Inspection on 12/02/07 for York Road (14a)

This inspection was carried out on 12th February 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Road (14a) 09/03/09

York Road (14a) 26/07/07

York Road (14a) 13/11/06

York Road (14a) 15/12/05

York Road (14a) 08/06/05

York Road (14a) 13/01/05

York Road (14a) 27/04/04

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 York Road (14a) 14a York Road Sutton Surrey SM2 6HG Lead Inspector James O`Hara Key Unannounced Inspection 12th February 2007 09:30 York Road (14a) DS0000007149.V330146.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 York Road (14a) DS0000007149.V330146.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. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York Road (14a) Address 14a York Road Sutton Surrey SM2 6HG 020 8643 9612 020 8643 1662 h4062@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mr Mohammad Iqbal Sohawon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 2006 Brief Description of the Service: 14A York Road is a purpose built facility situated in a mainly residential street, between Sutton and Cheam. The home is close to local transport and facilities. Threshold Housing and Support owns the building although the residential unit is managed and staffed by Men Cap. The home provides care to six service users who have learning disabilities, autism and challenging behaviour. There are six single bedrooms, a lounge, dining room, kitchen and laundry. There are bathrooms and toilets situated through out the home. The home also has a large garden to the rear of the property. There is also ample parking to the front of the house. The home has its own transport in the form of a people carrier. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key inspection carried out at 14a York Road this inspection year. The reason for this inspection was to follow up on the high number of requirements and recommendations set at a key unannounced inspection on the 13th of November 2006. Mr. Sohawon, Mr Iqbal Sohawon, was not available during that inspection but was present today. This site visit was carried out between 9.30 and 11.30 am on a Monday morning. Methods of inspection included a tour of the premises and a review of the previous requirements and recommendations with Mr Sohawon. Records examined included service users care plans, Statement of Purpose, adult protection issues, recruitment and selection, staff personnel records, staff supervision, staff training, health and safety and fire safety. What the service does well: What has improved since the last inspection? Significant efforts have been made and are being made by both Mr. Sohawon and Threshold Housing Association to improve the physical appearance of the home and to ensure that service users live in a safe, homely and comfortable environment. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 6 All service users now have a copy of their needs assessment/care plan on file as required at the last inspection. All but one member of staff has attended adult protection training. The remaining member of staff will attend adult protection training on the 6th of March 2007. Mr. Sohawon and the two deputy managers now supervise staff. Records show that since the last inspection all members of staff have received regular supervision. One member of staff has been off in that time and supervision has yet to be arranged. The fire door leading to the office has been replaced and records show that the homes fire alarm system is checked on a regular weekly basis. A member of staff has been delegated as the fire officer and is overseen by a deputy manager and Mr. Sohawon. 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. York Road (14a) DS0000007149.V330146.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 York Road (14a) DS0000007149.V330146.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): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users and their representatives with all the information they need to make an informed decision about whether or not to use the service. The Statement of Purpose has recently been updated. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Service User Guide includes all the necessary information specified in regulation 5 of the Care Homes Regulations. The Mencap organisation has its own guidelines for service users selection and assessment prior to moving to the home. The home only accepts referrals following an assessment completed by a care manager. The home also completes an assessment. Compatibility with others already living in the home is also taken into account. Any prospective service user would have a gradual introduction to the home with a series of short visits and overnight stays. The time frame would be flexible depending on the service user. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 9 All service users have contracts/licence agreements stating terms and conditions and fees charged. The range of fees charged at the home is between £1209.33 and £1251.45 per week. It was noted at an inspection at the home on the 13th November 2006 that the kitchen and laundry room doors are kept locked. The deputy manager stated that this was for the safety of some of the service users and that service users always have access to the kitchen and laundry when staff is around. It was recommended that the homes Statement of Purpose and Service User Guides refer to restrictions on the freedom of movement within the home and the reason for the restriction so that any prospective service user has all the information they need to make an informed choice about the home. These restrictions should also be discussed and recorded in individual service user needs assessments/care plans. The home Statement of Purpose was updated in December 2006 to include the reason for the restriction and how service users can access the kitchen. Mr. Sohawon stated that these restrictions will be included in the Service Users Guide and will also be discussed with individual service users and recorded in their needs assessments/care plans. York Road (14a) DS0000007149.V330146.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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In general service user plans include detailed information on their needs and personal goals. All service users have individual risk assessments and risk management strategies in place so that service users can participate in activities in the home and in the community in a safe manner. EVIDENCE: During the inspection on the 13th of November 2006 two service users files were examined. Both service users had a person plan book that included a communication profile, personal profile and important people in my life. The file also included weekly activity records, morning and evening routines, challenging behaviour guidelines. It was noted that all service users risk assessments are kept under regular review. