Care Home: De Lucy Street (5)

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What the care home does well Making sure that residents live in a comfortable, homely environment and are supported to add personal touches to their bedrooms to make them as homely as possible. Involving residents in decisions about how they spend their time. Supporting them to take risks in order to maintain as much independence as possible. Helping residents to attend day centres and take part in other planned activities, both within and outside the home. Ensuring care plans offer guidance to staff members so they can meet residents` needs. Allocating each resident a key worker, which helps to ensure continuity of care. Making sure residents have access to health and social care professionals as required. Offering staff members training opportunities that are relevant to their work in the home. What has improved since the last inspection? The home has addressed the requirements and recommendations we made at our previous inspection. These matters included installing a wash hand-basin in the kitchen, carrying out a survey of the views of residents and their relatives, and updating risk assessments. The manager has applied to us for registration. Personal and communal areas in the home have been redecorated and refurbished. What the care home could do better: Improve some of the ways in which they manage medication for residents. Address three specific aspects relating to health and safety. Strengthen the evidence of their review of staffing provision following the reduction in direct payment worker hours. Produce a summary of the findings of their survey of residents and relatives. Consider offering all residents a lockable space in their bedrooms. CARE HOME ADULTS 18-65 De Lucy Street (5) 5 De Lucy Street Abbeywood London SE2 9ER Lead Inspector David Lacey Unannounced Inspection 24th February 2009 10:00 De Lucy Street (5) DS0000036880.V373768.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 De Lucy Street (5) DS0000036880.V373768.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. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service De Lucy Street (5) Address 5 De Lucy Street Abbeywood London SE2 9ER 020 8311 1571 F/P 020 8311 1571 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) Greenwich Council Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places De Lucy Street (5) DS0000036880.V373768.R01.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 (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 9th March 2007 Date of last inspection Brief Description of the Service: The home is situated in a residential area, within easy reach of local amenities and public transport facilities. It is a two-storey, purpose built end of terrace property, which first opened in November 1988. It has two single bedrooms on the ground floor, two single bedrooms on the upper floor, two bathrooms with WC’s, a lounge, kitchen/diner and a laundry room. The house has a garden to the rear and off-street parking for two vehicles. The property is owned by London and Quadrant Housing Association and managed by Greenwich Social Services under the Greenwich Living Options Scheme. The home accommodates up to four adults on long-term placements. Please contact the provider for information about the fees for this care home. There had not been changes in the ownership, management or service registration details for De Lucy Street in the 12 months before our inspection in February 2009. De Lucy Street (5) DS0000036880.V373768.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 two stars, which means that people using the service receive a good service. The site visit for this key inspection was completed over a period of five hours. The provider was told of the inspection the day before the visit. All four residents were attending their day centre placements on the day of the inspection. The home’s manager facilitated the visit, and two members of staff were spoken with. The site visit included a tour of the premises and sampling of documentation such as care plans and records of care provided, staff recruitment files, and policies and procedures. The inspection included a review of information received about this service. Since our last key inspection, we carried out an annual service review of the home and used findings from that review in planning this key inspection. At our request, the care home provided us with its annual quality assurance assessment (AQAA), which also informed the inspection. This self-assessment document focuses on how outcomes are being met for residents and also gives us some numerical information. What the service does well: Making sure that residents live in a comfortable, homely environment and are supported to add personal touches to their bedrooms to make them as homely as possible. Involving residents in decisions about how they spend their time. Supporting them to take risks in order to maintain as much independence as possible. Helping residents to attend day centres and take part in other planned activities, both within and outside the home. Ensuring care plans offer guidance to staff members so they can meet residents’ needs. Allocating each resident a key worker, which helps to ensure continuity of care. Making sure residents have access to health and social care professionals as required. Offering staff members training opportunities that are relevant to their work in the home. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. De Lucy Street (5) DS0000036880.V373768.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 De Lucy Street (5) DS0000036880.V373768.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate admission procedures are in place to comply with this standard. EVIDENCE: The manager and her staff team are aware of the requirements should any new residents be admitted to the home, and there are appropriate admission procedures. However, the four residents have been living at the home since it opened so, to date, there have not been any admissions or discharges. Therefore, the admission procedures have not yet been implemented. