Care Home: Chandos Road, 167 (Consensa Care Ltd)

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What the care home does well The results from the homes` internal surveys shows that individuals in the home are generally well satisfied with the service and support which they receive from staff. Individuals` assessed needs are identified before they are admitted to the home. Individual care plans are well developed and the service specific to meeting each persons` needs. Individuals are encouraged and supported to maintain their independence and to engage in local and community activities of their choice. Residents` cultural needs and individual preferences are taken into account in service planning. Risk assessments are in place to support individual plans. There is regular contact with a range of health professionals to ensure that individual health needs are monitored and met. Contact with family is maintained and encouraged. Staff are well supported, trained and supervised. Policies and procedures are in place. Health and safety procedures are on the whole well observed. There is a good system of management auditing, checking the quality of records and ensuring that th homes` procedures are followed. Records are detailed and in good order. What has improved since the last inspection? The home has met the majority of requirements from the last inspection where shortfalls had been identified. Individual care plans are now signed showing involvement in their care planning and plans regularly reviewed; monthly residents` meetings take place where residents are encouraged to share their views on the service; identified repairs have been achieved; quality assurance surveys from residents are distributed to gauge their level of satisfaction in the service; three out of four health and safety requirements were achieved in respect of fire doors, fire alarm testing and fire evacuation drills. In response to how they have improved, the homes` AQAA states:"Consolidated the improvements that had been made in the previous 12 months, so as to make sure that they are embedded into the home and not a passing phase. Continual growth with regards to local PCT`s and social services being aware of our service and its` integral part in an individuals rehabilition following an acquired brain injury. Continued growth of knowledge of local services available for our specific client group." What the care home could do better: Two requirements are restated from the last inspection, to ensure that all significant incidents that are reportable by regulation are reported to CSCI and to the local adult protection coordinator if there are any adult protection concerns. Fridge temperatures must be maintained and must not exceed safe limits. Additionally, medication administration sheets (MAR) must accurately record all prescribed medicines to individuals. Effective action must be taken in relation to the pharmacist used by the home to ensure the accuracy of MAR charts or for the home to seek the use of an alternative pharmacist. The home must ensure that residents` complaints are better identified and recorded, including any actions taken and to record their outcomes. CARE HOME ADULTS 18-65 Chandos Road, 167 (Consensa Care Ltd) 167 Chandos Road Stratford London E15 1TX Lead Inspector Nurcan Culleton Unannounced Inspection 19th January 2009 10:00 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chandos Road, 167 (Consensa Care Ltd) Address 167 Chandos Road Stratford London E15 1TX 0208 534 1117 0208 471 9225 njr@consensacare.com 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) Consensa Care Ltd Miss Rebecca Rose Harland Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia Code MD The maximum number of service users who can be accommodated is: 7 26th January 2007 Date of last inspection Brief Description of the Service: 167 Chandos Road is a seven-bedded residential unit. It is owned and will be operated by the Consensa Care organisation that also operates several other residential homes in the area. The home provides residential care to service users with acquired brain injury. The home opened in 2005 and currently has three service users in residence. There is easy access to the nearby Stratford Town Centre where bus routes, tube and the Docklands Light Railway can be accessed. There is unrestricted parking outside of the home. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection that took place on 19th January 2009. The manager was not present as they were on annual leave on the day of inspection. We were assisted by three staff, who are called Rehabilitation Associates. We spoke with two people living in the home, toured the premises, examined four service user files and records and documents related to health and safety and internal audit checks of the service. The homes’ AQAA, their annual quality assurance assessment was also taken into account. There were six people living in the home on the day of the inspection. What the service does well: What has improved since the last inspection? The home has met the majority of requirements from the last inspection where shortfalls had been identified. Individual care plans are now signed showing involvement in their care planning and plans regularly reviewed; monthly residents’ meetings take place where residents are encouraged to share their views on the service; identified repairs have been achieved; quality assurance surveys from residents are distributed to gauge their level of satisfaction in the service; three out of four health and safety requirements were achieved in respect of fire doors, fire alarm testing and fire evacuation drills. In response to how they have improved, the homes’ AQAA states: Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 6 “Consolidated the improvements that had been made in the previous 12 months, so as to make sure that they are embedded into the home and not a passing phase. Continual growth with regards to local PCTs and social services being aware of our service and its integral part in an individuals rehabilition following an acquired brain injury. Continued growth of knowledge of local services available for our specific client group.” 