Care Home: Faraday House

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What the care home does well The managers of the home have been successful in meeting the requirements and recommendations made by the CSCI in their inspection report dated 18th March 2009 and the large majority of those made by The London Borough of Ealing and Ealing Primary Care Trust in their Placement Review dated 18th May 2009. Both of the current residents told us they were very happy living at the home. What has improved since the last inspection? Individualised risk assessments for the residents are now in place. A fire risk assessment has been obtained, though not yet acted upon. The administration of medication and its recording now meets the required standard. The Manager now does a regular medication audit. Residents are able to lock their bedroom doors. Residents’ notes are recorded separately and daily, and kept in a filing cabinet. Regular and recorded key working sessions are now undertaken. Revised care support plans have been produced. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Resident meetings and staff meetings are recorded in writing. The home’s policies and procedure documents have been weeded out. The back garden has been cleared of rubbish. What the care home could do better: The risk assessments for residents must include the risk of a fire caused by a resident smoking. The Support Plan should include the name of the Key Worker, who should also sign the plan as its author. The key descriptive details and photograph of each resident should be entered onto a form that can be handed to the Police if ever a resident needs to be reported as a missing person. It may be possible to include medication and health information so that the same completed form could be used for hospital admission purposes. Incidents involving residents where no one is hurt should not be reported as accidents using the RIDDOR reporting system. A separate reporting form or book is necessary for this purpose. Further detail is required in the support plans so that cultural, religious, social and nutritional care needs are shown to have been always considered. The carpet on the stairs and landing is dirty. Residents are not at present provided with a lockable storage space within their bedroom. Bedrooms are not at currently furnished with a table at which the resident may sit. Hot water is not available at wash hand basins within bedrooms, and the residents’ bathroom. The hot water temperature for the bath/shower is not adjustable to allow residents some choice in the matter. The job description for the Deputy Manager is not sufficiently specific to the Faraday House situation. The home does not have future training needs analyses for each member of staff, with the results combined together into a training plan for the year ahead. The home is not managed by someone with a recognised management qualification. The home does not have in place a suitable development plan for the year ahead. Everyone working in the care home should sign and date a document to say they have read and understood each of the home’s policies and procedures by name. The home does not have written policies concerning the possible acceptance of gifts, or on implementing the Mental Capacity Act and Deprivation of Liberty Safeguards. The findings of the fire risk assessment have not been implemented. Key inspection report CARE HOME ADULTS 18-65 Faraday House 16 Faraday Road Acton London W3 6JB Lead Inspector Robert Bond Key Unannounced Inspection 30th December 2009 10:00 Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Faraday House Address 16 Faraday Road Acton London W3 6JB 0208 248 4599 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) mrrajgopal@hotmail.com Mrs Solony Gopal Mr Runjith Gopal Mrs Solony Gopal Mr Runjith Gopal Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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: 3 18th March 2009 Date of last inspection Brief Description of the Service: Faraday House is a home for people with mental health needs. The home is situated in a residential area and in close proximity to Acton town centre, a mainline railway station and major roads into London. The Owners/ Registered Managers and their immediate family reside at the home, occupying part of the ground floor and top floor of the building. Residents are accommodated in single bedrooms. There is a small lounge, bathroom and separate toilet for residents’ use on the first floor. There is a small garden to the rear of the home which is used as a smoking area. Parking is available on the street outside. The home offers twenty-four hour support and care for people, where they can access local resources such as the Community Mental Health Team. Other community amenities, such as bus routes, shops and libraries are also available near to the home. Fees range from £750 upwards per person per week. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced ‘key’ inspection that considered mainly the home’s performance as measured against the anticipated outcomes for key National Minimum Standards (NMS) for Care Homes for Younger Adults as published by The Department of Health. We obtained from the home on the day of the inspection a completed Annual Quality Assurance Assessment (AQAA), and surveys completed by the two current residents. The home has one vacancy at present. We met and talked to the two residents, and interviewed at length the management team for the home. We examined a range of files, documents and policies, and toured the home including the residents’ bedrooms, with their permission. We considered the home’s success in implementing the requirements and recommendations of the last CSCI inspection report, and also those of Ealing’s last Placement Review. Equality and Diversity were considered throughout the inspection, and one requirement concerning these issues has been made The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: What has improved since the last inspection? Individualised risk assessments for the residents are now in place. A fire risk assessment has been obtained, though not yet acted upon. The administration of medication and its recording now meets the required standard. The Manager now does a regular medication audit. Residents are able to lock their bedroom doors. Residents’ notes are recorded separately and daily, and kept in a filing cabinet. Regular and recorded key working sessions are now undertaken. Revised care support plans have been produced. