Care Home: Wakeling Court

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What the care home does well The expert by experience made some very positive general comments about the home as follows: "One resident said she `liked the staff` and another spoke enthusiastically about her key worker, `laughing and joking` with her. The residents that I spoke to were unanimous in their praise of staff and weren`t afraid to speak out.They treated Wakeling Court as their own home and staff never tried to use excess control while I was there. People were given the freedom to please themselves, coming and going between the communal area sand their rooms as and when." The service is well structured with good reliable systems underpinning the work. The manager and staff are enthusiastic and the ethos of the home is empowering and supportive. The environment of the home is good. Service users have personal privacy, with access to staff and the company of other service users when they wish for it. Meals at the home are well prepared and served in a pleasant atmosphere. What has improved since the last inspection? The home has worked to better meet the needs of a service user who has sensory loss. The home has amended the service user guide which is now satisfactory. It has also amended its adult protection policy to correctly state the local office address of the CSCI. The home has acquired a copy of the local authority adult protection policy, to follow in conjunction with its own organisational policy. Food hygiene practice has improved with opened foods in the refrigerator being labelled with the date of opening. What the care home could do better: The inspection has resulted in 12 statutory requirements, one of which is restated, and three good practice recommendations.The manager must check that the claim in the statement of purpose that the fire brigade undertake an unannounced inspection once a year is actually correct. Risk assessments must be undertaken on all risks identified and all service users must have the opportunity to discuss afterlife arrangements and have their views recorded. All health needs must be recorded so that staff are aware of them. A service user indicated on their afterlife arrangements that they would like to make a Will and this must be followed up with staff offering the necessary support. The home must ensure that medication practice is safe and robust with all necessary recording made and the pharmacist signing for returned medication. Some organisational policies which are in frequent use, have not been updated and the manager needs to point this out to her senior managers. Regulation 37 notifications must be sent to the CSCI on every occasion listed in the regulation. Control of Substances Hazardous to Health (COSHH) practice must be improved with data sheets for all products stored. Staff must be trained annually in core basic topics including First Aid, unless the existing certificate indicates otherwise. We recommend that a computer be provided in a communal area of the home, fitted with a broadband connection to the internet. CARE HOME ADULTS 18-65 Wakeling Court 96A Halley Road Forest Gate London E7 8DU Lead Inspector Anne Chamberlain Unannounced Inspection 26th August 2008 09:45 Wakeling Court DS0000063897.V369227.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 Wakeling Court DS0000063897.V369227.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. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wakeling Court Address 96A Halley Road Forest Gate London E7 8DU 020 8472 9648 020 8471 8839 Mary.Draper@east-living.co.uk 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) East Living Limited Manager post vacant Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Wakeling Court DS0000063897.V369227.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: 22 1st November 2006 Date of last inspection Brief Description of the Service: Wakeling Court is a 22 bedded residential home which provides personal care and support to service users with mental health issues. Placements are funded by Social Services and East London City Health Authority (ELCHA). Fees are £550 per week. The home is situated in Forest Gate close to local amenities and with public transport links. It is purpose built and modern. As of 1st July 2005 the home is managed by East Living. There are 16 studio flats and six bedrooms. The six bedrooms are divided between two rehabilitation units. The rehabilitation programme offers intensive support towards independence and currently three people are participating. In addition to the manager there are ten permanent support staff. The home is staffed twenty four hours with one senior and two support staff on duty during the day and one waking senior and one support staff at night. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use the service experience good quality outcomes. The report is written on behalf of the Commission for Social Care Inspection (CSCI) and the terms we and us will be used throughout. Prior to the inspection seventeen surveys were received from service users. The home also submitted an Annual Quality Assessment Audit which contained much useful information. This was a unannounced key inspection and the site visit was carried out over one day and lasted some eight and a half hours. We spoke with several service users and interviewed a staff member. We looked at three service user files and three staff files. We also looked at key documentation and policies and procedures. We inspected the arrangements for the administration of medication and toured the communal areas of the premises and the kitchen. We were assisted in the inspection by the manager and deputy manager. We were also joined on the inspection by an expert by experience - a person who has personal experience of the type of service being inspected. The role of the expert by experience is to gather evidence from a users perspective to complement our evidence. Her findings have been integrated into this report. We would like to take this opportunity to thank all who participated in the inspection for their co-operation and assistance. What the service does well: The expert by experience made some very positive general comments about the home as follows: One resident said she liked the staff and another spoke enthusiastically about her key worker, laughing and joking with her. The residents that I spoke to were unanimous in their praise of staff and werent afraid to speak out. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 6 They treated Wakeling Court as their own home and staff never tried to use excess control while I was there. People were given the freedom to please themselves, coming and going between the communal area sand their rooms as and when. The service is well structured with good reliable systems underpinning the work. The manager and staff are enthusiastic and the ethos of the home is empowering and supportive. The environment of the home is good. Service users have personal privacy, with access to staff and the company of other service users when they wish for it. Meals at the home are well prepared and served in a pleasant atmosphere. What has improved since the last inspection? What they could do better: The inspection has resulted in 12 statutory requirements, one of which is restated, and three good practice recommendations. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 7 The manager must check that the claim in the statement of purpose that the fire brigade undertake an unannounced inspection once a year is actually correct. Risk assessments must be undertaken on all risks identified and all service users must have the opportunity to discuss afterlife arrangements and have their views recorded. All health needs must be recorded so that staff are aware of them. A service user indicated on their afterlife arrangements that they would like to make a Will and this must be followed up with staff offering the necessary support. The home must ensure that medication practice is safe and robust with all necessary recording made and the pharmacist signing for returned medication. Some organisational policies which are in frequent use, have not been updated and the manager needs to point this out to her senior managers. Regulation 37 notifications must be sent to the CSCI on every occasion listed in the regulation. Control of Substances Hazardous to Health (COSHH) practice must be improved with data sheets for all products stored. Staff must be trained annually in core basic topics including First Aid, unless the existing certificate indicates otherwise. We recommend that a computer be provided in a communal area of the home, fitted with a broadband connection to the internet. 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. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Prospective service users have information about the service and their needs are properly assessed before placements are offered. EVIDENCE: We looked at the statement of purpose. It gives a great deal of pertinent information about the service, but needs to be amended as follows:- to give the name of the new manager, to update the smoking arrangements, to correct the address of the CSCI which is Cranbrook Road, and to state the correct number of staff. The document states that the fire brigade conduct an annual unannounced visit and this claim should be verified in case arrangements have changed. The statement of purpose has a managerial flow chart which simply says service manager three times in three boxes. This needs to be amended to be meaningful. We looked at the service user guide and found it to be satisfactory. We looked at three service users files. There were two pages of key information at the front of each of the service users files, as well as reports Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 10 from professionals. The assessment information is quite comprehensive including social histories. We felt that prospective service users would be properly assessed before being offered placements at the project. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users needs are well documented in their individual plans. They are encouraged to make decisions about their lives, but risk assessments must be comprehensive. EVIDENCE: The three files we looked at all contained service user plans and one had a daily care plan sheet also. We felt that the meeting of service users needs was well planned. In surveys returned to us service users told us that they make decisions about what to do each day. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 12 One of the service users at the home is deaf and arrangements have been put in place for him to attend a deaf club lunch once a month, and to have television programmes with sub titles and signing. He has a volunteer visitor twice a week who signs with him and we were told that he really enjoys these visits. Two diversity officers have been appointed from within the staff group and have undergone additional training for their role. Risk assessment is undertaken at the home. The process is for a screening tool to be completed and then any risks identified are addressed separately with actions recorded to reduce the risk. These risk assessments had not been completed for every risk identified. On the file of one service user 6 risks had been identified on the screening tool but only two full risk assessments had been completed. The manager must ensure that a risk assessment is completed for every risk identified. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users take part in normal community leisure activities and they have relationships with their families and friends. Healthy well cooked food is offered at the home and mealtimes are enjoyable. EVIDENCE: The expert by experience reported positively on lifestyle aspects of the home. Four extracts from her report follow: She (the manager) told me that one resident was organising a Supper Club for those unable to sleep and signing up participants himself. She was receptive to new ideas and there was a suggestion box in the hallway, although she welcomed being approached personally. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 14 One resident asked a bank staff member if she could go out but accepted his reassurance that arrangements had been made for the next day. This lady was spoken to respectfully and I witnessed several friendly interactions between staff and residents during my visit. One resident asked for some of his money to go shopping and this was readily agreed. Visits from family and friends are encouraged, with a curfew, suggested by residents themselves, of 10pm, unless, of course, there were special circumstances. The service users at the home take part in a wide variety of activities. A number are able to access the community independently, a number visit with family locally and receive visits. One service user undertakes courses with a local college. Service users go shopping alone or with support. Some service users have paid part time jobs within the home. They also share in chores and are responsible, with support, for keeping their own studio flats clean and tidy. Currently service users have access to a computer but do not have an internet connection. The manager agreed that this facility should be provided and would be likely to be well used. We recommend that the home provide a computer with a connection to the internet, in a communal area of the home. A volunteer visits the home and goes shopping with service users and cooks with them. Three meals a day are provided in a communal dining room but service users also prepare food in their studio flats or the two kitchens in the rehabilitation units. One service user cooks Caribbean food quite often for herself in her own flat. The home uses an agency cook and staff also prepare the food served in the dining room. Service users assist in the kitchen. The manager stated that the monthly residents meeting is an opportunity for service users to make suggestions for the menu. We ate with the service users at lunchtime. The dining room was pleasant, tables clean, crockery and cutlery sound and the service users seemed to be enjoying their meals. There were second helpings available. There was a choice of dishes and the food was well cooked and nutritious. We felt that the presentation of the second course could be improved. Fruit was produced in a cardboard box. The bananas looked under ripe and there was a Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 15 choice of just bananas or tangerines. We recommend that fruit or any other course is presented to look as appealing as possible and with as much choice as possible. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Support is sensitively offered and physical and emotional needs are met. Medication practice can be improved and afterlife wishes must be sought for all service users. EVIDENCE: Most service user are semi independent in personal care, needing only prompting and supervision. Service user plans included these needs. There was evidence on files that service users health needs are met. A record is kept of visits to professionals and an account of the consultation. We noted that there was not a health action plan or a list of health needs for each service user. It was agreed with the manager that an existing record could be adapted to show the health needs of each resident. In this way workers will not be relying on their own knowledge of the person, or verbal handover of information from other staff. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 17 We inspected the arrangements for the administration of medication. All but one resident store their medications in their rooms. We looked at the medication for one service user. Most medication is dispensed in blister packs but some tablets are in containers. We balanced the stock of one such medication. The home enters an S in red pen on the MAR sheet on the day a medication is started but it would be helpful to have a balance brought forward figure recorded at the start of the MAR chart so that balances can be checked. We recommend this. We noticed that the Medication Administration Record (MAR) sheet had not been signed on two occasions on one day, but a line put through the box where the initials should be written. We brought this to the attention of the manager. Medications are recorded into the home on the MAR chart. The deputy manager stated that the practice is when medicines are disposed of back to the pharmacy, the pharmacist signs the MAR chart to acknowledge receipt. There was no evidence of this and a requirement has been made. There is no other system in place for the recording of medicines disposed of. We were told by a staff member that when a medication is refused the procedure is for details to be entered on the back of the MAR chart. However there was evidence that medications had been refused and no details recorded on the back of the chart. The manager must ensure that the medication policy and procedure of the home regarding refused medication, is followed. The home does have a form for the recording of afterlife arrangements but it had not been completed on the file of one service user. The opportunity to record views regarding afterlife care must be offered to every service user. It was noted on the afterlife arrangements of one service user that they had indicated they would like to make a Will. This must be followed up. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to express their views and any complaints and are protected from abuse. EVIDENCE: The home has a complaints policy, and complaints information, which were viewed and were satisfactory. In surveys service users told us that they know how to complain and they told the expert by experience that they werent afraid to speak out. The home has a protection of vulnerable adults policy, procedure and guidance. It also has a whistleblowing policy. The home now has copy of the local authority policy, to follow in conjunction with its own policy. Wakeling Court DS0000063897.V369227.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 and 30. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is safe and comfortable, clean and hygienic. EVIDENCE: We undertook a tour of the communal areas of the home. It has a comfortable safe environment. The décor is in good condition and there is a relaxed atmosphere. We observed that service users as well as spending time in their studio flats, use the whole home, sitting down in the lounge to relax for a while, chatting in the smoking den and walking around the garden. The home has contract cleaners and the standard of cleanliness was good. It is clean and hygienic and was free of offensive odours. Some residents are incontinent and the arrangements for laundry can support this. The laundry is Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 20 in a separate unit and no soiled laundry has to be carried through food preparation or dining areas. Wakeling Court DS0000063897.V369227.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 and 35. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The staff are competent and qualified but they need to undertake refresher training in basic topics regularly. Staff are well supported and supervised. EVIDENCE: The home employs 6 permanent full time staff, 4 part time staff, two full time deputy managers and a manager. All staff have NVQ level 2 or above. Bank staff are used to cover annual and sick leave and if not available agency staff. However the home limits the use of agency staff to those who have worked at the home before. We looked at three staff files. The recruitment practices of the home are safe and robust. Professional references are taken up and Criminal Records Bureau disclosure (CRB) undertaken. The actual disclosure is kept at the human resources office but the serial number is entered on the staff file. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 22 The expert by experience made a suggestion to the manager verbally and in her report, as follows: I asked if residents were involved in the recruitment process, such as interviewing prospective members of staff and the manager said that several residents had indicated their willingness to participate then were overcome with anxiety and dropped out. She said there was a pool of service users that East Living used for this purpose from other homes and I suggested that in future at Wakeling Court residents could be involved in staff interviews in an observer capacity initiall, in order to increase their confidence in the process and allay their fears. There was evidence that staff are supervised regularly and also receive annual performance appraisal. We looked at the training records for staff. Staff have induction training and undertake other relevant training but it was evident that they have not had up to date training in core basics, which we would expect to be renewed annually. The manager must ensure that staff all renew their training in core basics annually including First Aid, unless the certificate indicates otherwise. We interviewed a staff member. He told us about his background which encompassed much relevant work in social care. He confirmed that he had had induction and other training with the organisation, also regular supervision. He told us that he really enjoys working with the service users. The interaction which we observed between staff and service users was pleasant and supportive. Wakeling Court DS0000063897.V369227.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 and 42. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is well run and the views of service users are taken into account. There were shortfalls in this area. Notifications must be made appropriately, the new manager must apply to the CSCI to be registered and the arrangements for COSHH need to be strengthened. Policies need to be updated. EVIDENCE: The home has a new manager. She has a registered managers award and also NVQ level 4 in care. She has relevant experience having manager other Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 24 services. The manager must ensure that she registers with the CSCI without delay. The home is well run with structures and systems in place to support the work. However during the course of the site visit two incidents were mentioned which occurred and which should have been notified to the commission under regulation 37, and were not. The manager must ensure that she makes all necessary notifications to the CSCI. As mentioned in the summary, we received a number of surveys from service users. These were mainly completed with the help of staff. We suggested to the manager that service users should be supported with their feedback by more independent people outside the home like advocates, relatives or friends. She said that she would bear this in mind for next time. The manager stated that service users have a meeting every week and any quality issues raised there are addressed. The home has a business plan which we viewed. We also viewed two new resident feedback forms. The home has regulation 26 Person in Control visits from an independent manager. The quality assurance in the home is satisfactory. We noted that some of the policies and procedures for the home have not been updated recently. The confidentiality policy was last updated in March 2006, needs and risk management policy was last reviewed in May 2005 and there is no policy for the use of volunteers. There is a volunteers strategy which was supposed to be reviewed in February 2008 and was not. The home welcomes volunteers and has two visiting regularly. We feel that there should be a managing volunteers policy. We understand that the manager works with organisational policies and cannot produce her own, but recommend she raises this matter with her senior managers. We looked at the arrangements for COSHH. The products are kept locked away but there were not data sheets for all the products stored. Out of a random selection of three products only one had a corresponding data sheet. The manager must ensure that there are data sheets available for all the products stored. We looked at the Fire assessment and the policy procedure and guidance. The manager stated that emergency lighting and fire alarm are tested monthly and we saw that records are kept. Fire drills are held three monthly and one a year is at night. On the day of the visit the outside contractor was in repairing a fault in the emergency call system. The safety certificates for the hardwiring of the home was in date as was the testing of portable appliances. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 25 Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 x 34 3 35 2 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 3 2 2 2 2 x 3 x x 2 x Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The manager must ensure that the statement of purpose is amended as follows: to give the name of the new manager, to update the smoking arrangements, and to state the correct number of staff. The manager must verify whether the fire brigade conduct an annual unannounced visit and if this is not the current arrangement the statement must be deleted from the document. 2. YA9 13(4)(c) The manager must ensure that a risk assessment is completed for every risk identified. The manager must ensure that the health needs of residents are recorded, so that they can be fully met. The manager must ensure that medications are safely DS0000063897.V369227.R01.S.doc Timescale for action 01/10/08 01/10/08 3. YA19 13 (1)(b) 01/10/08 4. YA20 13 (2) 10/09/08 Wakeling Court Version 5.2 Page 28 5. YA20 13(2) 6. YA20 13(2) 7. YA21 14 administered, and MAR charts are signed on every occasion. The manager must ensure that a signature is obtained from the pharmacist when medicines are returned to the pharmacy. The manager must ensure that the medication policy and procedure regarding refused medication, is followed by staff. The manager must ensure that all residents are offered afterlife needs assessment. (This is a restated requirement previous timescale of 01/02/07 not met). 10/09/08 01/10/08 01/10/08 8. YA21 14 9. YA35 10. YA37 If a service user indicates on their afterlife arrangements that they would like to make a Will, this must be followed up with staff offering the necessary support. 18(1)(c)(1) The manager must ensure that staff renew their training in core basics annually including First Aid, unless the existing certificate indicates otherwise. 9 The manager must ensure that she registers with the CSCI without delay. 37 The manager must ensure that she makes all necessary notifications to the CSCI under regulation 37. The manager must ensure that there are data sheets available for all the COSHH products stored. 01/10/08 01/10/08 01/10/08 11. YA37 10/09/08 12. YA42 13 (4) (a) 01/10/08 Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 29 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 YA14 YA20 YA17 Good Practice Recommendations The home should broadband internet access in a communal area of the home. The manager should ensure that a brought forward figure is recorded on the MAR chart for medications not in blister packs We recommend that fruit or any other course is presented to look as appealing as possible, and with as much choice as possible. Wakeling Court DS0000063897.V369227.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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