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 9 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents may be confident their assessed and changing needs are reflected in their care plans. Residents are involved with decisions made about their lives and lifestyle, and are supported to maintain their independence. The key-worker system benefits residents. EVIDENCE: The care documentation for three of the four residents was examined. The individual care plans seen were comprehensive, identifying residents’ needs and the actions required to meet them. Residents and their representatives had been involved in drawing up and reviewing the plans. Care plans had been reviewed regularly, with outcomes clearly stated and agreed. Individual risk assessments were included and it was evident our previous requirement to keep these updated had been met. Our previous recommendation that care records are retained in care files had been met. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 10 Each resident is allocated a key worker from within the staff team. A support worker outlined her role as key worker for one of the residents. As part of her role, she liaises with relatives and visiting professionals, and keeps care records updated. She supports her allocated resident to carry out activities and follow interests. On the day of inspection, she had attended a review at the resident’s day centre before returning to the home to report the outcome to the manager and enter this into the care records to keep her colleagues informed. Care documentation showed that key workers compile monthly summaries of residents’ progress. It was evident residents are supported to take risks in order to maintain as much independence as possible. Any restrictions placed on residents are few and are for their safety and welfare, such as not leaving the home unaccompanied. The manager confirmed staff members have been helped by a speech and language therapist in how to assist residents with their communication difficulties. This has benefited residents, for example, staff are able to involve them more in the running of the home. Residents are helped to make choices about how they spend their time and about what they eat by showing pictures and by direct reference to specific items. All the residents have lived in the home for many years and knowledge built up about their individual preferences are recorded in their care documentation. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 11 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, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promotes residents’ independence, while at the same time ensuring risks to their safety are identified and minimised. Their leisure and social needs are met. Residents are encouraged and supported to maintain links with their families and friends. Residents are provided with a varied nutritional diet, planned to meet their choices and preferences. EVIDENCE: All four residents attend day centres for part of the week and staff members within the home support residents to develop daily living skills, in line with their individual capacities. One resident has a direct payment worker provided on other days, offering increased opportunity to develop life skills. It was understood that there has been an overall reduction in the level of direct payment worker support to residents at De Lucy Street since our last inspection, and further comment about this is made below under standard 33. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 12 It was evident from discussions and from examination of records that residents are supported to access leisure activities of their choice and to integrate with the community. Staff members accompany residents on shopping trips to, for example, choose their own clothes and hairstyles. Residents are also supported to choose their own decoration and personal items for their own rooms. Residents are encouraged to maintain contact with their families, where this is their choice. There was evidence of the home’s regular, written communication with the relatives of two of the residents whose care was tracked. Where residents do not have family contact, the home tries to arrange independent advocacy for them. Recently an advocate had been supporting one of the residents in relation to changes proposed to his bedroom. The home also provides information about local independent advocacy services. Residents are given a varied and nutritious diet and, as far as possible, menus are planned to meet their preferences. It is intended that meals are relaxed and enjoyable, taken in the company of staff members. None of the residents need a special or culturally appropriate diet but some require help with cutting up their food and assistance from staff to enable them to eat safely. The manager was well aware of the needs of people with the pica condition and the relevant risk assessments that are required. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 13 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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have ready access to health care services as they need, and their personal, physical and emotional needs are being met. The administration of medicines is generally satisfactory but specific aspects need improvement. EVIDENCE: All four residents have severe communication difficulties but it was evident that, as far as practicable, personal support is provided and their needs are met in ways they prefer. Health care services are made available to residents either in the home or by attending local clinics and surgeries. Each resident is registered with a local GP service. It was evident that staff members support residents to attend various healthcare appointments. The home’s management of medication was satisfactory in many respects but some areas needed improvement. Medication is stored in a lockable cabinet that is bolted to a solid wall. Each resident’s medicines are now kept within a De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 14 separate box within the cabinet. Medicines were being stored tidily as we had previously recommended but there was an external medication stored next to an internal one. These were re-sited by the manager when brought to her attention (see requirements). Each resident has a list of homely remedies, which had been agreed with and signed by the visiting GP. There were some examples seen on medicine administration records (MAR) where medications had not been signed as given. The manager stated these were medications to be given as required, in which case the prescriptions needed review to ensure accuracy. One resident was being prescribed