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 6 Resident meetings and staff meetings are recorded in writing. The home’s policies and procedure documents have been weeded out. The back garden has been cleared of rubbish. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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 Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s Statement of Purpose is a useful and well produced document. A satisfactory written assessment of needs is undertaken by the home before a resident moves in, and the resident’s support plan is based upon this assessment. EVIDENCE: We asked to see the home’s Statement of Purpose, which stated that the home had places for 9 residents. The Deputy Manager said this was a typographical error that would be corrected. In all other respects the Statement of purpose met the required standard. We asked to see the assessment documents for the most recent resident to move into the home. He had moved in two months before, having been placed there by The London Borough of Hillingdon who had supplied the necessary referral and assessment forms. A satisfactory written assessment had also been undertaken by the Deputy Manager. The support plan for this resident had been based upon the home’s assessment. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Basic support plans are in place, and recorded key working sessions have commenced. Residents’ views are ascertained at key working meetings, at reviews, by surveys, and at group meetings. Residents are supported to lead independent life styles so far as possible, but risk assessments, incident reporting, and missing person procedures require further work. EVIDENCE: We examined the support plans for both residents. These documents are typed and have been produced by the home’s Deputy Manager, who is the Key Worker for both residents. Both plans had photos of the resident attached. One care plan did not have the name of the resident on it, and his date of birth was incorrect, but the format used made it easy to find the assessed needs, and the identified actions that were necessary to meet those needs. Both support plans were dated and one had been signed by the resident to say that he Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 11 agreed with the contents. It is recommended that the support plans name the Key Worker, and that cultural and religious needs are included as a heading within the plan even if the plan is then marked that none have been identified as this evidences that these potentially crucial aspects of need have not been neglected. The Key Worker has commenced monthly key working sessions with each resident, and a typed record is kept of the agenda and outcomes. This development is commended. A daily record is now kept separately and securely on each resident, and a monthly summary report is produced. Formal meetings of staff with the residents collectively take place monthly and are recorded in writing. One resident is encouraged to manage his own finances. One resident is discouraged from smoking in his bedroom at night because of the fire risk. His care plan must contain the details of how is smoking is controlled. Individualised risk assessments have been undertaken on each resident. The risk associated with smoking in bedrooms had however been missed and must be added in. Residents are encouraged to help in the home and to lead normal lives outside. The London Borough of Ealing Placement Review identified the need for the home to introduce a better incident reporting procedure, and a missing person form but these actions have not yet taken place. Hence two associated recommendations are made within this report. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 12, 13, 15, 16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are encouraged and supported to develop interests in the wider community. Family relationships are promoted. A healthy and varied diet is provided. EVIDENCE: We ascertained that one resident goes to whole range of day activities. The other resident does not like to go out much. The social needs of both residents have been assessed and appear to be being met. Neither resident reports having any cultural or religious needs. Both residents have relatives who look after their best interests. Residents are now able to lock their bedrooms, but the rooms are not provided with a lockable cabinet or box for residents to keep items privately. A requirement is made about this issue. We noted a lunch of chilli con carne being served and residents told us that they enjoyed the food provided by the home. We examined a sample menu, and noted that the home records the food that is actually eaten by residents. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 13 In the residents’ survey handed to us, one resident wrote telling us about the various social activities he enjoys outside of the home, and said, “The meals (in the home) are well cooked.” Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s support plans do not yet include all aspects of the personal support that residents need. Residents’ physical and emotional health needs appear to be met, but their weight is not being monitored. Residents are encouraged to control their own medication where appropriate. The home has good procedures which are followed to store and administer medication to residents where necessary. EVIDENCE: Personalised support plans are in place for both residents but some additional detail is required concerning cultural and religious needs as indicated above in the Individual Needs and Choices section of this report. The care plan we examined in detail did not include a section on social needs. The Manager said this was because the resident liked to keep himself to himself. If this is factual as opposed to opinion, it needs to be recorded in his care plan. The assessment of the resident included concerns about his appetite. This led to us having a discussion about diet and nutrition. The conclusion was that the home will encourage the resident to eat a balanced diet. This also needs to be Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 15 recorded in the support plan together with detail about how to achieve it. It is also recommended that residents are weighed monthly and that the weight is recorded to ascertain whether significant weight changes are occurring. Both residents now have an identified key worker who also undertakes recorded key working sessions. Both residents are registered with a General Practitioner. We examined the home’s medication storage and medication administration and found them to be fully satisfactory. The home only holds medication for one resident. Residents receive depot injections at a health clinic. Both residents are supported by Community Psychiatric Nurses and are subject to the Community Programme Approach. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If a resident makes a complaint it is properly recorded in line with the home’s procedure. The home has the correct procedures in place to deal with any allegations of abuse that are made. EVIDENCE: We examined the home’s record of complaints. This contained one entry since our last inspection. This complaint from a resident had led to a safeguarding adults investigation which had been inconclusive and therefore not proceeded with. We examined the home’s complaints procedure as it appears in the Statement of Purpose. We examined the home’s Safeguarding Adults policy and agreed with the Manager a small change in the wording to clarify that it is the manager of the home who must investigate and discipline any member of staff suspected of abuse and who is responsible for reporting someone for inclusion on the POVA list. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The carpets in the residents’ part of the building are not as clean as they should be. Residents’ bedrooms are not furnished and equipped in a way to best promote independence and privacy. The absence of hot water in residents’ bedrooms and at the bathroom wash hand basin is an infection control concern. Residents are given no choice about the temperature of bath and shower water. EVIDENCE: Within the home, which is also the family home of the proprietors and one of their sons who is the Deputy Manager, each resident has a single bedroom and shared use of a small lounge, toilet and bathroom. We toured this part of the building. The bedrooms are sparsely furnished with non-matching furniture. One room did not have the required table lamp but this was provided whilst we were there. Neither room had a table to sit at. Neither room had a lockable storage space. The Manager responded that any valuables could be locked in the Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 18 home’s safe. Thus at present residents are not enabled to keep any personal possessions secure and private. The two bedrooms in current use have wash-hand basins, whereas the third vacant room does not. The hot water to both wash hand basins appeared to have been disconnected, hence the supply was cold water only. Neither room had any floor covering but the polished wooden floor was clean. However, the stair and landing carpet outside of the bedrooms was soiled. The Manager said he was considering removing this carpet also. Residents were asked by us in advance by survey what they thought about their care home. The questions included ‘Is the home fresh and clean?’ One resident chose to answer ‘always’ but one answered ‘sometimes’. The wash-hand basin in the bathroom also did not have a hot water supply, and in this case there was not even a hot tap. Thus is appears that residents do not have anywhere to wash their hands in hot water after using the upstairs toilet, which is a hygiene and infection control issue. The hot tap handle for the bath/shower was missing. Thus although the bath mixer faucet and shower head produced hot water of approximately the correct maximum allowed temperature (42 degrees Centigrade), it was not possible to adjust the temperature should a resident choose to have a warm shower, or indeed a cold shower. Hence residents are allowed no choice in the matter. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are well supported by competent and qualified staff that forms a small, stable and cohesive family group. EVIDENCE: The staffing of the home is the Manager and proprietor, his wife and joint proprietor, and one of their sons, who is the Deputy Manager. No other people are employed but another son sometimes helps out. Hence no recruitment takes place and no agency staff are used. The management team told us that all three of them had valid CRB disclosure certificates. We asked if anyone had a job description and were shown one for Deputy Manager that had been prepared in connection with the NVQ in care level 4 that he was undertaking. This job description referred to ‘the company’ hence it is not sufficiently specific to Faraday House which is not operated by a company so far as the CQC is aware. We looked at training records for individual staff members that indicated for example that the Manager had received training in the Mental Capacity Act. There was no training plan for the year ahead available for us to inspect. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards within the home have continued to improve over the years due to the combined efforts of the management team. Satisfactory quality assurance systems are in place but the annual development plan requires further work. The home has a range of policies that are kept under review but two additional policies are necessary. Health and safety within the home is generally acceptable with the exception of certain fire protection measures. EVIDENCE: The home is unusually registered with two managers but this report has treated Mr Runjith Gopal as the manager as he took the lead during this inspection. He told us that he is a Registered Mental Nurse. He has been considering obtaining a current management qualification for some time, as Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 21 noted in previous inspection reports, and hence a recommendation is made this time, which might become a requirement if not acted upon (see NMS 37.2ii). All of the requirements and recommendations from our last report have been acted upon by the management of the home, as have most of the requirements made by the London Borough of Ealing. In terms of quality assurance, the Manager now undertakes a monthly audit of medication held and administered by the home, and we saw surveys that had been undertaken which included the views of residents, care managers and the home’s pharmacist. A development plan has been produced for the period 2009-2010. However this document contains a lot of information that is not development work, being a description of the home, and routine monitoring objectives. It is suggested that the main focus of the plan should be meeting the requirements and recommendations from this report, and other improvements that are the management and residents’ choice, including the intended possible extension of the home to include next door, together with a target date for achieving each aspect of development. The home has largely weeded out duplicate policy and procedure documents. Two new policies that are needed are ‘policy on accepting gifts from residents’ and ‘policy and procedures for implementing the Mental Capacity Act and Deprivation of Liberty Safeguards.’ It is suggested that the London Borough of Ealing are asked for assistance with the latter. Policies have been reviewed and signed by the Manager, but not by the other staff. It is recommended that a system is set up whereby all staff other than the Manager signs and dates a document to declare that they have read and understood each policy and procedure by name. Under health and safety, we ascertained that the home had current gas and electrical safety certificates. The previous CSCI inspection had required the home to complete a detailed fire risk assessment. This requirement had been met by the home commissioning a surveyor to undertake the assessment. His report was dated 2nd September 2009 and it contained a number of requirements including the installation of self-closing fire doors onto the stairwells. This report is now four months old and no action has yet been taken to implement its findings. We asked the Manager how long he needed to ensure appropriate actions are completed and he responded ‘three months’. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 22 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 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 2 25 x 26 2 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 3 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 x 2 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 2 3 3 x 3 x 2 3 x 2 x Version 5.3 Page 23 Faraday House DS0000027704.V378795.R01.S.doc 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 YA9 Regulation 13 Requirement The risk assessments for residents must be kept under review, and the risk of fire caused by smoking must be included. This is intended to make the home a safer place. Further detail is required in the support plans so that cultural, religious, social and nutritional care needs are shown to have always been considered. This will help ensure that all the residents’ various needs are met. The carpet on the stairs and landing must be shampooed more often, or replaced. This will make the home a more attractive place. All residents must be provided with a lockable storage space within their bedroom. This is to ensure that items can be stored securely and privately by the resident themselves. If a risk assessment determines that this practice is unsafe for particular individuals, this must be recorded in their support plan, and agreed by the resident or DS0000027704.V378795.R01.S.doc Timescale for action 01/02/10 2 YA18 15 01/02/10 3 YA24 23 01/02/10 4 YA26 16 01/02/10 Faraday House Version 5.3 Page 24 their representative. 5 YA26 16 The management of the home must consult with the residents about the provision of a table within each bedroom at which the resident may sit. This is to enable residents to study or to eat within their room if they wish. If the resident decides they do not want a table, this must be recorded within their support plan. The management of the home must ensure that hot water is available at wash hand basins within bedrooms, and bathrooms. The hot water temperature for the bath/shower must be made adjustable. These measures are part of infection control, and to enable residents to have greater choice and control over their environment. The home’s current development plan must be reworked so that it becomes an annual plan that considers only those new developments that are planned for the year ahead. The Registered Manager must ensure that appropriate action is taken to implement the findings of the independent fire risk assessment. 01/02/10 6 YA30 16 01/02/10 7 YA39 24 01/04/10 8 YA42 23 01/04/10 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 YA6 Good Practice Recommendations The Support Plan should include the name of the Key Worker, who should also sign the plan as its author. DS0000027704.V378795.R01.S.doc Version 5.3 Page 25 Faraday House 2 YA9 3 YA9 4 5 6 7 8 9 YA19 YA31 YA35 YA37 YA40 YA40 Incidents involving residents where no one is hurt should not be reported as accidents using the RIDDOR reporting system. A separate reporting form or book is necessary for this purpose. The key descriptive details and photograph of each resident should be entered onto a form that can be handed to the Police if ever a resident needs to be reported as a missing person. It may be possible to include medication and health information so that the same completed form could be used for hospital admission purposes. The weight of residents should be measured monthly, and recorded in a way that shows the extent of any weight gain or loss. The job description for the Deputy Manager should be made more specific to the Faraday House situation. The home should undertake training needs analyses for each member of the management team and combine the results together into a training plan for the period ahead. The Registered Manager should urgently undertake the Leadership and Management course that the CQC recommends. Everyone working in the care home should sign and date a document to say they have read and understood each of the home’s policies and procedures by name. The home should have a written policy on the acceptance or refusal of gifts from residents and others. The home should also develop a policy and procedure for meeting the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards. Faraday House DS0000027704.V378795.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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