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 11 Neither file included copies of the service users care plan/placement review. A requirement was set that Mr. Sohawon contact all of the service users care managers and request a copy of the most up to date service users care plan/placement review and this must be kept on file. Following the inspection Mr. Sohawon contacted the service users care managers. Two service users files were examined at random, both had a copy of their needs assessment/care plan. Mr. Sohawon stated that all service users have copies of their needs assessments/care plans on file. York Road (14a) DS0000007149.V330146.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): 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. Provision is made so that all service users attend appropriate social activities, day centres and become part of the local community. Appropriate arrangements are made so that service users have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and eaten by the service users. EVIDENCE: York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 13 Service users attend various day services and colleges during the week and have a set home day when they carry out personal tasks such as cleaning, laundry, shopping and cooking. Service users attend the Jan Malinowski Centre, Cheam Centre, Hallmead Day Centre, Generates, Schola and Orchard Hill College. Some service users also attend social activities at the Tuesday Club, Gateway Club and the Sunday Club. Service users go to Church on Sunday if they wish and some service users go to the cinema and bowling. Some service users are able to travel alone to Sutton for personal shopping or to visit cafes some service users need support from staff to do this. The home has visitor policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Visitors are welcomed and the service users families are invited to their reviews. Visitors can be seen in any of the homes communal areas as well as the service users bedrooms. A number of Commission For Social Care Inspection questionnaires were returned to the Commission as feedback prior to the last inspection. Some indicated that they were not able to visit their relative/friend in private. It is recommended that Mr. Sohawon send a copy of the homes visitor’s policy to all of the service users relatives. All but one of the service users has regular contact with their relatives. One service user has a Mencap befriender who visits once a month. In house activities offered to the service users include arts and crafts, games and cooking. Staff supports service users to cook evening meals. The homes menus indicated that the meals presented to the service users were varied, balanced and nutritional. York Road (14a) DS0000007149.V330146.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): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the health care needs of the service users are good and service users receive personal support in the way they prefer. EVIDENCE: The service users wishes on how they are supported with personal care are outlined in their personal files. Service user files examined indicated that service users attend regular appointments with health care professionals. Service users have access to relevant professional support to maximise independence, including the Community Team for People with Learning Disability. Service users files include guidelines for staff to support some service users with challenging behaviour. These had been drawn up by the home with support and advice from health care proffessionals. Medication is stored in a locked cabinet in the office. Medication administration records checked on the 13th of November 2006 were up to date and accurate. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 15 Service users medication records also contain a medication profile and recent photograph. The home has a policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. At the last inspection the deputy manager stated that she has booked staff training on first aid and moving and handling. Training records show that most staff has attended first aid and moving and handling training. Mr. Sohawon stated that the remaining staff would attend this training in either March or April 2007. York Road (14a) DS0000007149.V330146.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): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure. So that service users can be sure that they are not at risk of harm or abuse the home must ensure that the occurrence of any event in the care home that adversely affects the well being or safety of any service user is reported to the Commission and their care managers without delay. EVIDENCE: The home has a copy of the local authority Adult Protection Policy on site. Mr. Sohawon advised the Commission that there had been a number of incidents were service users had hit one another or members of staff. Mr. Sohawon stated that a Vulnerable Adult Protection Strategy Review meeting was due to be held on the 16th February 2007 however following the inspection the Commission was informed that the meeting was cancelled and another meeting would be arranged. Mr. Sohawon stated that previously arrangements had been made with care managers from placing authorities, the Mencap organisation and the Commission for the reporting of untoward incidents. On the 7th of February 2007 a record/summary of these incidents were sent to the Commission on request. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 17 In light of the nature and frequency of these incidents these arrangements are not appropriate. A requirement has been set that Mr. Sohawon must give notice to the Commission without delay of the occurrence of any serious injury to a service user; and any event in the care home that adversely affects the well being or safety of any service user. The registered manage must ensure that service users individual care managers are given notice of any untoward incident involving their client. Following the inspection a number of regulation 37 reports were received at the Commissions office and had also been sent to the respective service users care managers. Mr. Sohawon also confirmed that he had discussed Mencaps Adult Protection policy with his staff team and in particular reporting incidents under regulation 37 of the Care Homes Regulations. A requirement was set at the last inspection that all members of staff must attend training on adult protection. Since then all but one member of staff has attended adult protection training. The remaining member of staff will attend adult protection training on the 6th of March 2007. York Road (14a) DS0000007149.V330146.