Inspection on 07/04/08 for Downs Park Road (93)

This is the latest available inspection report for this service, carried out on 7th April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Downs Park Road (93) 19/12/06

Downs Park Road (93) 30/11/05

Downs Park Road (93) 19/04/05

Downs Park Road (93) 28/10/04

Downs Park Road (93) 13/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Downs Park Road (93) 93 Downs Park Road Hackney London E5 8JE Lead Inspector Nurcan Culleton Unannounced Inspection 7th April 2008 10:00 Downs Park Road (93) DS0000010267.V361299.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 Downs Park Road (93) DS0000010267.V361299.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. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downs Park Road (93) Address 93 Downs Park Road Hackney London E5 8JE 020 8533 5340 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) downspark@hilt.org.uk Hackney Independent Living Team Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. House not to be left unattended when any tenant is in the house. A worker will always be available by radio pager when house is empty 8th July 2007 Date of last inspection Brief Description of the Service: 93 Downs Park Road is a care home offering support, personal care and accommodation to a maximum of four service users who have learning difficulties. The home offers support 24 hours a day. The home is a large three-storey terraced house situated in a residential area of Clapton, in the London Borough of Hackney. The home has good bus links and is within walking distance of local shops, and amenities. Hackney Independent Living Team, (HILT) manages the home, which is a voluntary sector provider of care services. The rate of fees charged by the home varies according to individual needs and currently starts at £1220 per week. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 07th April 2008. The inspection involved discussion with the new manager who has been in post since December 2007; discussion with a support worker; observation of the interaction between staff and two people living in the home. An examination of the homes records and documents was undertaken, including individual people’s files and staff files. A tour of the premises took place at the time of inspection. Also undertaken into account was the homes’ existing AQAA and three surveys, one from an individual in the home, one from a relative and one from a staff member, whose views are incorporated. What the service does well: What has improved since the last inspection? A new and experienced permanent manager has been appointed who intends to make an application to become the Registered Manager, providing stability and leadership to the home. Care plans have been revamped and are following the Person Centred Planning approach, focusing the service to the needs of the individual which is likely to have improved outcomes for them. The majority of requirements from the previous inspection have been met. Staff now receive regular supervision, care plans have been reviewed, health care needs are well recorded, staff are undertaking NVQ training and staff files contain necessary employment documents. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 6 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. Downs Park Road (93) DS0000010267.V361299.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 Downs Park Road (93) DS0000010267.V361299.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): 1-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and people currently using the service are provided with sufficient information about the home to enable them to make an informed choice about whether to move into the home. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service Users Guide in place. The Statement of Purpose describes the philosophy of care provided stating that “People will make informed choices about how their service is provided … and make their own decisions.” The Statement also includes details of the aims and objectives of the home, the organisational structure, and details of the staff team and their qualifications. The Statement is written in plain English, and is subject to review. The Service User Guide is produced in plain English and pictorial form. The Guide contains essential information about the home, including the homes’ physical environment and the complaints procedure. Brochures are also available providing information about Hackney Independent Living Trust (HILT), the organisation that runs the home. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 9 There have been no new admissions to the home since the previous inspection. Previous records seen have evidenced that appropriate pre admission assessments have been carried out in the past. The home has an admissions procedure stating that pre admission assessments would be carried out on any referrals, and that prospective service users should be given the opportunity of visiting the home prior to making a decision as to move in or not. A survey received as part of this inspection from a person living in the home indicated that they were asked if they wanted to move to the home and had received information about it. All service users are provided with a tenancy agreement in line with National Minimum Standards. These include details of the fees charged, the accommodation provided and of the rights and obligations of both parties. Downs Park Road (93) DS0000010267.V361299.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): 6-10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service are enabled to communicate their choices of activities and assisted to maintain control in their daily lives. Care plans have been improved and give consideration to meeting people’s individual and diverse needs. EVIDENCE: All three people living in the home had care plans in their files. These had been drawn up with from the available knowledge and involvement of the individual, their relatives and staff from the home. Care plans seen had been subject to review. Care plans have been restructured as part of a new system of Person Centred Planning (PCP) which has now been introduced in the home. These were seen colourfully displayed on individual bedroom walls, including pictures Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 11 and symbols and the ‘dreams’ or aspirations of the individual. The PCP work culminates in action plans available on the computer and seen in individual folders. Plans addressed issues around equalities and diversity, for instance around disability and religion. Two individuals are supported to attend church of their choice every Sunday. One individual had expressed an interest to go on holiday which she identified through pictures and by the homes’ communication with her aunt who knows her well as the individual is nonverbal herself. This is recorded as a target in her action plan and the Manager discussed about planning a holiday for this year. PCP is a positive development in the home putting the people using the service at the centre of service planning and tailoring the service holistically to identify and meet each individuals’ needs. Statutory and internal reviews are taking place regularly and a decision has been taken to conduct them at the same time, at least once every six months. Risk assessments are in place and seen for all service users, and these have been subject to regular review. They contain clear information and instructions on how