Care Home: Therese Care Home

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What the care home does well The staff member on duty stated that in her view residents received a high standard of care and were treated as part of a family. Staff felt that they worked well as a team and communicated well with each other. Staff are knowledgeable about residents and their needs, as they have all worked in the home for many years. What has improved since the last inspection? A accurate record of fridge and freezer temperatures is being kept. A more accurate record of meals being eaten is being kept. The roster reflects the staff member on duty. CARE HOME ADULTS 18-65 Therese Care Home 144 Gassiot Road London SW17 8LE Lead Inspector Davina McLaverty Key Unannounced Inspection 29th April 2008 09:00 Therese Care Home DS0000010231.V362139.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 Therese Care Home DS0000010231.V362139.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. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Therese Care Home Address 144 Gassiot Road London SW17 8LE 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 8767 5407 Ms Iolenta Castelino Ms Iolenta Castelino Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Therese Care Home DS0000010231.V362139.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: 3 31st August 2007 Date of last inspection Brief Description of the Service: Therese Care Home accommodates three residents with a mental disorder. The home is a two-storey terrace house with a small garden to the front, and larger garden to the rear of the home. It is situated close to the busy shopping centre of Tooting Broadway and so within easy access of the public amenities and transport links served by the area. The home is owned and managed by Ms Iolenta Castelino, the Registered Person. The weekly fee charged is £350 per week. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The unannounced site visit was undertaken as part of the inspection started at 11.00am and concluding at 3.00pm on the 29th of April 2008. The site visit included viewing the premises, reading records, discussions with the staff member on duty and two people who use the service. In addition, the inspection took account of information received about the service since the last key inspection on the 31st August 2007. Prior to the site visit the home had been required to carry out their own self assessment of the service and submitted the assessment to the Commission for Social Care prior to the inspection. This is called the Annual Quality Assurance Assessment (AAQA) and is referred to in the report. Surveys forms were sent to the home to distribute to all residents, staff and professionals working with the residents. A poor response was received, with just one person residing in the home responding. Where relevant their comments are reflected in the report. People spoken to on the day of the inspection stated that they were happy and satisfied with the care and support provided. Comments included, “Its ok here”, “The staff are good”, and “I would not want to live anywhere else”. What the service does well: What has improved since the last inspection? A accurate record of fridge and freezer temperatures is being kept. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 6 A more accurate record of meals being eaten is being kept. The roster reflects the staff member on duty. 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. Therese Care Home DS0000010231.V362139.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 Therese Care Home DS0000010231.V362139.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): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide sets out information about the home. Both documents require minor amendments to fully meet the standards. An assessment procedure is in place to ensure that the home can meet the residents assessed needs. Visits to the home would take place prior to an admission. EVIDENCE: As stated at the last inspection the home has a Statement of Purpose and Service Users Guide. The Service User Guide requires minor amendment to fully comply with the regulations e.g. stating the home’s rule that the kitchen is unavailable at night. The people living at the home have all lived there for several years and copies of their original assessments are on file. The home has an admission procedure and the manager is fully aware that any new person must only be admitted after a comprehensive assessment has been carried out, which will involve the views of all professionals involved with the person, as well as the person them self. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 9 The admission policy examined included visits to the home to meet the other residents and staff as well as to enable the person to decide if Therese Care is the right place for them. The person’s representatives would also be welcomed. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place, but should be more ‘person centred’, stating how peoples individual needs are to be met. Evidence of reviews and residents involvement was seen, although these should be integrated into one comprehensive care plan. EVIDENCE: Two care plans were examined. The inspector observed once again little change in them since the previous inspection. Neither resident spoken to appeared aware or involved in their care plan, although their signatures were on them. One of the plans had been reviewed by the person’s social worker the other seen was overdue. