Inspection on 16/11/07 for Wheathill Road, 19

This inspection was carried out on 16th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wheathill Road, 19 26/09/06

Wheathill Road, 19 25/01/06

Wheathill Road, 19 01/09/05

Wheathill Road, 19 07/12/04

Wheathill Road, 19 04/05/04

Wheathill Road, 19 20/11/03

Wheathill Road, 19 01/09/03

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 HOME ADULTS 18-65 Wheathill Road, 19 19 Wheathill Road Penge London SE20 7XQ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 16 and 25 November 2007 10:30 th th Wheathill Road, 19 DS0000006907.V356912.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 Wheathill Road, 19 DS0000006907.V356912.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. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheathill Road, 19 Address 19 Wheathill Road Penge London SE20 7XQ 020 8659 7425 F/P 020 8659 7425 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) Community Options Limited vacant post Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category MD(E) for named service user only. 26th September 2006 Date of last inspection Brief Description of the Service: The home is a large house located in a residential area of Penge. The facility is part of the Community Options group, which operates the home, whilst Hyde Housing owns the building. The home is for five residents who have long-term mental health problems. All residents in this home are on Enhanced Care Programme approach (CPA). The main purpose of the home is rehabilitation into the community, with residents developing the skills for more independent living. Residents are encouraged and supported to be independent in all activities of daily living. In addition integration into the local community and accessing local services including health provision is promoted. The home has its own staff team with a Manager and Deputy Manager heading it up. Senior management and personnel are provided through the head office of Community Options. On call support and advice are also available through the company seven days a week 24 hours a day. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home is a mental health facility providing rehabilitation accommodation and support to residents who are suffering from long term mental health problems. The site visits were conducted over two days. On the day of the first site visit, staff and residents had arrangements for a communal meal to a local pub. The inspector undertook a second site visit on a Sunday to complete the inspection process. Prior to the inspection the AQAA had been completed and forwarded to the CSCI. During the two site visits the inspector met with staff on duty including the newly appointed Manager who was present for the first day. The inspector spoke with several of the residents during the lunch outing, which was a good opportunity to meet resident in a more informal setting. A tour of the premises was undertaken. Records were inspected including those relating to residents and the overall running of the service. The staff personnel files were inspected on a separate visit to Community Options Head Office and found to be to a good standard. What the service does well: What has improved since the last inspection? Since the last inspection Community Options have appointed a new Manager to the facility who is hoped will be a long-term appointment as movement of Manager has been an issue in the past. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 6 It was evident that the new Manager wants to enable residents to participate more in the local community and engage positively with rehabilitation. She had already started improving activities and involving residents in the organisation of events. 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. Wheathill Road, 19 DS0000006907.V356912.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 Wheathill Road, 19 DS0000006907.V356912.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with information on the service and trial visits are facilitated to enable them to sample the service. Not all assessment information is available and utilised by staff prior to admission hence staff may not be working consistently with the CPA care plan therefore objectives may not be achieved. EVIDENCE: The assessment of the newly admitted resident was inspected. The inspector has sampled and inspected most of the other resident’s information on previous inspection to the service. The assessment record was dated 23/8/07, which was three days after the resident had been admitted. The Deputy Manager, who was working in the home when this resident was admitted, stated that there was no assessment information received prior to the resident moving into the home, although this comment was later changed. It was stated that the assessment had probably been conducted by the previous Manager, at Repton Road, who gave the information to Tracy Simpson. That Manager had since moved to another Community Options facility. The Deputy Manager stated that the resident had visited the home twice prior to admission, on both occasions with staff from Repton Road accompanying him. There was no record of either of these trial visits or any information that may of assisted staff in gathering information about the prospective resident. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 9 Other information in the file included documentation relating to an in house review, which had been conducted 27/7/07. In addition there was a Consultant Psychiatrist letter dated 16/3/06 and an Enhanced CPA letter of the same date. Other information received by Wheathill Road included the risk assessments conducted by Repton Road. Information pertaining to the current CPA care plan was unable to be located. There were Terms and Conditions of residency signed by the residents dated 10/8/07 and a Hyde Housing licence agreement was also on file. The certificate of registration, Statement of Purpose and Service Users Guide will al need to be amended to reflect the change of Manager. Please see requirement 1. Wheathill Road, 19 DS0000006907.V356912.