six creams, some as required but one three times a day. The manager stated this could not be given as prescribed as the resident attends a day centre and the cream can only be applied when the resident has a bath. This was another prescription that needed review to ensure the resident receives the treatment intended (see requirements). Handwritten amendments were seen on two MAR, including a full prescription and an amendment to a prescription. As well as a lack of signatures to these changes, the actions appeared to contravene the provider’s medication policy that stated staff must not write on the MAR unless in an emergency situation to reduce the risk of error (see requirements). To maintain the improvements once they have been implemented, it is strongly recommended the “regular and random management checks” referred to in the provider’s medication policy are made evident (see recommendations). De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 15 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. The home has systems to make sure residents are protected from abuse. Staff are aware that residents must be protected from abuse, and have received safeguarding training in adult protection. Residents’ financial interests are safeguarded. Any concerns and complaints raised by residents or their representatives will be taken seriously, and appropriate procedures are in place to manage any complaints received. EVIDENCE: The commission has not received any complaints or concerns about this home since our previous inspection, and we are not aware of any safeguarding allegations regarding the people living at De Lucy Street. The home uses the provider’s policies and procedures to deal with complaints, though the manager confirmed that none had been received in the previous year. The home has the local authority (Greenwich) safeguarding policies and procedures. Staff members have received training in protecting adults and understand their responsibilities in relation to safeguarding the residents in the home. It was noted that a discussion about safeguarding was an agenda item at a recent staff team meeting. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 16 The manager showed the arrangements in place for the safe keeping of money on behalf of residents. Written records of all transactions are retained. Records of transactions and money held were sampled during the inspection with the help of the manager and found to be satisfactory. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment. The home is clean and tidy, and there is a programme for refurbishment, such as replacement of flooring, and for redecoration. The home is suitably equipped to meet the needs of its residents. EVIDENCE: Each of the residents’ bedrooms was inspected during a tour of the premises with the home’s manager. Three of the bedrooms had been recently decorated and the fourth was in the process of refurbishment. Bedrooms had been personalised by the individual occupant with help from relatives and staff, and were furnished to meet the needs of the individual occupant. Only one of the bedrooms had a lockable space and this should be offered to all the residents (see recommendations). It should be recorded if a person chooses not to have a lockable facility or if an assessment shows providing lockable space would not be in a person’s best interests. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 18 It was evident the home had met our previous requirements to install a wash hand basin in the kitchen, and to take action in respect of one resident, in relation to tripping hazards. For the latter, advice had been obtained from the local authority’s sensory team. With the approval of the other residents, primary colours had been used in some of the communal areas to aid the resident’s visual impairment and padded headwear had been provided for indoor use. The outdoor space is not very private, as it is bordered on one side by a public pavement and road. The space needed some attention to make it more attractive. The manager explained there are plans to improve the space and a recommendation is made to support this initiative (see recommendations). The home was clean and tidy on the day of the inspection, and cleaning materials were locked away and subject to COSHH procedures. The kitchen work surfaces were clean and tidy, and utensils and equipment were properly stored. Soap and towels were available in the bathrooms and toilets. The home has a laundry room, which has walls and floor that can be washed. The manager stated residents only occasionally use it and only under close supervision by staff. The washing machine had a sluicing facility, and the laundry equipment was working well on the day of inspection. The laundry room was very hot, partly because it does not have natural ventilation. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 19 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, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust, which helps to protect residents. Staff have training that is relevant to their work and are supervised regularly. Evidence of the review of staffing provision should be strengthened. EVIDENCE: It was evident from interviews with care workers, discussion with the manager, and scrutiny of relevant documentation that staff members are provided with appropriate training for their work with residents. All new staff complete induction training, both corporate induction and orientation to the home. Staff continue their training and development during their employment at the home, through NVQ programmes and completion of mandatory update training on issues such as fire safety and moving and handling. From discussions, staff members either had or were developing through training and support the necessary skills and experience to care for residents effectively. Staff rotas for two weeks during February 2009 were examined and confirmed the home is staffed throughout the 24-hour period. One full time support worker is male, which improves the gender balance of the staff team so it De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 20 matches more closely with that of the resident group. Staff said they are not required to work day shifts either side of a night duty shift, and the worked rotas seen confirmed this. As indicated under the Lifestyle standards above, there had been an overall reduction in the