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 11 The staff member on duty was aware of the care plans, but stated that the manager wrote and reviewed them. The staff member reported that in their view the home worked in partnership with other professionals and cited the District Nurse when one of the resident broke their leg. The inspector’s view, as stated at the previous inspection, is that the care plans were still quite basic and lacked sufficient detail to fully understand the resident’s needs. However, the staff member reported that all staff have worked at the home many years and are very familiar with the residents needs. The manager in her AQAA continuously states that the residents are well supported and receive a good standard of care. Both residents spoken with said that they were happy in the home and got on very well with the staff. As stated at previous inspections, people living in the home sign their care plans and have agreed to various house rules. e.g. medication being given by staff, the kitchen being locked at night and staff supporting them to manage their money. In previous discussion with the manager she has stated that the restrictions in place are as a result of health and safety, and are to prevent self –harm or self neglect and ultimately, have benefited the people who live there. The inspector does not agree, as residents are very dependent on staff to support them, with residents doing very little for themselves, in particular around independent living skills. Risk assessments are in place, but they are basic and mainly focus on keeping people who use the service safe, rather than encouraging a degree of risk to be taken. The home had updated one of the resident’s risk assessments around their mobility following his visit to the fracture clinic, but the assessment was not signed by the person carrying out the assessment or the resident. One resident said that he liked living in the home and got on alright with the other two people living there. The other resident spoken to found it more difficult to form a view, due to his mental health, but he appeared very much at home and relaxed as he sat in his chair watching television. Both residents responded warmly to the staff member who interacted appropriately with them. The manager is her AQAA has stated that the home will “continue as always having put our residents first and ensuring they have a good quality of life at all times”. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff continue to be aware of the need to support the people who live in the home, however, residents should be encouraged to develop basic independent living skills. Residents are encouraged and supported to access the community. EVIDENCE: We met two of the three people who live in the home, both of whom were appropriately dressed and seemed relaxed watching television. One person said that that’s all they wanted to do and did not wish to go anywhere apart from outside to have their cigarettes. The other resident said that he also enjoyed watching the television, but also enjoyed spending time in his room. He told the inspector that following an accident last year, when he was knocked down by a car and broke his leg, he Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 13 has not really been out much. He said he missed going to church and seeing his friends, however, his church minister visits him at the home to give him communion. The staff member stated that the third resident was at his monthly art club which he really enjoyed going to. Some of this residents work is displayed in the house. The back room was adequately furnished with three comfortable chairs, dining table and chairs, a television and music equipment. Both residents were positive about the staff and their interaction with them. One person appeared more contented at the home than the other, but overall, both said that they liked living in the home. In discussion with the staff member on duty they confirmed that numerous attempts are made to encourage the resident who just watched television all day to do other things, but they were not interested. The manager in her AQAA in response to this section stated that the home supported its residents by “ensuring individually, residents have access to what they need to make their lives happy and content”. She felt that they did this well, as they communicated and listened at all times. Visitors are welcomed, however, residents do not have active involvement of family members or friends who can visit due to distance and their own health needs. The visitor’s book was examined and the inspector noted that there were regular visits from health care professionals to the home. Unfortunately, no surveys were received from health professionals. One resident said that there should be more drinks offered. The inspector noted that a jug of water and cups were on the dining room table. Both residents said that they do not go into the kitchen and that staff do everything, and that whoever is on duty will make them drinks if they request it. In discussion with the staff member they stated that residents could go into the kitchen if they wish, but staff always offer and that there is no need. Due to residents mental and physical health staff tend to offer appropriate drinks e.g. one resident who is diabetic, will make drinks with too much sugar, which is partly why staff do not actively encourage people to make their own drinks and meals. However, the inspector held the view that this issue could be addressed with the individual and form part of his care plan. A record of meals prepared is kept. Again, staff decide on the meals, but will offer alternative dish if they know someone does not like the meal being prepared. The staff member stated that as all staff know the residents very well, there is no need to meet with them formally to discuss menus. A notice is displayed in the kitchen stating mealtimes e.g. breakfast 9.00am, lunch 1.00pm, tea 6.00pm and supper 8.30pm. In discussion with the staff member Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 14 on duty this is just a guide and residents can eat earlier or later depending on what they want. The inspector noted that the freezer was well stocked and adequate supply of food was in the home. The resident spoken with said that they had sufficient food given to them. The inspector heard staff offer a choice of soup, or a sandwich to residents for lunch. The kitchen continues to remain locked at night, although it is unclear why. A risk assessment dated October 2003, states that this is due to ‘health and safety regulations’, due to absent staff; however, the home is now staffed at night. There is no evidence that this has been reviewed since 2003, or what the health and safety reasons are. There was also no evidence in the care files that any resident would be at risk if the kitchen were not locked. However, the inspector noted that people resident in the home have agreed to this practice. As stated at the previous inspection, this practice should be included in the home’s Statement of Purpose and Service User Guide to ensure that any new resident would be aware of this practice. ”. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 15 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. People who use the service have access to health care services both within the home and in the local community. A medication procedure with guidelines for administration in place and staff have received training in this area of their work. EVIDENCE: The care plans indicate that the residents generally attend to their personal care needs, although prompting is given e.g. encouraging people to have a bath, brush their teeth. The staff member stated that residents have access to baths when they wanted and appropriate encouragement would be given where residents were seen to be neglecting their personal care. The staff member stated that residents are quite institutional in that they like to have their baths on particular days, however, this is not set in stone and any resident can have a bath when they want. One of the two residents confirmed Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 16 this to the inspector but also said that they liked to have a bath three times a week. A record is kept of appointments with GP’s, dentists and CPN’s, and care managers. Both residents reported that staff would accompany them on appointments to health professionals. The accident book detailed the accident to the resident that occurred in October 2007. The first aid box was well stocked and contained a post stick note stating it was checked in 12/02/07. The staff member said that it had not been used since the date as residents have not had any accidents whilst in the house. They did not feel the need for regular checking of the box as items would be replaced soon after being used as additional supplies are kept in the home. The home has a medication policy, which staff signs to state that they have read and understood its content. They also receive external training in administering medication. Medication Administration sheets (MAR) were seen to be appropriately completed. However, on checking the storage of the medication of two of the residents, two medications labels were not specific enough one stated “as directed”, another said “to be given every day”, but staff had decided to treat as PRN as the resident did not want or need Senna tablets every day. Medications labels must be specific as to how the Doctor wants the staff to dispense the medication. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 17 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. There is a complaints procedure at the home. Safeguarding of adults guidelines have been updated to ensure that appropriate action will be taken in the event of abuse being identified or alleged. EVIDENCE: The home has a complaints policy that provides suggestions of different people to whom a resident can complain, such as the home manager, social worker or the CSCI, and then states the steps that will be taken. No complaints had been made since the previous inspection. The manager in her AQAA stated in this section that the home has all relevant policies in place and that the home has received no complaints or grumbles from residents, their families and friends, staff or professionals as to how we look after our residents. She felt penalised by the regulating body that continually raised a number of practices issues maintaining that the residents are happy and receive a good standard of care and support. Staff had all received training in protection of vulnerable adults and evidence of this was seen on staff files examined. Wandsworth Inter - agency guidelines were available in the home. As detailed at the previous inspections there is still no policy or procedure at the home to detail the practices regarding resident’s monies and financial Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 18 affairs. The current arrangement for one resident is that his personal allowance is paid into the Managers account and she provides him with a daily allowance. However, despite the resident and social worker agreeing with this practice, this should be reviewed. The staff member said that this practice was about to change as the resident was getting a passport as he now had a document with his address on. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28 & 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 comfortable and reasonably decorated throughout. EVIDENCE: The home is adequately decorated, and clean. The resident spoken with said that they liked their bedroom, which was very spacious. All three bedrooms were seen and were adequate. Bedrooms varied in respect of personalisation. There were few pictures on walls or personal belongings evident; however clothes were seen to be neatly stored in wardrobes. One resident’s bedroom blinds were damaged and need replacing. Consideration should be given to putting up curtains as this will make it easier for the person Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 20 to look out, as found out in discussion with the staff member this person likes to look out the window, which is how the blinds got damaged. The resident confirmed that staff respects their privacy when they are in their room and will knock/ call them if they want them. We noted that where one of the floor tiles in the kitchen was cracked and loose, that a mat had been placed over it, which we felt, is now a potential tripping hazard. However, the staff member said that residents do not go into the kitchen and staff are fully aware of the mat. Also, at the previous inspection, a new door had been installed in the rear lounge. This was observed to have a crack in the glass. This door was also wedged open, as were all doors throughout the home. The staff member confirmed that doors are always wedged open and that the manager had agreed this. A copy of the risk assessment for the home was not available, fire doors should not be wedged open and this has been stated to the manager on numerous occasions. As stated at the previous inspection, consideration should be given to installing magnetic doorstops. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment checks are in place. Staff development and training continue to improve. EVIDENCE: No new staff had been recruited since the previous inspection when staff files were seen to meet the regulations. In respect of the staff team, the manager in her AQAA stated that, “our residents never complain and always tell their social workers, GPs and others how much they love our staff”. The staff training programme remains in place, which is monitored by the manager. The staff member stated that various refresher training courses had been agreed with the Local authority. None of the current staff employed hold an NVQ level 2 in care. The manager stated that her staff were not forthcoming in wanting to undertake the NVQ in Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 22 care qualification, but enjoyed their work and attending one-day courses run by the local authority. However, in view of the national minimum standards and regulations, the recommendation made at the previous inspections remains. The staff member spoken to was very positive about working at this home and stated that she felt supported by her colleagues as well as by the manager, who was hands on and always contactable. She stated, “I feel happy doing everything for the residents, we have lots of communication and everything is ok”. As already stated above this person also stated that she got on well with the residents who she saw as an extension of her own family. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 23 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 manager is aware of the need to promote safeguarding, and health and safety in the home, however, systems in place were not always seen to be up to date. EVIDENCE: As stated at previous inspections the manager does not wish to undertake the ‘Registered Manager’s Award’ (RMA). She has stated in her AQAA ‘ whatever I say about my management is always to no avail, because instead of looking at outcomes of our residents lives and their contentment over the years, I am denigrated for not having the RMA, individuality should also be taken into consideration when assessing a manager of every care home. After all, surely outcomes of our residents are paramount. The manager has run this home Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 24 successfully for seventeen years and has always maintained that despite changes in legislation, the current service users, their families and health care professionals have collectively found our services at Therese Care “exceptional”. She also stated on previous occasions that not having the ‘registered managers award’, “has not hindered me in doing a thorough efficient and appropriate management of the home”. The manager, however, stated in her AQAA that she is still looking to do an equivalent course to the RMA that “fits in with my schedules at the present time”. The inspector saw copies of questionnaires completed by residents regarding the services they receive at the home which were positive, but the questionnaires lacked dates. As stated at the previous inspection, the quality assurance should also consider the views of relatives and other stakeholders e.g. care managers, and comments incorporated into a brief report concluding with any steps that need to be taken as a result of their comments. Health and safety records were sampled. Hot water checks are not carried out as the manager has stated that residents are not at risk of scalding themselves and have signed to say that they are aware of the risks. Fire records were not available, but the staff member stated that the alarm is tested weekly and residents confirmed this. Fridge and freezer temperatures records and COSHH assessments were seen and found to be satisfactory. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 x Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The manager must ensure that medication when prescribed states how it is to be administered and where medication is not being prescribed as detailed the persons GP must be contacted for advice. A comprehensive fire risk assessment must be available in the home. Timescale for action 10/06/08 2 YA42 17(2) Sch 4 (14) 10/06/08 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. 3. Refer to Standard YA1 YA6 YA13 Good Practice Recommendations The statement of Purpose and Service User Guide should include all restrictions imposed on residents. Care plans should be more person centred and relevant to the service and the residents. Residents who wish to participate in the community must DS0000010231.V362139.R01.S.doc Version 5.2 Page 27 Therese Care Home 4. 5 6. 7 7 8 7. YA23 YA24 YA32 YA37 YA39 YA42 YA42 be encouraged and supported. A review of resident’s finances with interested parties should be undertaken and clear records maintained. The damaged blind should be replaced in the residents bedroom. The Manager should ensure that all care staff at the home undertakes the NVQ level 2 in Care qualification. The manager should continue to seek an equivalent course to the Registered Managers Award. The quality assurance system should include all stakeholders e.g. relatives, social workers. The cracked pane of glass in the fire door should be replaced. The home should not use door wedges but give consideration to installing an electromagnetic doorstop that is linked to the fire alarm system, which will ensure that fire doors are automatically in the event of a fire. Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Therese Care Home DS0000010231.V362139.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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