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place, which reflect the physical psychological and rehabilitation needs of the residents although the different formats are confusing, and documentation cumbersome. It was difficult to establish if these reflected those objectives set out in the CPA information, hence consistency in approach and achieving objectives may have been compromised which would not be conducive to residents well being. Individual risk assessments are in place. EVIDENCE: The residents in this facility have enduring mental health problems and as such are subject to aftercare procedures, referred to as the Care Programme Approach, CPA. Care plans in this home should work around rehabilitation objective sand those identified in the CPA care plans. The standard of care plan content, interventions and objectives have been the source of much discussion. The documentation has been amended and reviewed to improve the standard of documentation. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 11 The care plan of the recently admitted resident was inspected. The care plan identified issues relating to physical health and well as mental health. The content of the interventions were good and review dates were in place although the” outcomes “, were not specified hence staff would be unsure what they were aiming towards. Other areas, which had been identified, included rehabilitation activities including attending a day centre, social activities and household chores. All of these areas had been signed by the resident and key worker and included the date. Another support plan format identified issues including management of medication, money and college courses. Again the content was to a good standard with review dates stated. The inspector recommends that care plans be reviewed so that all issues are set out on a standard format with objectives clearly stated, comprehensive reviews recorded and reflective of those objectives as set out in the CPA (Care Programme Approach) care plan. Documentation must reflect inclusion by the residents and the staff member. In this file the Community Options Support Package was partially completed. Included within this file was an overview of risks and specific risk assessments for missing persons, fire, COSHH and others specific to the resident’s own needs. The resident’s signature was in place as well as that of the staff member. There was a weight chart, which had two entries for August and September 07. This was in relation to information in the support plan referencing the need to reduce cholesterol levels and preventing weight loss. General risk assessments are maintained to cover areas in the home and to address the tasks that residents undertake as part of rehabilitation. All resident files are safely stored in the staff office. Please see requirement 2. Wheathill Road, 19 DS0000006907.V356912.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to be independent and involved with the local community. Maintaining family contact is important and this is encouraged and facilitated by staff. Staff support residents to ensure that they make the right dietary choices including healthy eating. EVIDENCE: The inspector met with many of the residents several of whom have been interviewed on previous inspections and know the inspector. The newest resident to be admitted to Wheathill had previously been in Repton Road. All of the current residents have relatives who are involved with their rehabilitation. Two of the residents with whom the inspector met, did go home for periods, one for weekends every two weeks, the other about every three months. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 13 Residents are encouraged to be as independent as possible and engage with the local community. All resident use public transport and Freedom passes enable them to travel free. The new Manager has placed great importance on structured rehabilitation social and leisure activities. On the first day of the inspection the staff and residents were going out for lunch to a local pub. It was good to see that one particular resident, who rarely gets involved, was present for this social event. The lunch was one of the first such events that the new Manager had organised and she hoped to address more in the future. Residents seemed to enjoy the lunch; they were seen to engage positively with staff and one another in the pub. Visiting is open and several resident go to their family for periods including overnight stays. Residents do access the local facilities and as part of rehabilitation which includes local shopping. Residents in this home are supported and encouraged to do their own food shopping, menu planning and are assisted to prepare meals. Residents may be accompanied by a member of staff, who will assist them with the shopping, budgeting and buying the right ingredients for meals. Preparation of meals and menu planning is part of the ongoing rehabilitation that most residents require. Residents have set tasks that they are expected to do on a daily basis. These include cleaning of their own bedrooms as well as communal areas under staff supervision. Motivation of resident can be difficult especially around tasks however in this home areas were well maintained. Wheathill Road, 19 DS0000006907.V356912.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents access health care through the community resources and are supported by staff to access these. As part of ongoing rehabilitation to enable more independent living, self medication procedures are promoted in a safe and supported environment. Not all relevant and current health information was available which for residents with mental health issues is essential to ensure continuity and consistency in care provided. EVIDENCE: As part of rehabilitation residents are encouraged and supported to access all healthcare within the community setting. Domiciliary visits are discouraged except in the event of an emergency. In the file selected for case tracking on the sheet headed” Primary Care Interventions” there was reference to two dental appointments. Other information included a Consultant Psychiatrist‘s letter regarding self administration of medication. There was little in respect of current CPA information including the care plan or risk assessment. As stated previously the only CPA information was stated March 06. As this resident was on Enhanced CPA it is essential that all Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 15 information is retained and available for staff to reference and utilise appropriately. The medications were inspected at the second site visit. Currently there are no residents who are fully self medicating although two are at the initial stages of this. The resident who was part of the case tracking is on stage two of self medicating procedures. The process is in four stages, which starts with staff prompting and initiating the procedure to full administration collection and management by the resident. When this resident goes on home leave his brother collects and administers the medication to ensure it is correctly addressed. This has not always been correctly addressed as on one occasion the medication was forgotten and staff were not alerted to this. This resident did not have a lockable cabinet for self administration this must be addressed. Medications are securely stored in the office cupboard. Medications are subject to weekly audits. There were no controlled drugs in use during the two site visits. The home should be aware of the changes to storage facilities in respect of controlled drugs, which become operational 2008. Medication charts had resident’s photographs attached. Information sheets in the medication file provided good information on the specific medication and the side effects, which may occur. Those medications which are administered” as required “are recorded on a separate sheet. One medication to be administered as required, did not include details of the maximum dose to be administered, this needs to be addressed. Staff checks medications received into the home and those disposed of are recorded. Please see requirement 3. Please see recommendation1. Wheathill Road, 19 DS0000006907.V356912.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on how to make a complaint was available and on display It was also incorporated into other information provided to residents. Residents can be assured that complaints are taken seriously by Community Options who operate an open culture. Staff were aware of what action to take in the event that abuse was suspected which provides further safeguards to residents living in the home. EVIDENCE: Community Options have a procedure on display in each of their homes providing details of how to complain and it included the contact details of the CSCI and local ombudsman. In previous dealings with Community Options the inspector has found the organisation to be receptive to complaints and that they take the matters seriously. The CSCI has received no complaints regarding this service. The home has received no complaints about the service. Community Options have standard documentation and forms to complete in the event that a concern is raised. The home is reminded that all concerns must be logged and investigated with supporting records retained. Two staff with whom the inspector met at the site visits both demonstrated a good knowledge of adult protection and whistle blowing. They confirmed that they had received training on the topics during induction and thereafter at refresher study days. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 17 Residents with whom the inspector met were confident that they could raise concerns several of the stating that they would go to the Head Office, which is always an option, open to residents. Please see recommendation 2. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is maintained in good order. Residents are provided with individual bedrooms and spacious communal areas. EVIDENCE: The communal areas were to a good standard and improvements were evident in these. Two new sofas had been purchased for the ground floor lounge, this area was particularly pleasant, light and airy. In the smoking areas a new wooden floor had been laid and this had improved this area. Staff will need to ensure that this area is maintained as with so many smokers in the home areas can quickly deteriorate. The inspector was able to view three bedrooms, which were to a satisfactory standard. The bedrooms inspected were personalised with items of furniture, soft furnishings, pictures etc. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 19 The kitchen was clean, tidy and organised. Resident have allocated space for storage of their food purchases including space in the fridge. The staff office had been reorganised and this provides more space for checking medications. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents needs. On call managerial systems are in operation for emergency situations, which provides staff with support. Staff are subject to robust recruitment procedures followed by an induction period and thereafter supported by on going training to address the work they do. EVIDENCE: Wheathill road employs six staff including the Manager and the Deputy Manager. Staff do internal rotation as part of their full time working week. The home has no vacancies currently. At the time of the site visit her were no staff who were on long term sick. The inspector met with the Deputy Manager. He is NVQ level 4 qualified and is addressing further personal study for a mental health diploma. He confirmed statutory training in manual handling, health and safety and a three day first aid course. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 21 The inspector checked two training files and within these there was evidence of induction, including TOPPS induction, medication proficiency documentation and a number of course certificates, covering both mandatory topics as well as those related to resident’s conditions. Staff meetings are held at least two monthly and more frequently if there are any issues to discuss. The minutes of the last staff meeting were inspected. Community Options produces an annual staff survey to canvass the opinions of staff on their employment and working lives. Staff confirmed that they are provided with a lot of training and updates offered at set intervals. The inspector attended Community Options head office to view the staff personnel files as restricted space in the individual homes makes safe storage of these difficult. In general the staff personnel files were organised with information easy to access. Sections indicated where items could be located. The