible. People’s plans lead from their assessments and contained good details of how to deliver care. However, care plans could be more person centred. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 11 We found care plans in place for each person who uses the service. Care plans provided good information on the needs of individuals with some good information on the wishes of each person. Staff have included some good information on personal preferences but this could be expanded. For example some care plans had information on preferred clothing and which brands of toiletries a person wanted to use. Care plans showed a commitment to promoting and maintaining independence. This could be further developed by setting goals at reviews along with timescales. We found one file contained good information on the person’s life history and experiences. Consideration should be given to people who use the service and staff sharing their life history and experiences. Some care plans seen did not show who was involved in compiling the plan. Evidence of consultation with people who use the service in compiling their individual plan should be available. Staff need to take care that all documents are signed and dated. Each person who uses the service is provided with a key worker from the staff group and they can meet with their key worker each week. Personal information on what support people want to meet their social needs is recorded. This included; who people wish to keep in touch with, significant birthdays and events and whether they want to be reminded of these, if they would like an advocate and how they would like their personal shopping done. We found good records of the one to one keyworker meetings. Staff should ensure that information on any changes is added to the care plan that will ensure that all staff are kept informed. Individualised risk assessments were in place and covered areas such as falls, nutrition and skin integrity. It was noted that risk assessments for behaviour patterns had information on appropriate interventions and how situations should be managed, i.e. one person could become verbally and physically abusive, the instructions were to allow the person time to calm down and at an appropriate time offer to discuss with the person what triggered the behaviour and how staff could help with the situation. However the assessments in relation to nutrition were not fully completed in two instances and where there were large variations in weight between one month and another not action was recorded as being taken. Staff should take more care in ensuring the nutritional needs of individuals are assessed and acted upon. Each plan had a section on fulfilment and this covered interactions with other people who live in the home e.g. ‘talks with fellow residents and is a caring [person], likes quiz games on TV, soaps and 6pm news.’ Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 12 Some people in the home smoke cigarettes and there were detailed risk assessments for those who wish to smoke cigarettes in their rooms. Language used in care plans respected the people who live in the home as individuals, i.e. ‘declines to have a bath’. Daily records also contained good detail on appropriate staff interactions, e.g. ‘down and tearful’; time spent talking with the person concerned. People who live in the home present with complex medical histories and there was evidence through the care plans and reviews of involvement of the person and other agencies, to achieve a good outcome. End of life care and death has been dealt with sensitively, with people’s wishes being recorded. The home’s AQAA states that some barriers to improving the service offered is: ‘Service users are sometimes discharged from local psychiatric services even though they continue to require support from them.’ It has in some cases lead to people being sectioned and admitted into hospital, due to the delay in a new referral being acted upon by specialist services, which the home do not think is in the best interests of the person. All of the people using the service are registered with local GP practices. An optician visits every six months and a chiropodist every three months. Appointments are made with a local dental surgery for check ups and treatment. There was evidence in the plans of visits from other health professionals, such as psychologist, community nurses and the general practitioner. We found medication administration sheets were up to date and accurate. Staff confirmed that they had received training on the management of medication. Medication is supplied to the home once a month and any medication left over is returned to the pharmacy each month. A record of medication received into the home and returned to the pharmacy is kept. Medication profiles are in place. We noted that the cupboard holding the medication was very warm. This needs to be monitored to make sure that the temperature does not go above the recommended levels for storing individual medication. Staff installed a thermometer in the cupboard on the day of this visit and informed the inspectors that they would monitor the temperature. It is recommended that the temperature is checked and recorded each day. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Individuals’ independence is promoted and people are able to pursue interests of their choosing. Spiritual needs are acknowledged and supported. Staff need to demonstrate a thorough understanding of individual’s wishes to develop or maintain personal relationships. Mealtimes are a social event and there is a choice of menu available. Individuals are encouraged to be independent in preparing drinks and snacks. EVIDENCE: We found individuals were encouraged to maintain their independence through going out to local shops, to Croydon, attending local churches and visiting family and friends. A monthly programme of activities is produced. The activities on offer are discussed and decided at regular meetings between staff and people who use the service. Activities included art, monopoly, soft ball exercises, card games and dominoes. Three people attend a local day centre twice a week. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 14 People are able to continue practising their chosen religion, either in the home or at organised services in the community. The AQAA states that’ volunteers and relatives are requested to escort clients to places of worship.’ The expert by experience spoke to several of the residents and they told her of an outing to London to see the Christmas lights, and in the summer a trip to Brighton. These were thought to be excellent and a good time was had there. She was also informed that an activities lady is employed to visit once a fortnight for games such as skittles, darts, and exercise. On other days staff organise some activities, including the well-liked Bingo. A resident did say she would like more to do, but knew staff could take her out if she requested it. The expert by experience reported that links to the community were kept by visits out to the shops and phone calls to friends and families. Each room had a telephone and a payphone was in the hallway. The home’s AQAA indicates that they try to organise outings to local areas with a small group of people with staff members, and the purchase of a minibus has enabled more outings to occur. However, funding limits mean that not all people can be offered regular one to one outings if they are reliant on staff support. The expert by experience observed the lunchtime meal and provided the following information on the experience for people who live in the home: ‘The dining area is a conservatory on the side of the building. Tables were set around the edge in small groups. The floors and tablecloths were clean and cared for. I observed a mid-day meal. Most people thoroughly enjoyed what they ate. The portions were of a good size, and several vegetables were served with meat and potatoes. I did not witness anyone requesting, or having more food. I was told by both staff and residents that if they did not like the meal they could have an alternative. I witnessed one lady complaining the meal had got cold. A staff member dealt with this concern. The menus for the home are currently being updated. The manager advised me that a meeting had been held to discuss choices.’ This was also re-stated in the home’s AQAA. People who use the service told us they enjoyed the food provided and “always have plenty to eat”. The kitchen is open throughout the day and at night. Individuals are encouraged to help out in the kitchen and to make their own drinks and snacks if they wish. We observed people who use the service using the kitchen and being supported by the cook. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 15 One of the cook’s was spoken with and they said that fresh ingredients are used whenever possible, the supper for the evening of the site visit was a homemade savoury flan. Two people who live in the home are able to continue their relationship and share a room. They are able to go out in the community for walks and other activities when they choose. Another person goes to stay with their significant other regularly overnight and for weekends, this is achieved using a risk-assessed approach. People who use the service told us they could have visitors at any time and that they could meet with their visitors in the main lounge areas or in the privacy of their room. We found little information on care plans about supporting people to maintain or develop personal relationships. It is recommended that staff be provided with training on sexuality. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Any concerns or complaints a person might have are dealt with appropriately, however there must be accurate records of these. People who live in the home are protected from harm by good Safeguarding Adults procedures. EVIDENCE: The home’s AQAA indicated that they have not received any complaints or concerns during the past twelve months. CSCI has not received any concerns regarding the Warren. People who live in the home confirmed that they were confident that if they had a complaint the manager would deal it with. The complaints procedure is on display in the home. Systems are in place to record any concern or complaint. We noted that several pages had been torn from the book used to record complaints. One complaint from several years ago was recorded. Although staff informed us that most concerns were dealt with straight away it is recommended that all staff are reminded to record any complaints. This will ensure that it can be shown that staff listen to people who use the service and act upon any concerns. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 17 The AQAA indicated that staff had received training in Safeguarding Adults and there are policies and procedures available for staff to access if necessary. This was confirmed during discussions with staff. Staff were aware of their individual responsibility to report any allegations or suspicions of abuse. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People are able to personalise their rooms and only share a room if they have chosen to. The home was found to be clean and tidy and free from unpleasant odours. There is ongoing maintenance and decoration of the home, but consideration needs to be given to accelerating this process as some areas are tired and worn looking. EVIDENCE: People who live in the home have access to a pleasantly set out garden. There were tables and chairs, pots for plants, with a pond in the middle, containing fish. People stated how they enjoy sitting in the garden in good weather, and are able to have meals outside if they wish. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 19 There are some very steep steps down to the road with a large dustbin at the bottom. The access was open to the road. This was discussed with the manager and she stated that the bin would be moved to a more appropriate place. The home has two lounges, one for smokers and another for non- smokers. Both rooms had a new television with Sky TV available. The television in the smokers lounge had all the movie channels, which pleased the residents. This television was a little out of focus but the manager advised that the engineer is due to return soon to amend the wires to improve the signal. Several people were sat in the main lounge watching the television. The controls were held by one lady, however she was happy to adjust the viewing as the group suggested. The decoration was clean, although a little dated; the carpets appeared well cared for and quite new. Bedrooms viewed on the tour of the premises were tidy. People had their own photos, personal items, and in some cases pictures on the walls. There were only two double rooms. A couple shared one room; they had been offered a double bed but had declined. The other shared room was inhabited by two people who had been together for many years. They had formed a bond together. The younger of the two cared for the older one. Their beds were fairly close but could be divided by a curtain for personal privacy. The room was quite large and could have been reorganised for further privacy if either person required or requested it. Generally the carpets and decoration were clean and maintained. However, there was some decoration work being carried out on the top floor at the time of the site visit. Some decoration, such as in the toilets were tired and worn, but clean. One toilet had two doors, one did not lock and the other would not close. The manager was aware of this and the matter was being dealt with. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff need to be recruited in a safe manner to make sure that people are protected from harm. Training is provided to staff, but more emphasis needs to be placed on specialist training. People who live in the home are supported by sufficient numbers of staff that respond appropriately to their needs. EVIDENCE: People who live in the home are supported by staff that have undergone a recruitment process, however they need to be confident that it is a safe process. Examination of staff files showed that generally an application form was completed and references requested, but one file did not have an application form, however this person was employed many years ago by the home. However, references on all three files examined were not always from the previous employer and were from friends of the person applying. It is important that professional references are obtained from the previous employer and the reference can be easily traced to the company or person. There also needs to be evidence of references requests in staff files. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 21 The application forms required reviewing to make sure that the prospective employees full job history is detailed. All files had evidence of Criminal records bureau checks and permissions to work. The manager stated that job descriptions are currently being reviewed and each member of staff will be supplied with their relevant job description. We found sufficient staff on duty to meet the needs of people who use the service. We found staff had a good understanding of the needs and personal preferences of individuals. Staff interacted positively with people who live in the home. Their communication skills were seen to be good and they spoke at an appropriate pace for the person to understand them. It was not easy to identify staff, but all staff spoken with were polite and introduced themselves to the inspection team. It is recommended that staff wear badges to aid identification. None of the people who live in the home raised any concerns about delays in having their needs met. Some said that if they needed help the staff were always happy to help them, day or night. Staff spoken to had completed NVQ level 2 and 3 and was in the process of completing level 4. Some had completed a one-day training course on mental health. It is recommended that staff are provided with more in depth training on supporting people with mental health needs. Another member of staff had completed NVQ level 4 and Assessors Award. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 35 People who use the service receive excellent quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported by a manger that runs the home in their best interests. People live in a safe environment. People’s finances are managed appropriately and securely. EVIDENCE: The home completed an AQAA that contained good details of how the home is operating and areas that they consider need work on. The AQAA states that surveys are sent to people and their relatives or friends for comments on how the home is run. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 23 The manager of the home has many years experience of working in the care sector. She has been registered with CSCI as ‘fit to manage’. During the site visit we were able to speak with the manager and discuss her plans for the home. She was person centred in her approach and recognised the importance of putting the person first, as The Warren is their home. The manager informed us that once a month she undertakes a night duty to make sure that care given at night is appropriate and allow her time to talk with the people who live in the home. This was verified by checking the duty rota. Facilities are available for people who use the service to deposit small amounts of money in the home for safekeeping. Individual records are kept for any money held in this way. We found these records to be well maintained. All transactions are recorded with receipts kept for any expenditure. Individuals are encouraged to manage their own finances, in some instances with support from staff. Staff spoken to felt well supported by the manager. Staff told us they receive regular one to one supervision. Meetings are held on a regular basis with people who use the service. No major health and safety issues were identified on the site visit, although there is concern that carpets have been laid on uneven floor surfaces, which should have been fixed prior to new carpeting being laid. The expert by experience visited the laundry and recorded the following: ‘I visited the laundry, which was down many steps; however the door was locked when not in use. The laundry was well ordered, and each resident had a container for their clothes. The staff advised me they do the washing in the course of their duties. The towels & flannels observed were clean but very old and faded.’ Some people chose to have kettles to make hot drinks in their rooms, these people have written risk assessments in place. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Requirement There must be appropriate references obtained on people who want to work in the home. There must be a full employment history for each person. This will make sure that good recruitment processes are following, thus protecting people who live in the home from harm. Timescale for action 30/07/08 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 OP7 OP7 Good Practice Recommendations It is recommended that care plans are person centred and have achievable goals set to enable people to lead a fulfilled life. It is recommended that care plans consistently record the involvement of the person in developing the plan and up to date information to make sure staff are aware of changes in need. It is recommended that people nutritional needs are acted upon. DS0000025856.V358546.R01.S.doc Version 5.2 Page 26 3 OP8 Warren The 4 5 6 7 8 9 OP9 OP12 OP15 OP16 OP19 OP27 It is recommended that medications are kept at the appropriate temperature and the storage facility is monitored to achieve this. It is recommended that staff receive training on sexuality to enable people who live in the home to develop or maintain significant relationships. It is recommended that menus are displayed on tables at mealtimes to make sure that people are aware of the choices available. It is recommended that all concerns or complaints are recorded, with actions and outcomes detailed. It is recommended that consideration is given to accelerating the redecoration process to provide a good environment for people to live in. It is recommended that staff have name badges to enable people to identify them. Warren The DS0000025856.V358546.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Warren The DS0000025856.V358546.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!