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. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 1-5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective individuals’ are provided with information about the service; their needs are assessed and they have the opportunity to visit the home prior to their admission. Individuals have signed contracts about the homes’ terms and conditions. EVIDENCE: The Statement of Purpose and Service Users Guide are both available in the home. The Statement of Purpose states that the aim of the service is to provide “residents with therapeutic and supportive accommodation within a framework that is enabling and empowering to the residents, encouraging selfresponsibility and nurturing a climate of informed choice.” The Statement of Purpose was updated in January this month. The Statement of Purpose and Service Users Guide need to be updated to include the current contact details for CSCI. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 9 Individual files examined evidenced that the home obtains relevant information from other professionals and carries out its own assessment as part of the referral process for potential service users. The home was able to evidence that it operates in a service that responds well to individual needs. Each file contains comprehensive accounts about the needs, wishes and support needed for each individual. We saw, for example, guidelines for how a support worker could conduct an individuals’ diary sessions in a way that is more effective to that person. We also saw use of a guide from an individuals’ family about approaches that work with their relative regarding effective management of their personal hygiene and their cigarettes. One person assessed as not having mental capacity had a record sheet in their file recording the periods of lucidity that they experience and the comments they made. People are able to visit the home to decide if they wish to be admitted. One person who was newly admitted last week had visited and slept over before they were admitted. Contracts were seen signed in personal files. The admissions book records who is funding the placement. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 6-9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual needs are addressed through well-developed care plans that are regularly reviewed. Risks to the safety and wellbeing of individuals are fully assessed. Individuals are consulted upon for their views about the service, though the outcome to their requests or suggestions could be better evidenced. EVIDENCE: We examined four personal files, each showing that individuals’ health, personal and social care needs were comprehensively addressed and their individual service provision identified. Three out of four of the care plans were signed and dated by the residents concerned, evidencing their involvement in the planning process. Care plans were reviewed and updated at least every six Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 11 months and the review process had been standardised as required at the last inspection. Risk assessments were available for each person in their files, addressing a range of activities identified in the individual plan. These stated the likelihood and severity of risk and controls in place. Individuals’ in the home have the opportunity to formally express their views about life in the home through monthly meetings and monthly key working sessions. A staff member records the agenda and takes the minutes. Minutes seen showed that individuals discussed their likes and dislikes in the home, menu planning and requests for social and leisure activities. Individuals had been consulted about their rooms and they were noted to be happy with them. However these minutes showed that occasionally requests were made by individuals and the outcome was not always clear and not clear whether their requests were achieved. One person informed us that the majority of residents had asked for Sky TV and they were told this would be looked into but they had heard nothing. It is recommended that residents’ comments are addressed through matters arising as a regular agenda item. Currently no one is entirely managing their own finances, however, management of personal spending money is identified as part of individual plans and key-working sessions and individuals are supported to be as independent as possible, for example, being given money to spend on items of their choice in local shops and to check their change, with support of staff. Residents have key-working sessions. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 11-17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to maintain or develop their independent living skills with support to achieve individually identified goals. The service supports people to engage in local and community activities of their choice. EVIDENCE: Individual files contained structured daytime activity programmes including activities that helped to maintain and develop their independent living skills and to help people grow in confidence. Residents undertake household chores and are involved in planning and preparing meals. Individuals continue to receive regular sessions from staff aimed at developing and maintaining cognitive skills that is in line with the goals identified in their individual plans. Staff also support people to access work, educational or social activities within the local community. Activities currently pursued by individuals in the home Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 13 include college courses for English and Maths, a horticultural project, a support group and a day centre. Individuals also attend the library, go swimming, attend the hairdressers and eat out once a month in a café or restaurant. Individuals are supported with their travel arrangements and risk assessments are in place. All individuals have a Freedom Pass. Records seen in individual daily records showed that individuals maintained significant contacts with family and friends. Most of the residents are independent with their personal care with some prompting and have responsibility for maintaining their rooms and their laundry with prompting or with staff supervision. Individuals are supported to do shopping wherever they can, subject to their individual plans. Meal preparation is also identified in individual plans and some residents prepare their own meals with some supervision. Individuals’ dietary needs and meal preferences are identified. We were informed that two individuals expressed that they did not eat pork for cultural reasons. The menu planning folder was seen and showed that meals were varied, balanced and nutritious. Exceptions to the main menu are noted for individuals eating alternative meals. All individuals have a daily food intake chart. . Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 18-20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical, mental and emotional health needs are identified and supported by the home. The service maintains close involvement with health care professionals to ensure that individual health needs are met. The need to ensure accurate recording of medicines on individual medication administration records must be effectively addressed. EVIDENCE: Records seen in files demonstrated that individuals are regularly consulted for their preferences in how they wish to receive their personal support. Each file seen contained details of contact with health professionals, the date of appointment and outcome for each healthcare appointment attended. Appointments attended included routine GP and practise nurse appointments and hospital outpatient appointments with a range of consultants for individuals’ specialist needs. Healthcare assessments, reports and Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 15 correspondence were available in all files examined, as was evidence of contact and involvement of a range of healthcare professionals in review meetings. We were informed that currently no residents are self-medicating. The Inspector sampled the homes medication policy. This includes guidance on the administration, storage and disposal of medication and the use of “as required (PRN)” medication. The policy addresses self-medication and identifies the need for this to occur within a risk assessment framework. We noted that PRN medication for one individual of Senna and Paracetamol had been recorded on the Medication Administration Record (MAR) chart. Prescribed Cream and powder, including where to apply these had also been recorded on the MAR chart. The receipt and quantity recorded of medicines were appropriate signed on the MAR chart. Medicines returned to the pharmacist were recorded and kept separately. However the symbol O was recorded in the MAR chart, indicating Other, but the reason for not administering the medication to the individual was not recorded on the MAR chart or elsewhere. The reason for not administering prescribed medication to individuals must be clearly documented. Leave medication was clearly recorded when individuals were absent from the home. There were no medicines kept in the fridge at the time of inspection. We were advised however by a support worker of a problem with the pharmacist of the home who has frequently incorrectly dispensed medicine into the blister packs, sometimes giving too little or too much medication and that the MAR chart for one individual gave the wrong instruction of their medicine being needed in the morning rather than at noon. The support worker informed that the matter was regularly brought to the attention of the pharmacist and the manager later informed that an alternative pharmacist is being sought. Effective action must be taken as regards the pharmacist used by the home to ensure that MAR charts accurately reflect the medicines and medication administration regime prescribed to individuals. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 22-23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals know how to complain, are generally well satisfied and incidents affecting individuals are generally well responded to. However, whilst the home has a complaints policy, the home needs to demonstrate that the service responds effectively to any individual complaints. Whilst the home has an adult protection policy, the home must ensure that it is fully implemented and promptly reports all adult protection concerns to CSCI and the local adult protection team. EVIDENCE: The service has a complaints policy that outlines the procedure for dealing with complaints, including the timescales the home aims to adhere to when responding to complaints. The home has developed a complaints log in which to record complaints, but had none recorded at the time of inspection. We saw that dissatisfaction expressed by residents ad been recorded in incident sheets. This was subsequently discussed with the manager as feedback following the inspection and the service has been advised