Care Home: Keats Way, 97

What the care home does well The home provides residents with the opportunity to make daily decisions and choices about their lives. The Manager and staff are aware of how to support residents with mental health needs and tailor the care to suit individual preferences. What has improved since the last inspection? Overall the home has made improvements to the environment and this needs to continue to ensure the home remains presentable and welcoming. Care plans and risk assessments were more detailed, recording resident`s individual needs. The home had considered activities and how to encourage resident`s to engage more with staff and each other. It is recognised that this can be an ongoing difficulty. Consideration had been given to meal provision and the home continues to provide meals using healthy fresh produce. Training for staff had improved with staff receiving training on subjects relevant to supporting people with mental health needs. Residents` views had been sought by the home and are obtained on an ongoing basis. CARE HOME ADULTS 18-65 Keats Way, 97 Greenford Middlesex UB6 9HF Lead Inspector Sarah Middleton Key Unannounced Inspection 28th May 2008 09:30 Keats Way, 97 DS0000027753.V363947.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 Keats Way, 97 DS0000027753.V363947.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. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keats Way, 97 Address Greenford Middlesex UB6 9HF 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) 020 8575 3986 020 8575 8632 ramanah@hotmail.co.uk Mr Rajgopal Ramanah Mrs Premila Ramanah Mr Rajgopal Ramanah Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Keats Way, 97 DS0000027753.V363947.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 - 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: 6 22nd May 2007 Date of last inspection Brief Description of the Service: Keats Way is a large end of terrace house on a corner plot in a residential area. The property is situated on the borders of Greenford and Southall. It is near to small local shops and a short distance by transport to a larger town. A bus route runs nearby providing transport to mainline railway and underground services, which are only a few miles away. There is a small front paved front garden and an enclosed back garden which has a small patio and grass area. The home is registered for six people who have mental health needs. The local mental health team is accessed, along with the day centre for those wishing to use this service. Primarily the home caters for residents who can manage the stairs, as there are only two bedrooms on the ground floor. The communal rooms are located on the ground floor, where there is an open plan dining room and lounge. The Registered Manager and support workers provide daily care and support to the residents. One member of staff sleeps in the home at night. The home is staffed twenty-four hours a day. The Registered Manager, who is also the Registered Provider, lives very close to the home. Fees range from £600-£650 per resident per week. Keats Way, 97 DS0000027753.V363947.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. We visited the home between 9.30am-4.40pm. Three residents and two staff were spoken with. We viewed various documents, such as health and safety records, staff files and residents’ files. One health professional and three residents had completed and returned postal surveys. Relevant comments have been included in this report. The Registered Manager will be referred to in this report as the Manager. The Manager had completed an updated Annual Quality Assurance Assessment. Since the last key inspection the home has extended with a further two bedrooms available, making it a six bedded home. Eleven of the thirteen previous requirements were met and three new requirements were made. All of the key National Minimum Standards were assessed. Equality and diversity issues were considered and where identified have been included into this inspection report. What the service does well: What has improved since the last inspection? Overall the home has made improvements to the environment and this needs to continue to ensure the home remains presentable and welcoming. Care plans and risk assessments were more detailed, recording resident’s individual needs. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 6 The home had considered activities and how to encourage resident’s to engage more with staff and each other. It is recognised that this can be an ongoing difficulty. Consideration had been given to meal provision and the home continues to provide meals using healthy fresh produce. Training for staff had improved with staff receiving training on subjects relevant to supporting people with mental health needs. Residents’ views had been sought by the home and are obtained on an ongoing basis. 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. Keats Way, 97 DS0000027753.V363947.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 Keats Way, 97 DS0000027753.V363947.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. Prospective residents are assessed prior to moving into the home. EVIDENCE: A new resident had moved into the home since the last key inspection. The Annual Quality Assurance Assessment states that a prospective resident would be encouraged to visit the home and stay for a weekend. The new resident confirmed they had visited the home and stayed overnight before making a decision to move into the home. They said it had been their second choice to move to this care home, but so far they were happy. They are currently on a six- week trial to see how they settle into the home. The Manager had carried out a pre-admission assessment and attended a predischarge meeting. The home’s pre-admission assessment is basic and this was raised with the Manager. He confirmed that along with this assessment, other professional reports and assessments are obtained and only then is a decision made. The Manager should consider if the pre-admission assessment needs to be reviewed and updated to consider more details regarding a prospective resident. Keats Way, 97 DS0000027753.V363947.