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): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant efforts have been made and are being made by both Mr. Sohawon and Threshold Housing Association to improve the physical appearance of the home and to ensure that service users live in a safe, homely and comfortable environment. EVIDENCE: At the inspection on the 13th of November 2006 it was noted that the laminate flooring on the ground floor had been damaged due to flooding. At this visit Mr. Sohawon stated that the flooring is due to be replaced with an appropriate replacement possibly non-slip linoleum. At the inspection on the 13th of November 2006 it was noted that the kitchen was in a poor condition with some drawers missing from cupboards and flooring coming away from the walls. At this visit Mr. Sohawon stated that Threshold, the housing association, have agreed to replace the kitchen and work is due to commence next week. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 19 At the inspection on the 13th of November 2006 it was noted that the kitchen floor was dirty around the base of the cupboards and fridge/freezer and that the doors to the kitchen and in the hallway were sticky to the touch and in need of washing down. A requirement was set that Mr. Sohawon ensure that the homes cleaning programme is adhered to. At this visit Mr. Sohawon stated that he is consulting with his managers about employing a cleaner at the home. An action plan sent to the Commission on the 29th of January 2007 stated that immediately following the inspection the deputy manager discussed this requirement to each member of staff. The deputy manager has ensured that each member of staff is aware of the homes cleaning programme and is monitoring the cleaning of the home. It was observed at the last inspection that the fire door leading to the office had been removed. A requirement was set that Mr. Sohawon ensures that the fire door leading to the office is replaced as soon as possible. The fire door was replaced on 19.12.06. A requirement was set at the last inspection that Mr. Sohawon ensures that when there is any future issue were the fire safety of the service users and staff could be at risk then the homes fire risk assessment must be reviewed. Immediately following the inspection the deputy manager carried out a workplace fire risk assessment. Since the fire door leading to the office has been replaced, the former workplace fire risk assessment has been reviewed by the other deputy manager and signed off by other members of staff. It was noted that some of the tiles in V’s en suite bathroom are broken. A requirement was set at the last inspection that Mr. Sohawon ensures that the broken tiles in V’s en suite bathroom and the dripping tap in the bathroom were replaced or repaired. The broken tiles and dripping tap in V’s en suite bathroom were repaired on the 11th December 2006. It was noted that the chest of drawers in C’s room is broken. A requirement was set at the last inspection that Mr. Sohawon must ensure that the chest of drawers in C’s room be replaced or repaired. The chest of drawers in C’s room was repaired on the 5th December 2006. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 20 It was noted at the last inspection that the dining room had recently been redecorated. It was recommended that the pictures were re hung in the dining room. Pictures were re-hung in the dining room on 15th December 2006. It was noted at the last inspection that a light switch in the hallway was faulty and had been reported by the deputy manager to the housing association on the previous Friday and that on the day of the inspection, Monday, the deputy manager was concerned that no one had come to repair it. Immediately following the inspection, the deputy manager contacted Threshold and asked when the light switch was going to be repaired. The light switch was repaired on 23rd of November 2006. A requirement was set at previous inspections that Mr. Sohawon must replace the bulbs in the circular ceiling lights in the homes communal areas and investigates the reason why they have a short lifespan. Mr. Sohawon stated that he had been pursuing the matter with Threshold, the homes housing association, and that they had originally agreed to replace the light fittings by the timescale of the Commission’s previous requirement, and that the work was overdue by the time of the last inspection. All bulbs have now been replaced by Threshold. Also, there is an agreement with Threshold to monitor and continue to replace the bulbs when the home notifies them. This is so that Threshold can investigate the reason why the bulbs have a short lifespan. Mr. Sohawon is liaising with Threshold’s Agency Liaison Officer and surveyors on the matter. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 21 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): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been a significant turnover of staff at the home over the last twelve months. The challenge for Mr. Sohawon and the Mencap organisation is to establish a staff team that can meet the needs of the service users in the longer term. EVIDENCE: At the last inspection it was noted that seven members of staff had left employment at the home since the previous inspection. Since then another member of staff has left. Mr. Sohawon stated that because of the nature of the service and the challenges it presents it has been difficult to retain staff. It is recommended that the Mencap organisation and Mr. Sohawon consider how the home can establish a staff team that can meet the needs of the service users in the long term. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 22 As required at the last inspection a file for each member of staff is now kept in the home. Each file includes copies of each individual’s birth certificate, passport, two written reference and a recent photograph. A requirement was set at the last inspection that Mr. Sohawon must ensure that references are taken up for the two new members of staff and any future members of staff on company headed paper and or include a company stamp. Mr. Sohawon stated that he would ensure that references for any future members of staff would be requested on company headed paper and or include a company stamp. A requirement was set at a previous inspection that the home manager must ensure that all staff receives regular recorded supervision. At the inspection in November 2006 the staff files indicated that this requirement had not been met. Mr. Sohawon and two deputy managers now supervise staff. Records show that since the last inspection all members of staff have received regular supervision. One member of staff has been off in that time and supervision has yet to be arranged. As recommended at the last inspection the home now records training attended by all members of staff. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 23 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): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mr. Sohawon has worked hard to address all of the requirements and recommendations set at the inspection on the 13th of November 2006. The challenge to for Mr. Sohawon is to build a new staff team that can meet the needs of the service users. EVIDENCE: Mr. Sohawon is currently completing the Registered Managers Award and NVQ Level 4 in Care. Regulations 26 visits are carried out by the organisation in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 24 a written report on the conduct of the care home. Copies of these visit reports are regularly sent to the Commission. Prior to the inspection in November 2006 a number of Commission For Social Care Inspection questionnaires were returned to the Commission as feedback. Generally relatives indicated that they were happy with the overall care provided. Some comments included “X has been a resident since the home was opened. He is very content and he is well looked after” but three raised concerns about the health care needs of the service users. It was recommended that Mr. Sohawon seek the views of the service users relatives and friends about the quality of care provided in the home. Mr. Sohawon stated that he has sought the views of four of the service user’s families and advocates about the quality of care provided in the home in individual Person Centred Planning meetings. Mr. Sohawon stated that he plans to meet with the remaining service users families. Some relatives said that they were not aware of the homes complaints procedure. It is recommended that Mr. Sohawon send a copy of the homes complaints procedure to all of the service users relatives. Mr. Sohawon stated that copies of the home’s/MENCAP’s national complaints procedure were given to family/advocates of three service users in individual Person Centred Planning meetings and copies have been sent to the remaining service users relatives. At the last inspection the deputy manager stated that she was not sure of the homes procedure for testing for legionellas. A requirement was set that Mr. Sohawon must ensure that Legionella testing is carried out at the home and it was recommended that Mr. Sohawon clarify the homes policy on legionellas in writing to the Commission and all staff at the next team meeting. Immediately following the inspection, the deputy manager arranged for legionella testing to be carried by Threshold. Legionella testing was carried out at the home on the 12th of December 2006. A copy of the certificate was sent to the Commission. Following a recommendation at another Mencap care home to inform the Commission of Mencaps policy for controlling legionellas the following advice was passed to the Commission from Mencaps Senior Health & Safety Consultant. “There is a recommendation (HSE) to chlorinate tanks but at this point in time is not a Mencap requirement as the properties in question are homes and not industrial sites”. It is recommended that Mr. Sohawon clarify Mencaps policy for controlling legionellas to all staff at the next team meeting. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 25 At the last inspection the deputy manager could not locate the whereabouts of the Portable Appliance Testing Certificate. Mr. Sohawon stated that a Portable Appliance Test had been carried out in 2006 and that he has requested a copy of the certificate. Mr. Sohawon stated that Mencaps policy for Portable Appliance Testing is that it is carried out once every two years. It is recommended as good working practice that Portable Appliance Testing is carried out annually. A requirement was set at the last inspection that Mr. Sohawon must ensure that the fire alarm system is checked on a regular weekly basis. Records show that the homes fire alarm system is checked on a regular weekly basis. A member of staff has been delegated as the fire officer and is overseen by a deputy manager and Mr. Sohawon. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000007149.V330146.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York Road (14a) Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 27 No 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 YA23 Regulation 37 (1). Requirement A requirement has been set that Mr. Sohawon must give notice to the Commission without delay of the occurrence of any serious injury to a service user; and any event in the care home that adversely affects the well being or safety of any service user. The registered manage must ensure that service users individual care managers are given notice of any untoward incident involving their client. Timescale for action 13/02/07 2. YA23 12 (1) a. 13/02/07 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 YA15 YA32 Good Practice Recommendations It is recommended that Mr. Sohawon send a copy of the homes visitor’s policy to all of the service users relatives. It is recommended that the Mencap organisation and Mr. Sohawon consider how the home can establish a staff team that can meet the needs of the service users in the long term. DS0000007149.V330146.R01.S.doc Version 5.2 Page 28 York Road (14a) 3. 4. YA42 YA42 It is recommended that Mr. Sohawon clarify Mencaps policy for controlling legionellas to all staff at the next team meeting. It is recommended as good working practice that Portable Appliance Testing is carried out annually. York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 29 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 York Road (14a) DS0000007149.V330146.R01.S.doc Version 5.2 Page 30 - 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!