to ensure that any individual complaints, however they come to the attention of staff and whether formal or informal are recorded in the complaints folder. The service must be able to demonstrate that individuals are listened to, that the home responds to and takes effective action to complaints made by individuals. The home must be Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 17 able to evidence this through the documentation of any complaints, the actions taken and the outcome to the complaint. Two residents complained to us about the racially offensive language used by another resident. The manager later informed that this individual lacked insight into their behaviour and evidenced the behaviour management plan that was in place for the individual. It is recommended that all service user complaints are documented, including the actions taken and the outcome of the complaint. Staff interviewed informed that staff had received adult protection refresher training. We noted that incidents that are reportable to CSCI and the local adult protection team were not being recorded. These were incidents that had been documented in the homes’ incident sheets that included risks to the safety and wellbeing of residents, often triggered by the behaviour of other residents. We informed the manager about the importance of reporting these incidents after the inspection. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 24-30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is suitable to the needs of residents who benefit from a comfortable, homely environment that is well maintained. EVIDENCE: The home is double fronted, extended Victorian terraced property. We were informed that the home has been refurbished. On the ground floor there is a large entrance hall, two lounges furnished with sofas, armchairs, coffee table, TV and stereo. There is a large kitchen with patio doors to the garden and a separate dining area that also has garden access. A small room off the dining area houses the freezer. There is a utility room that incorporates a toilet. Two bedrooms are also housed on the ground floor, both of which have ensuite bathrooms. The ground floor itself is wheelchair accessible, with a ramp available for the front step. The only exception is that access to the dining Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 19 area would be limited unless assisted, as there is a large step down into the dining area. The two lounges however are wheelchair accessible as are the two downstairs bedrooms and service user bathroom. There is a large well-maintained garden at the rear of the building. There are a further five bedrooms and a small staff office. All the bedrooms and en suites and furnished with a bed, wardrobe and chest of draws. The home was seen to be clean, hygienic and generally well- maintained with regular maintenance work carried out. One observation was made, that each person had their weekly programme on display in one of the lounges. This was discussed with staff in terms of confidentiality and the institutional appearance created by having these programmes on display in the lounge. We recommended that these programmes were removed to individual rooms or the office and to put up instead a picture or more appropriate homely adornment on the lounge wall. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 31-36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are sufficient in numbers according to the needs of people in the home. Staff are sensitive to the support needs of individuals and are aware of their roles and responsibilities. Staff are skilled, adequately trained and supported to carry out their duties. EVIDENCE: Staff displayed good knowledge and sensitivity to the needs of people living in the home, showing respect to individuals in their interactions with them. We were unable to view staff personnel files which were locked on the day of inspection as staff on duty did not have the authorisation to access these files. However we spoke with three support workers who confirmed that they had each completed an application form, supplied two references, had their CRB and POVA checks and followed an interview process. Each confirmed that they Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 21 had received a job description and a staff handbook that outlined the homes’ main policies and procedures. Each said they had received an induction. Staff informed that most of the support workers had either completed or were in the process of completing their NVQ Level 2 qualification. We examined the staff training folder. Certificates were available for first aid, health and safety, food handling/hygiene, medication, infection control, moving and handling, NVQ courses and staff induction. The organisations’ training and business plan was also seen in this folder. Also seen in the training folder was a certificate of staff attendance to a one day course in Breakaway techniques for the control of violent situations; care planning and risk assessment training and brain injury awareness. A timetable for an induction programme was available for newly recruited staff. It is recommended that staff also have an annual appraisal as staff informed they had not received this. We examined the rota which accurately reflected staff on duty on the day. There were two support workers on duty during the day at all times, which was considered to be sufficient given the present needs of people in the home. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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): 37-43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is good management in the home and good systems and procedures in place to ensure the effective running of the service. The manager is supportive towards staff. Health and safety procedures are generally well observed however a requirement is restated to ensure the fridge maintains its temperatures within safe limits. EVIDENCE: We were unable to speak to the manager on the day of inspection. Staff we spoke with however informed that the manager was supportive to them and someone they could easily approach. The manager has a Registered Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 23 Managers’ Award and NVQ4 Management and long term experience of working in social care. Records evidenced that the manager has good systems and procedures in place to ensure the effective running of the service. A requirement to implement the homes’ quality assurance surveys has been achieved. Residents were given surveys to gauge their views on the service including their support from staff and these were given to the manager. The last surveys were distributed before Christmas. The quality assurance folder was examined. These contained a timetable for 2009 to audit the quality of various documents such as care plans, medication, risk assessments and daily records. The folder also contained care plan audits by the manager completed a week before this inspection and records checking the quality of records made by staff, adding notes for actions needed. Five residents’ surveys were completed in October 2008. Generally positive comments were received, indicating that residents feel their privacy is respected, safe and secure. Four out of five individuals stated that they considered the staff team to be caring, supportive and helpful, one stated that some staff were. Monthly senior management reports were seen, however the last report was dated 29th December 2008. Monthly reports were not available in the file examined. Senior management monitoring (PIC) visits must take place monthly and written reports must be prepared and available for inspection after each visit. The policies and procedures folder seen contained a comprehensive list of policies and procedures that are relevant to the home. There was a record in the folder stating that they had been reviewed in April and March 2008. Records in the home are generally well maintained and of good quality. Daily records in individual files gave detailed observations about the state of wellbeing of each individual, their behaviour and descriptive accounts of their daily activities. One record, for example, noted an individuals’ mood, what they were also doing whilst watching TV and a full description of the tasks and activities the individual had undertaken in the house throughout the day. Health and safety practices are, on the whole, well observed. There are smoke detectors in all of the rooms. Fire doors now have an automatic locking facility. The emergency lighting and fire alarm was being checked on the day of inspection. Fire drills are taking place. COSSH safety data sheets are kept. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 24 Valid Health and safety certificates were available for gas and electricity. The home’s AQAA recorded that water safety had also been checked. Portable appliances had been tested. Health and safety risk assessments and policies were in place. A valid insurance liability certificate was on display. One action that remains outstanding from the last inspection is the temperature of the fridge. Records showed that the temperature of the fridge at times reaches 10 degrees, exceed the safe temperature limit of 8 degrees. freezer temperatures. A certificate from the Newham Food safety unit dated 22nd January 2008 stated that more efficient refrigeration was required or as an alternative to replace fridge. This restated requirement must be now be met. Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 3 2 3 3 3 4 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 3 3 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 YA20 Regulation 13 & 17. Requirement In the event of an individual not being administered their prescribed medication the home must ensure that the reason for this is clearly documented. Timescale for action 18/03/09 2. YA23 13 & 21. Effective action must be taken as regards the pharmacist used by the home to ensure that MAR charts accurately reflect the medicines and medication administration regime as prescribed to individuals. The home must report all adult 25/02/09 protection allegations to the local adult protection officer and the Commission for Social Care Inspection promptly. This is a restated requirement. 3. YA42 12, 16 & 23 The home must ensure that fridge and freezer temperatures do not fall outside of agreed parameters. 25/02/09 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.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 YA1 Good Practice Recommendations The Statement of Purpose and Service Users Guide need to be updated to include the current contact details for CSCI. It is recommended that residents’ comments are addressed through matters arising as a regular agenda item. It is recommended that all service user complaints are documented, the actions taken and the outcome of the complaint. We recommended that these programmes were removed to individual rooms or the office and to put up instead a picture or more appropriate homely adornment on the lounge wall. Senior management monitoring (PIC) visits must take place monthly and written reports must be prepared and available for inspection after each visit. 2. 3. 4. YA8 YA22 YA24 5. YA39 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Chandos Road, 167 (Consensa Care Ltd) DS0000062699.V373674.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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