level of direct payment worker support to residents at De Lucy Street since our last inspection. Previously, this service was available for three residents who received 21 hours each, whereas at the time of the present inspection only one of the residents was receiving such support. It was understood a review of staffing provision had been undertaken by the provider in line with our previous requirement but written evidence for this review was not available (see recommendations). Three personnel files were examined and recruitment practice was found to be in accordance with the requirements. Robust recruitment and selection procedures are operated to benefit people using the service and help to ensure their protection. Staff files are held centrally by the provider but were delivered to the home for the purposes of our inspection. Records of staff supervision sessions were on file. The manager and staff member interviewed confirmed one-to-one supervision is carried out regularly. There are regular staff meetings, which staff members said they found helpful. Minutes of these meetings were available for inspection, and recent agenda items had included safeguarding and equality and diversity. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 21 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appointed a permanent manager, who has applied to the CSCI for registration. The home is managed well and in the best interests of its residents. The health, safety and welfare of residents, staff and visitors are promoted but there are specific items needing attention. The home has improved its quality assurance strategies and now should make the findings of its satisfaction surveys available. EVIDENCE: At the time of this inspection, the home’s acting manager was in the process of having her application for registration assessed by the CSCI. The manager is experienced in caring for people with learning disabilities and has an appropriate management qualification. Feedback to the inspector showed the De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 22 manager is approachable and supportive, and has a clear focus on the welfare of the people living in the home. At our last inspection, we had required the home to conduct annual surveys of the views of residents, their relatives or advocates and involved professionals. Residents meetings must be held on a regular basis. It was evident a survey had been carried out in January 2008. The manager explained the survey had not yet been repeated in 2009 as the provider’s management group was still reviewing the questionnaire format. A summary of survey findings is needed, so the results can be published and made available to residents, their representatives and other interested parties (see recommendations). The inspector sampled the home’s documentation relating to health and safety, and found most items to be up to date and within the appropriate timeframes. However, there were some matters needing attention and these were raised with the manager so she could begin to take the necessary action. The fiveyearly test of the home’s electrical installation had been due in 2008 but there was no evidence it had been completed (see requirements). The bath hoist had last been serviced in June 2008, with the next service due in December 2008. There was no evidence the December service had been completed (see requirements). The manager advised that some staff members had held first aid certificates that had been valid for three years. These certificates had expired recently and the staff members now needed to complete a full course again rather than being able to do only an update. This training was to be arranged shortly. The commission’s expectations with regard to the standard about first aid provision were discussed and the manager was referred to the specific guidance for providers that is available on our website. Either there needs to be a risk assessment in place to decide the home’s first aid needs or the home must have someone on duty at all times who has undertaken a suitably approved first aid at work qualification (see requirements). De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 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 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement The registered person must ensure that internal and external medications are stored separately. The registered person must ensure medications are always given as prescribed, and ensure prescriptions are reviewed as needed. The registered person must ensure two staff members sign any handwritten amendments on medicine charts, to reduce the potential for error. Staff must remain aware of the provider’s medication policy to only write on a medicine chart in an emergency situation. The registered person must ensure the five-yearly test of the home’s electrical installation is carried out by a competent person and relevant certification obtained. The registered person must ensure the bath hoist is inspected by a competent person at the appropriate intervals and relevant certification obtained. The registered person must DS0000036880.V373768.R01.S.doc Timescale for action 31/03/09 2 YA20 13 31/03/09 3 YA20 13 31/03/09 4 YA42 13 31/03/09 5 YA42 13 31/03/09 6 YA42 13 30/04/09 Page 25 De Lucy Street (5) Version 5.2 either complete a risk assessment to decide the home’s first aid needs or have someone on duty at all times who has undertaken a suitably approved first aid at work qualification. 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 3 4 5 Refer to Standard YA20 YA24 YA26 YA33 YA39 Good Practice Recommendations The registered person should ensure regular, recorded medication audits are carried out. The registered person should consider how to improve the quality of the outdoor space available for residents. The registered person should consider offering all residents a lockable space in their bedrooms. The registered person should strengthen the evidence of the review of staffing provision and make it available for inspection. The registered person should ensure the findings of quality assurance surveys are summarised into reports that can be made available to residents, their representatives and other interested parties. De Lucy Street (5) DS0000036880.V373768.R01.S.doc Version 5.2 Page 26 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. 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