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’ needs are outlined on care plans and risk assessments. Residents are able to make daily decisions about their lives. EVIDENCE: Samples of care plans were viewed. These covered a wide range of needs, such as social, personal and health needs. Spiritual and religious needs are also considered. These care plans are reviewed on a monthly basis. The Manager explained that the care plans are an ongoing assessment of the resident’s individual needs. Care Programme Approach reviews, held specifically to review the resident’s mental health needs and general needs are also held every six months. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 10 The new resident, who had only moved in very recently, stated that staff do most things around the home. The Manager and staff said this was not an accurate picture of the support offered to residents. Some residents are more independent and motivated than others. Where possible residents are asked to engage in tasks in and around the home. Residents do not have independent advocates to offer objective support and advice. Samples of risk assessments were viewed. The Manager completes the care plans and risk assessments, although the Manager confirmed that he has been involving one of the members of staff in the process of assessing new residents. Risk assessments look at various potential risks and records ways to minimise those risks. Previous risks are also noted to ensure staff are fully aware of all identified and assessed risks. Those residents that are independent are encouraged to go out without staff support. This is carefully monitored and is not encouraged for those residents deemed to be too vulnerable. One resident had gone missing from outside the home earlier in the year. The home was swift to take action and the resident was found safe and unharmed. Keats Way, 97 DS0000027753.V363947.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. Overall residents are encouraged and have the opportunity to engage in activities and interactions with others. Residents are able to develop and maintain social relationships with family and friends. Residents’ rights and choices are respected and supported. Residents are provided with healthy meals that meet individual preferences. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home identified a local day centre that residents can attend as and when they wish to. This is a place where residents can meet others and engage in the activities on offer. One resident said he enjoyed going out independent of staff, as he liked to choose where and when he went out. Another resident acknowledged that he was unmotivated to engage in activities and that he liked to watch television and smoke. One postal survey completed by a resident stated that they “didn’t like to participate in activities and that they were not interested”. We discussed with the staff and Manager the need to continue to keep motivating residents and that the staff team need to support residents to take part in activities both in and out of the home. One resident is from a particular faith and confirmed that occasionally they attend a place of worship. The Manager also said that any resident would be supported to follow their religious practices. Most of the residents have little contact with family or friends. The Manager said contact with family or friends would be encouraged and supported if this is what the resident wanted. Residents have a key to their bedrooms. Residents can also receive their own personal mail. The Manager explained that due to the risks there were no residents who held keys to the front door. If able to, residents manage their own finances. Residents confirmed they chose the meals they want to eat. The home can cater for those residents with particular dietary requirements. The home has a new kitchen since it expanded and this is more modern than the previous one. Residents are encouraged to take part in some of the meal preparation, although some residents are not interested in taking part. Traditional and cultural meals are offered to provide a varied diet. The difficulty the home has regarding those residents who go out in the community alone, is that the home does not know what meals are eaten. As some residents need their weight monitored, this is an ongoing difficulty. Food that is opened is covered and dated when stored. Keats Way, 97 DS0000027753.V363947.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 are supported with their personal care in their preferred way. Residents’ health needs are recorded and were being met. To ensure the residents’ health and safety is being met, medication needs to be given as prescribed. EVIDENCE: We were informed that residents need assistance with personal care in different ways. Some need reminding to change their clothes, whilst others need support and encouragement to clean their teeth on a regular basis. Other than one female member of staff, the staff team and Manager are male. All the residents are male, therefore same gender personal care is provided as and when needed. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 14 One resident received specialist treatment and is currently well. All but one resident has annual blood tests to check for common problems such as diabetes and cholesterol levels. All residents have a GP and the Annual Quality Assurance Assessment stated that the relationship with the GP had improved, with the GP being more sympathetic towards the residents. Records are kept of any medical appointments attended. Medication was assessed and a sample of medication was checked and counted. Medication is stored in a wooden lockable cupboard in the office. Although at the time of the inspection the home did not have any controlled drugs, due to changes in legislation, it was recommended for the home to purchase separate lockable storage for controlled drugs, so that appropriate storage is available should a resident be prescribed a controlled drug. The Manager explained that each member of staff receives training on medication. New staff observe medication being administered. Discussions took place with the Manager to ensure staff receive regular training and updates on changes to legislation relating to medication. Evidence was seen that medication is counted and checked on a weekly basis. It was noted that one resident had not received their prescribed medication on the morning of the inspection. A requirement was made for all medication to be administered as prescribed. Keats Way, 97 DS0000027753.V363947.