Care Home: Cloudesley Road (92)

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What the care home does well Generally there is a relaxed atmosphere and good interaction between staff and people using the service. This is also the finding of the expert by experience person who also found that people who use services were very helpful in assisting staff to put away the grocery shopping. The expert by experience also found that residents are consulted on the weekly menus and that a choice of meals seemed well balance and that special diets are catered for.Most residents are supported to keep in touch with family members and friends. Most residents are involved in spiritual, creative and leisure activities and regularly attend day centre services and their individual faith centres. This ensures that individual`s cultural and religious needs are appropriately addressed by the home. What has improved since the last inspection? CARE HOME ADULTS 18-65 Cloudesley Road (92) 92 Cloudesley Road Islington London N1 0EB Lead Inspector Pearlet Storrod Key Unannounced Inspection 24th – 26th September 2008 10:00 Cloudesley Road (92) DS0000020971.V372042.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 Cloudesley Road (92) DS0000020971.V372042.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. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloudesley Road (92) Address 92 Cloudesley Road Islington London N1 0EB 020 7833 2326 020 7833 2326 josephkissoon@gmail.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) Psychiatric Rehabilitation Association Mr Joseph Kissoon Care Home 7 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (0), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (0) Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Home for adults (male and female) with needs relating to mental disorder including old age, and including one adult with learning disabilities. 27th July 2006 Date of last inspection Brief Description of the Service: Cloudesley Road is a registered residential care home for 7 people with mental health problems. The home is a four storey building located in a quiet residential area of Islington within close proximity to local shops, transport and other amenities. Psychiatric Rehabilitation Association is responsible for management of the care and support provision. The aim of the service is to encourage and support service users individually with their development in social and life skills. Family Mosaic owns the premises and as such, is responsible for maintenance of the property. Each service user has a licence to occupy the home. The cost of a placement at Cloudesley Road is approximately £578.37 per week. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection took ten hours to complete. An independent inspector to conduct this inspection accompanied me and they were able to speak with people using this service as a group as well as individuals. Information from their findings is outlined in the report and below in the summary. Information from the (AQAA) Annual Quality Assurance Assessment was used in the process. All key standards were inspected. We toured the building and I examined records and files for staff and for people who use the service and scrutinised the policies and procedures we were able to observe the operational practices within the home. Two surveys were returned from people who use services both of which in many respects commented favourably about the service. One person did say, “Some people make a mess”. We would like to thank all of those who participated in the inspection process. What the service does well: Generally there is a relaxed atmosphere and good interaction between staff and people using the service. This is also the finding of the expert by experience person who also found that people who use services were very helpful in assisting staff to put away the grocery shopping. The expert by experience also found that residents are consulted on the weekly menus and that a choice of meals seemed well balance and that special diets are catered for. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 6 Most residents are supported to keep in touch with family members and friends. Most residents are involved in spiritual, creative and leisure activities and regularly attend day centre services and their individual faith centres. This ensures that individual’s cultural and religious needs are appropriately addressed by the home. What has improved since the last inspection? What they could do better: The service could address the outstanding recommendations as well as respond to an individual about his continuous complaints about the noise situation, which prevents some others from using the non-smoking communal lounge on occasions. They also need to write a risk management plan for people transporting hot liquids through the door on the ground floor in order to access the stairs and lounge areas. In addition they need to provide an activities plan and more structured support to another individual newly moved in to live at the home, which should be used with a consistent and supportive approach and measured at various intervals to check on the progress being made. There are other actions outlined in the report that the manager has given and undertaking to address. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 7 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. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 8 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 Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service users guide needs further review in respect to clear aims and objective and complaints process. Prospective people who use services have their individual aspirations and needs fully assessed. EVIDENCE: The aims and objectives outlined in the statement of purpose and service users guide needs to be more clearly defined and the complaints process needs to be updated with the changes that have occurred since the document was drawn up as discussed at this inspection. The service has a clear referral and assessment process. Evidence suggests that people who use the service can be assured that they will be assessed to ensure that their needs can be met and their aspirations ensured. Three files were examined including the file of a person newly admitted to the home. Pre admission assessments were undertaken comprehensively, which included visits to the home. Over night stays are offered to referrals that demonstrate an interest to live at the home; this would give the existing people using the service to meet and gel with the prospective resident. A key worker is allocated with responsibility to learn as much as they are able about the individual. This may involve visiting and speaking to previous carers. All Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 10 the information gathered from the various sources is used to generate a care plan and a risk assessment. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 11 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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place, which ensures that people who use services are afforded opportunities to make decisions and choices about their needs. Risk assessments are appropriately in place. EVIDENCE: The individual needs and personal goals of people who use services are outlined in their respective files and there is evidence to demonstrate that progress and achievements are measured. Care plans are detailed and they demonstrate the needs and support according to individual need and requirements. There is evidence that individuals living at this home are supported and encouraged to make decisions with assistance where this is deemed to be necessary. There was evidence that some individuals required more appropriate practical support with development in their individual lifestyle skills. We observed, used cups and other crockery left in the garden, the smoking and non-smoking lounges, to an extent that an individual did not have a clean cup available for Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 12 use at the time when they needed one. People who use services said that they had reported this to the manager previously; the individual must have an activities programme drawn up and support to this individual should be continuous with a consistent approach by staff. Individual risk assessments are available though we had discussed with the manager the need for these to be more robust for some individuals. For example, one of the people using the service uses a walking stick and they tend to carry hot drinks such as tea/ coffee upstairs to their room. It is noted that the carpet is badly stained on the ground floor between the hall and area leading to the staircase demonstrating spillages of one kind or another. It was suggested that this situation is included in the individual’s risk management plan. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 13 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. People who use services are supported to maintain as much independence in their lives as is possible. Efforts are made to ensure that the meals provided are enjoyed by the people who use services. EVIDENCE: People who use services are supported as appropriate to enjoy an assortment of activities providing the resources are available to meet such identified needs. For example, an individual mentions at each inspection visit about his desire to play table tennis. The matter was discussed with the independent inspector and the manager has given an undertaking to assist the individual to fulfil this achievement. There is supporting evidence that some individuals would benefit from more structured activity plans. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 14 At this visit I was accompanied by an expert by experience person to assess the quality of services provided to people living at this home and to give their independent view from their experiences gained throughout this inspection visit. They made the following comments. Discussion with staff and evidence seen indicated that individuals go on holidays to different places of their choice. Some of the people who use the service went on a holiday trip to Folkestone during the summer and commented on their enjoyment, stating that they are, “looking forward to the next holiday”. The manager asserted that a holiday did not occur last year because of a lack of staff resources. Some residents said they would welcome more leisure activities, especially at weekends when day centres are closed. It was suggested that the manager explore residents’ ideas further during house meetings and to implement these. “Most residents are very much involved in spiritual, creative and leisure activities and regularly attend day centre services and their individual faith centres”. One person receives pastoral care from her church and another regularly attends church. Family members are encouraged to maintain relationships with their relatives as appropriate and this is borne out by the comments of the expert by experience inspector who said, “most residents keep in touch with family members and friends. Though the manager would like to have more involvement by residents’ family and friends the rights and wishes of residents have to be respected”. People using the service are also encouraged to develop new relationships though it should be said that there is some uneasiness amongst some of the people living at this home; the newest person exhibits challenging behaviour, which is causing some uneasiness for some people who uses the service. Evidently, a structured approach is needed to appropriately support this individual and the manger confirmed that some progress has been made and much encouragement is needed to support this individual and others to take more responsibility for themselves and the home. There was conflict in the use of the non-smoking lounge by two individuals. One person wanted to watch their programme and hung on to the remote control. The behavioural traits of this individual, who habitually make noises, make it difficult for some other people to enjoy using the communal lounge. Some people commented that because of this, they would remain isolated in their rooms as opposed to use the communal lounge. The independent inspector noted that the person reported to hug the television seemed to increase their intelligible chatter if another person entered the communal lounge; the noise would cease when the person or persons that entered left the room. We discussed this with the manager who said that the individual had been left some money that the individual intend to spend on him or herself. This might be an opportunity for the individual to purchase a small Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 15 television with dvd compartment for their room, which may alleviate the problem. This would not necessarily mean that the person would stay in their own room in an isolated way, as they may wish to sit in the communal lounge with the other people who live at the house. The manager must explore ways in which to address this situation. Meal arrangements are satisfactory. The findings of the independent inspector is that, “residents are consulted on weekly menus; the choice of meals seems well balanced and special diets are catered for”. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 16 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. Personal and healthcare supports for people who use services are met. EVIDENCE: Assistance with personal care, where necessary, is carried out in a sensitive and respectful manner. The physical and emotional health needs of people who use this service are generally met and there is evidence of regular multi disciplinary input. Overall, the system in place in respect to medication management is satisfactory. The process for the administration of medication is good with clear and comprehensive arrangements in place to ensure that the medication needs of people who use the service are met. Some individuals are encouraged by staff to self medicate as appropriate and one person had commenced the process of self-medication and assumes minimal support from staff in respect to managing, checking and re-ordering his medication. This individual discussed the fact that the inadvertently took a second dose of tablets and the action he took to deal with this. Though he did not discuss the Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 17 matter with staff in the home the action he described that he took when he realized his mistake, was appropriate. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 18 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. People who use services are encouraged to raise concerns and complaints. People who use the service are protected by the home’s policy and procedures. EVIDENCE: The service welcomes complaints, compliments and suggestions in various ways. People who use this service have opportunities to raise concerns or complaints at key working sessions, weekly house meetings and monthly monitoring visits. According to the complaints register seven complaints were received since the last inspection and these appear to be managed well. There is an issue though that an individual voiced a concern that he does not feel that his complaints are listened to. For example, this individual commented in his survey, “sometimes people make a mess”. The manager is fully aware of the nature of this concern and believes that the matter is being addressed but that it is an on-going problem that they are trying to deal with gradually and sensitively. As discussed, the manager needs to provide a written response to the complainant so that the individual does not feel that they are not being listened to, this would show the individual that their concerns are taken seriously though the matter is on going as there is no immediate solution, but working towards addressing the problem. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 19 The majority of the staff at this home has attended adult protection training. This is also covered as part of the induction training for the home. A whistle blowing policy is also available. Staff appear to have awareness of the actions to be taken in the event that an allegation is made. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 20 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, 26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Cleaning is needed in some areas of the home including the rooms of some individuals to make it more attractive, comfortable and safer. EVIDENCE: We toured the building and looked in the rooms of three people who use services with their expressed permission. We observed that decoration was needed to these rooms and more importantly, one room particularly stood out as it was sparsely furnished in that it had no chair to sit on, no table lamp, no headboard and the room was generally in a poor state of cleanliness. With regard to one other room, the individual who uses this room appeared to make their bed and picked up rubbish from around the area of the rubbish bin and commented that they would vacuum their room later. The bed linen in use needed to be changed but instead they were reused to make the bed. The other room observed was in good order. The doors to the rooms upstairs that were seen have approximately one and a half inch gaps between the doors and floor; daylight shone from beneath these doors during this visit. These are potentially hazardous situations if a fire was to occur as the half hour Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 21 protection that the doors would generally offer until the fire brigade arrived would not be of any use. Fire and smoke would seep beneath them. It is of utmost importance that these matters are addressed as of the people are known to smoke in their rooms and cigarette burns were observed on the floor, bedclothes and the bedside table of an individual. Further, two people affected have a disability also, which would make it more difficult for them to vacate the building in emergency situations. We discussed the possibility of the manager arranging a magnetic door closer to be fitted to the door on the ground floor between the hall and half landing leading upstairs. The carpet is in a poor condition and the manager asserted that the condition arose from the amount of spillages that occur from people carrying various hot and cold liquids upstairs. The magnetic closers would make it easier for people to generally transport things via the doors in question and at the same time, add protection if an emergency was to occur. The manager was proactive in dealing with this problem and an undertaking has been given to add a threshold on each door or to even out the floors in the rooms affected. I had the benefit of speaking with a surveyor contracted by the landlords who visited the home following this inspection. We further discussed the possibility of replacing all the window stops with more appropriate equipment and the manager gave an undertaking to do this; he commented further that they had already made some improvements in that area and this was evidenced. During the tour we observed a partly rusted radiator which some of its paint had peeled off. The manager said that he was unaware of the situation. This should have been spotted by the manager via a checklist when inspecting the premises and or reported by staff, to prevent the damage from worsening. In 1996 staff from Islington Environmental Health Department visited the home and produced a report with their findings and submitted a copy of the report to the Commission. The requirements and recommendations were inspected at this visit and we are please to state that these matters have been addressed. The kitchen and lounge areas were in good order. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 22 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent staff team supports people who use the service. EVIDENCE: The staffing complement is satisfactory. The majority of the staff have achieve NVQ level 2 in care management. Arrangement has been made for one of two newly appointed care workers to attend mandatory training in food hygiene, health and safety, medication management and POVA. Training for the other care worker was pending. The recruitment protocol has been under review since 2006 and this now needs to be addressed. I spoke with two care workers and the domestic staff who works part time that I met at the other registered service. The three workers expressed general satisfaction with the services provided at the home. The domestic staff confirmed that they did not receive supervision at this service or the registered service. A job description must be drawn up for the domestic staff and support/supervision introduced so that the manager is informed of pertinent Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 23 issues like the rusty radiator in the bathroom as mentioned earlier for example. Supervision, training and staff appraisals observed during the inspection are presently sound. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 24 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. People who use services are involved in the running of the home. Monthly monitoring visits occur. EVIDENCE: The home is generally managed well though more input is required to manage the use of the non-smoking communal lounge. A newly appointed care co-ordinator is in post and the monthly monitoring report was sent to us on 30 September 2008. The Provider explained during the inspection process that the commissioning authority has tendered the contract for services at the project according to European Union Regulations and that the outcome will be announced in the New Year. The provider must notify the Commission in writing about any changes in respect to registration of their services. Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 25 A number of policies and procedures were observed and as the previous report outlined, a majority of the documents are old and needs review. An example was given of the complaints procedure and adult protection policy; also to be included is the recruitment policy and statement of purpose /service users guide. The manager has developed a development plan. This should be enhanced and signed off by senior management. The health and safety issues raised by environmental health in 2006 have been appropriately addressed and I understand that copies of the reports demonstrating the progress and outcome have been issued to the relevant Environmental Health Officer. The views of people who use the service are sought in a variety of ways including house meetings, monthly monitoring visits and key work meetings. In areas where individuals raise concerns, like the on-going noise situation and crockery left scattered in various places, these issues need to be more appropriately and continuously addressed so that those raising such concerns do not continue to feel that are not being listened to as discussed earlier. Cloudesley Road (92) DS0000020971.V372042.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 2 2 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 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 3 3 2 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 3 X 3 x Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4 and 5 Requirement The Registered Person must ensure that the Statement of Purpose and Service Users Guide are reviewed. The Registered Person must ensure that a structured programme of activities is drawn up for the latest arrival to the home and that they are offered some practical support to if deemed necessary to develop their life skills The registered Person must review the risk management plan of an individual to take account of the mobility situation when transporting hot liquids through door entrances. A risk management plan must also be drawn up to take account of the doors, which does not provide half hour protection in event of a fire or other DS0000020971.V372042.R01.S.doc Timescale for action 30/11/08 2 YA8 16 (2) (n) 30/11/08 3 YA9 13 (4) 30/11/08 Cloudesley Road (92) Version 5.2 Page 28 emergency situation. 4 YA16 12(3) The Registered Person 30/11/08 must ensure that the wishes and feelings of people who use services are undertaken in respect to the use of the non smoking communal rooms in respect to the used crockery and cups left inside and outside the premises The Registered Person 30/09/08 must ensure that adequate furniture and furnishings, clean bed linen, head boards, appropriate chair, table lamps, lamp shade are provided in the room of an individual and that the rooms used by individuals are appropriately decorated. They must also ensure that appropriation is taken to address the doors to the rooms of some individuals as discussed in this report. 5. YA24 16 (2) (d) 23(2)(d) 23(4) (c )iii 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 YA22 Good Practice Recommendations The complaint regarding the noise and mess must be kept under review. (see standard 22) DS0000020971.V372042.R01.S.doc Version 5.2 Page 29 Cloudesley Road (92) 2 3 YA39 YA40 YA41 The development plan drawn up by the manager must be signed by senior management so that they take ownership The Registered Person must ensure that all of the records and policies and procedures including complaints for this home are reviewed regularly and updated as necessary. The updated policies and procedures must be signed and dated by the Responsible Individual Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 30 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 Cloudesley Road (92) DS0000020971.V372042.R01.S.doc Version 5.2 Page 31 - 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. 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