standard of information included was good. Evidence that recruitment checks are made prior to employment were on file including application forms, interview information, two references, CRB clearance, offer letter and contract. Information relating to the CRB was evidenced either by the CRB document itself, or those which had been destroyed, on the advise if the CRB helpline, evidence was on the file including the reference number, date of issue and an indication of whether it was satisfactory. The CSCI state that CRB’s should be retained for inspection, however the current system was seen to be working satisfactorily. There was discussion at the Head office relating to retaining records of discussions when convictions which appear on CRB checks. The record should include evidence of the discussion and the outcomes arising from this, on whether to employ the candidate or not. In addition any gaps in application forms or conflicting information included within it, must be explored and written notes retained with the reason provided. Community Options needs to obtain verification in writing, of any person who has worked in a care employment, either working with adults or children. This record needs to specifically identify the reason for leaving the employment. Community Options are undertaking the recommendation that CRB’s be repeated every three years. All of the recruitment issues were identified in a separate letter to Community Options Head Office. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced individual supported by experienced managerial personnel. Health and safety issues are well addressed which provides residents with accommodation, which is safe to live in. Quality assurance measures include resident’s, staff and relatives views on the service the results of which are taken forward as part of on going improvements in the service. EVIDENCE: The home has appointed a permanent Manager to this facility. On the first day of the site visit the inspector met with her, she had been in post two weeks. She related that she had previous experience in a management role having Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 23 managed in a domestic violence unit. She is qualified to a degree level. She is undergoing the registration process with the CSCI to become the registered Manager. The new Manager has supervision from another Manager in the Community Options group. This Manager is well qualified in her role and has a number of years of experience she is also located close to Wheathill Road. The inspector was advised that formal supervision takes place weekly although it is intended that monthly will be the frequency. A selection of health and safety certificates were inspected. There are no lifting aids of passenger lifts in this home. The five-year electrical inspection included a certificate for remedial work 2006, and the portable electrical appliances had been inspected January 07. The fire equipment had had an annual service November 07 and July07 when new smoke detectors were recommended. The fire alarms are tested weekly and records reflected this. Monthly emergency lighting checks are made. Fire drills had been conducted January and June 07 records for these included a list of staff and residents although no signatures were present. The inspector recommended that in a home wher there are a lot of residents who smoke, and who may lack awareness in health and safety issues, that more fire drills are conducted to maintain knowledge on the subject. The annual gas safety check was conducted March 07 and the Environmental health had inspected the premises May 06. Hot water temperatures were checked monthly and descaling of the showerheads took place November 07. The home were asked to clarify the current status on legionella testing. All staff do a one day first aid course as part of core training. In the home there are four resident who have their finances overseen by the staff. The home have a balance sheet to record transactions this included staff and residents initials for transactions. Receipts are only produced if the residents provide these. The money checked was correct in all cases. There are two weekly audits on the finances and staff checks these at shift handover. Residents meetings are held, the last minutes seen were for the meeting held October 07. Community Options conducts an annual staff survey, the results of which are collated in to a graph and those areas, which require action, are taken forward. Residents are encouraged to attend the board meetings and be instrumental in the further development of the service. The Regulation 26 visits are conducted by other managers within Community Options, although the reports were not checked. Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 24 Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement The Manager must ensure that all assessment procedures are concluded and evidenced prior to any admission taking place. Evidence of information provided to the residents and their family should be recorded. Confirmation of the home’s ability to meet all of the resident’s identified needs must be in place. This is now outstanding. Previous time frame for action 28/3/07 inspection. The Manager must ensure that all care plans are fully reflective of the resident’s needs and reflective of those issues identified in the CPA care plan to ensure consistency of approach. The Manager must ensure that all health information is retained on site for staff to utilise. Timescale for action 28/01/08 2. YA6 15 28/01/08 3. YA19 13 28/01/08 Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 27 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 YA20 Good Practice Recommendations The Manager should ensure that adequate storage is provided for all resident who require it for medication purposes. The Manager should ensure that a complaints log is devised to accurately reflect all complaints received with details of date, investigation route and the satisfaction of the complainant. 2. YA22 Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 28 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 Wheathill Road, 19 DS0000006907.V356912.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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