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. Residents are aware of how to make a complaint. Systems are in place to protect residents from abuse. EVIDENCE: Residents spoken with were aware who to talk to if they had any concerns or issues. The home had not received any complaints. The complaints procedure was seen in the entrance hall. There had been no abuse allegations made. The home has relevant policies and procedures on adult abuse. The staff team attend annual training on adult abuse. Details of the Local Authority’s adult abuse co-ordinator should be made easily available for staff. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is now more welcoming and comfortable for the residents to live in. The home was clean and odour free. EVIDENCE: There had been previous ongoing concerns about the general maintenance of the home. This has slowly been addressed, with the new open plan living room and dining area proving residents with a lighter and brighter place to sit in. Residents are able to sit outside to smoke, although one resident was seen to smoke in the dining area, until staff advised the resident to smoke outside. There are two drain covers that have needed to be left as they are, so that they can be easily accessed. These are both in the new living room. Both were covered with laminate flooring, however one did need some further attention, as the flooring was slightly raised. The television was partly over this raised area and this did press down making the hazard minimal. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 17 The Manager is aware that this is an issue and is seeking to solve this problem. We were satisfied that this will be addressed and risk assessed. The staff team, along with some input from residents, keep the home clean and tidy. On the day of the inspection, the home was clean and free from unpleasant odours. The Manager was advised to obtain paper towels for the kitchen and downstairs toilet. Having paper towels made available, the home would be following infection control procedures. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 18 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, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent staff team support the residents’. Residents could be at risk if there are not sufficient numbers of staff working in the staff team. The residents’ welfare could be at risk if all recruitment checks are not carried out. Overall an appropriately trained staff team supports the residents. EVIDENCE: The staff team is small but is slowly expanding. One new member of staff has recently joined the team and has some previous care experience. A new member of staff, due to start in the next few weeks, has no previous care experience. The Manager was aware of the need to have a balanced staff team, who can provide various skills and knowledge to the home and residents. Those staff spoken with were committed to ensuring residents are supported to be as independent as possible. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 19 One member of staff has just completed an NVQ level 3 and is hoping to study for an NVQ level 4. The Manager confirmed that the two new members of staff, once they have completed their probation, would study for an NVQ level 2. The Annual Quality Assurance Assessment stated two members of staff work the early shift and two work the late, (afternoon shift); this had been the agreed staffing level at the time the two extra bedrooms were being registered. The rota showed that two members of staff were on shift, but that on many days the newest member of staff and the Manager were recorded as working from 7.30am-10pm. This was discussed with the Manager, as this is not an acceptable way of working and indicated there were not enough staff working in the team. The Manager must ensure he has sufficient numbers of staff available to work. In addition, adequate time off for staff must also be given. As mentioned above, a new member of staff is due to join the team and this might assist with the issues the Manager has faced in ensuring two members of staff are working on a shift. A requirement was made for this to be addressed. The Manager was asked to forward to the Commission a copy of the amended rota and this was seen. The Manager needs to be mindful that new members of staff need time to learn and observe how the home operates and not be placed immediately on the rota working as the second person. Furthermore the Manager needs time to manage the home and ensure it is running smoothly. By working on the rota and such long hours, some of which is providing care support to the residents, means that some managerial tasks might be left unattended. It is recommended that the Manager does not work excessive direct care and support hours with the residents. Two staff employment files were viewed. These had completed application forms, although the application form did not ask for the applicant to record the details of the two referrers. This was discussed with the Manager as the form needs to request references so that appropriate checks can be carried out, such as ensuring one of the references is from the last or current employer. On one file there was a Criminal Record Bureau Check, photograph and two references. The health declaration had not been completed but was done so on the day of the inspection. The second file had little information on the applicant’s recent employment history. This person had not completed a health declaration form. A POVA first check was seen and the Manager was waiting for the Criminal Record Bureau check. Although this second person had not started working in the home, we were informed they were due to start in the next few weeks. A re-stated requirement was made for the Manager to ensure all necessary robust recruitment checks are carried out before a person works in the home. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 20 We viewed the induction and training provided for staff working in the home. The induction for new staff comprises of shadowing existing members of staff on shift and working through the in-house induction checklist. This was viewed and covers the basic information, such as, medication procedures and health and safety. The Manager also showed the Skills For Care Induction booklet that he is planning to use for new staff. This is more detailed and would benefit new staff working in the home. The home does not currently record training on an overall training plan. This was discussed with the Manager, as it could be useful to devise such a plan so that it can easily be used to monitor when staff need to attend training. Individual training records are used, although these did not record the inhouse training the Manager provides to staff. It is advised that all training is recorded to show each member of staff’s personal development. The health professional’s comments stated that the home could further improve by offering “continuous professional development/training for all the staff involved”. Overall the staff team were up to date with training on subjects such as adult abuse, fire awareness and health and safety. However it was noted that all staff had received this training in one day on the home. This needs to be carefully monitored, to ensure staff are receiving quality and detailed training on important subjects. This issue was raised with the Manager. The residents during this training day were also in the home, but with no staff directly supporting and engaging with them. This was discussed with the Manager and relates to the issue regarding sufficient numbers of staff working in the team. The Manager needs to consider how best to offer training for the staff team, without placing residents at risk of being left alone for any length of time. This is linked to the requirement made in relation to the rota and staffing numbers. There was some evidence that staff had received information on the new Mental Capacity Act 2005. The staff team now need to consider how and when this legislation will used. Staff will also need to think about how they will evidence when this new legislation has been used. Keats Way, 97 DS0000027753.V363947.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. Overall the home is managed in the interests of the residents. Residents would benefit from knowing there are procedures and a report in place showing how the home has made improvements. If all health and safety procedures are not followed, the residents’ welfare could be placed at risk. EVIDENCE: The Manager is also the Registered Provider and has managed the home for several years. The Manager had started the Registered Managers Award but this was not completed. Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 22 It was not clear if the Manager would be intending to study this qualification at a later stage. The Manager needs to consider if he is to study for an up to date managerial qualification. As noted earlier, another member of staff is keen to study further and the Manager confirmed he would support this member of staff to gain a managerial qualification. The home holds resident meetings and residents are asked to complete surveys about the home. Evidence was seen that the Manager considers the findings of the surveys. The Manager had not developed an overall short review report about the home and this is a re-stated requirement. Health and safety records were viewed. The Manager had completed a general fire checklist each month, but this did not provide a detailed risk assessment report. Neither was there a floor plan outlining where the fire exits and the fire equipment was located in the home. The Manager must ensure that all potential risks to residents and staff are considered and noted in this assessment. Fire drills had been held at different times of the day and with different staff. Other checks such as gas safety, testing for Legionella and Portable Appliance test were all up to date. Keats Way, 97 DS0000027753.V363947.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 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 3 36 x 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 2 x x 2 x Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement In order to ensure resident’s health needs are met, medication must be given as prescribed. In order for residents to be supported by staff who are competent and effective, staff must not work excessive hours during the day or during the week. There must be sufficient numbers of staff working in the staff team. In order to protect residents, details on persons working in the home, as outlined in Schedule 2, must be available for inspection. (Previous timescale 23/05/07 not met). Residents would benefit from the Registered Person establishing a system for reviewing and improving the quality of care provided in the home. A report of such a review must be available for inspection and for residents. (Previous timescale 31/08/07 not met). Timescale for action 29/05/08 2. YA33 18(1)(a) 29/05/08 3. YA34 Schedule 2 30/06/08 4. YA39 24(1)(2) 01/08/08 Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 25 5. YA42 23(4) To protect the health and safety of the residents, an up to date fire risk assessment and floor plan must be completed. 26/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA33 Good Practice Recommendations The home should obtain a separate controlled drugs cabinet to store all controlled drugs. The Manager should not work excessive direct care and support hours with the residents, that could affect the managing and running of the home. Keats Way, 97 DS0000027753.V363947.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. Extracts may not be used or reproduced without the express permission of CSCI Keats Way, 97 DS0000027753.V363947.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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