identified risks can be managed and reduced. The format of risk assessments is also under review to integrate them into the PCP process. There is evidence that the home has taken steps to address equalities and diversity issues with regard to communicating with service users. Some service users have some signs they use to communicate and staff were observed to have developed a good understanding of this. The home makes good attempts to communicate with people in the home. For one resident whose first language is Arabic is the home has various key phrases on display for example “Would you like a drink” in Arabic to aid communication with this resident. There is also a phrase book in Arabic and English and an Arabic cook book in the kitchen. The home holds weekly meetings for individuals in the home, the records of which show engagement with individuals in choosing and planning their activities. However minutes of the last meeting were dated 19/03/08. The support worker spoken to informed that staff may be writing the minutes elsewhere. See recommendation 1. The homes menu is planned for the week during these meetings, and an extensive picture card system is used to enable service users to choose and plan their own menu. Pictures are also used to help plan leisure activities and holidays. The home has a confidentiality policy in place. This makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Confidential records are stored securely, and staff and service users can access their records as appropriate. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 12 Downs Park Road (93) DS0000010267.V361299.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): 11-17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals are supported to live valued and fulfilling lives and have regular access to activities of their choice in the local community. EVIDENCE: Individuals are encouraged to maintain their independence as much as possible. Activity logs show that people are supported to help with hovering, laundry and cleaning their bedrooms at weekends and preparing lunch, such as peeling potatoes, making tea or light a light snack. The service ensures that individuals have regular activities both in the community and at home. One person who is of Caribbean ethnic origin likes to Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 14 eat at a local Caribbean restaurant, while two service users are supported to attend church on a weekly basis in line with their religious beliefs. Other regular activities include visits to the cinema, pubs, cafes, bowling and parties organised by the home and by other HILT projects. People continue to be supported in activities to help promote a healthy lifestyle, including for example, swimming. The home’s weekly activities plan was on display within the home. A range of activities are available in the house, including television, music and dancing and cards. The manager informed that as people lead active lives in the community they tend to opt for more relaxed activities at home. One individual has a range of tactile objects available to her which she enjoys, as recommended by the Occupational Therapist. Another individual who likes to play the keyboard was supported to purchase his own electronic keyboard in their bedroom after a recommendation received from his day centre. Following an unsettled period last year in management arrangements, residents did not have an annual holiday last year, however a new manager is now in place and a holiday is being planned for this year. Individual have access to suitable day services. These day services provide opportunities to develop and maintain relationships, and also the opportunity to participate in a variety of activities, such as gardening and art classes. Two individuals were attending day services on the day of the inspection and the other two individuals who were at home were due to go out to access activities or visit places of their own choice in the community with support from workers from a community resource service. Local community facilities, such as shops and banks, and use public transport networks are accessed. People are involved in the day to day routines of the home, as detailed in their PCPs and activity plans, including setting the table for lunch, help with the washing up, assisting with tidying bedrooms and their laundry. Visitors are received at any time and in private if individuals’ wish. People maintain links with their family and friends, visiting their family on a regular basis. One person stays overnight with their family at weekends on a weekly basis and other people stay overnight on an occasional basis. Individuals are given their own mail to open, and have access to a telephone, which they can use in private. Records are kept of menus, and these indicated that service users are offered a varied, balanced and nutritious diet. The home actively encourages people to eat healthily, for example, assisting to manage one person’s weight issues by not having sweets or crisps in the house. The home prepares culturally appropriate food, for example Caribbean cuisine, and ensures that other ethnic foods are also cooked on a cultural day once a week. There was evidence that Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 15 fresh produce is routinely used in cooking. Fresh fruit was available on the day of inspection. Individuals are involved in food preparation, including buying the food. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. Downs Park Road (93) DS0000010267.V361299.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): 18-21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals’ personal support and health care needs are generally met in the home. The home must seek to identify people’s wishes in respect of terminal illness and arrangements in the event of death to ensure their wishes are respected. EVIDENCE: Individuals are supported to manage their own personal care to help promote and develop independence as in line with their action plans. The home has a log book which records individuals’ daily activities where support has been offered, including personal care, medication, medication, attendance at a day centre, and where support is refused, planned, completed, refused or substituted. People are able to choose their own clothes to wear, and were appropriately dressed on the day of inspection. Female staff always gives any personal care Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 17 provided to females in the home. The home has a key-worker system to help ensure continuity of care and all service users have an allocated key-worker. Individuals are registered with a GP and detailed records are maintained of medical appointments, including details of any follow up action necessary. These show that people have access to a variety of health professionals, including dentists, chiropodists and opticians. The home has an appropriate medication policy, and medications were stored securely in a locked cabinet inside the office. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record charts are maintained and were up to date and accurate. Most staff who administer medications have had appropriate training in this area. The manager has recently undertaken a training needs analysis form which has identified whether any staff require refresher training as regards medication. The form has been sent to the training needs co-ordinator at HILT. The home is now also required to have a Controlled Drugs cupboard for the storage of Controlled Drugs that meets the requirements of the Misuse of Drugs Regulations 1973. At the previous inspection it was highlighted that the home must be seek and record individuals’ views on the arrangements to be made in the event of their death as this information was not available for all. The manager informed that it had been difficult to obtain this information from families given the sensitivity around it, particularly for one family who had been bereaved. This information must be sought in the best interests of the individuals living at the home, as required at the previous inspection. Downs Park Road (93) DS0000010267.V361299.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): 22-23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The complaints procedure is made available to people who use the service leading. The lack of complaints demonstrates that people are largely satisfied with the service. The adult protection policy has not been updated as previously required. EVIDENCE: The home’s complaints procedure has been produced in pictorial form to help make it more accessible to the people using the service. It includes timescales for responding to any complaints received making appropriate reference to the CSCI. There were no recorded complaints in the homes’ complaints log and the inspector was informed that no complaints have been received since the previous inspection. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. At the last inspection, it was required that the policy is amended to state that the host local authority of Hackney rather than the referring local authority has lead responsibility with regard to any allegations of abuse. Additionally, the policy and procedure does not have the correct contact details of the CSCI and must again be updated. Staff have Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 19 received POVA training and through their NVQ courses. However additional training is being planned through HILT. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 20 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 environment is comfortable and homely for people using the service. Adequate communal and private space is provided. Whilst the home is generally well maintained, there are some maintenance issues that must be addressed to further improve the appearance of the environment and to ensure it is safe for people in the home. EVIDENCE: The home is a terraced house situated in a residential street convenient to local amenities and transport. The house is well maintained externally, although internally at the time of the inspection, some maintenance issues were identified as follows: Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 21 A hole in the roof of the hallway in the basement to be repaired following a leak from the boiler on the first floor. The manager informed that this hole has now been fixed after the inspection and during the writing of this report. Decoration/repair to the walls in the laundry room where the paintwork is chipped. Decoration/repair to the bathroom walls on the first floor. Taps spitting out air and running cold water for long periods in people’s bedrooms. These must be addressed, both to help ensure the health, safety and welfare of service users and others, and to ensure that they live in a homely environment. It was noted at the last inspection that taps in individual’s bedrooms were “push” taps, i.e. to get them to work, it is required to press down on the top of the tap, rather then turn the tap. This means that water only comes out of the tap for a very limited period of time before they have to be pressed again, thus causing an inconvenience during personal care such as shaving or brushing teeth. The manager and support worker informed that these push down taps were preferred to running taps due to the fact that an individual once flooded a bathroom by leaving the tap on. Window restrictors are now in place throughout as previously required. The home is built over three floors. Communal areas consist of a sitting room, a kitchen/dining area and a garden. The garden was well maintained, with appropriate garden furniture. The home was well decorated a the time of inspection and communal fixtures and fittings were well maintained and domestic in character. Bedrooms meet National Minimum Standards as regards size requirements and contain adequate furniture, including table, chairs, chest of draws and a wardrobe. Carpets, curtains and bedding were well maintained and domestic in character. Bedrooms had been personalised with family photographs and personal possessions and decorated to suit individual tastes, including one person’s room which was decorated as chosen by her. Bedrooms have adequate natural light and ventilation. All bedrooms are centrally heated and radiator covers have now been ordered, though this has been outside of the timescale for a requirement given for this at the last inspection. Bedrooms were clean and tidy, and service users have responsibility for keeping their rooms tidy. The home has two bathroom/toilets, and a single toilet. Both baths also have showers fitted, thus people have a choice of bath or shower. Bathrooms were Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 22 clean and tidy and a lock has been fitted to the bathroom on the second floor as previously required. However it was noted that the bathroom on the second floor was unwelcoming compared with the homely appearance of the bathroom on the first floor, which was pleasantly decorated with adornments on the walls, in contrast to the other bathroom. A metal cabinet used by staff which is also situated in the bathroom on the second floor further contributed to the lack of homely appearance of this bathroom. See recommendations. The home has a separate laundry room, with an impermeable floor covering. Laundry facilities are appropriate in scale for the home. Hand washing facilities are situated around the home, and protective clothing such as gloves and aprons are available to staff to help prevent the spread of infection. None of the current service users require any specialist adaptations around mobility. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 23 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): 31-36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are knowledgeable about the needs of people using the service and how best to support them individually. Staff are adequate in numbers and receive training and supervision to assist them further in their support duties. Staff training records and evidence of staff training must be available in the home. EVIDENCE: There are adequate numbers of staff on duty to meet the needs of individuals in the home. The staffing rota on display within the home accurately reflected the staffing situation on the day of inspection. The rota shows that the home provides 24-hour support and indicates that staff work flexible shift patterns, based around the needs of people using the service. It was apparent through observation and discussion that staff have built up good relations with people and that they have a good understanding of the individual needs of service users. The support worker on duty was observed to interact well with both individuals in the home in a friendly and respectful Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 24 manner. They were knowledgeable about the needs of individuals in the home and how best to support them and were clear about their role and responsibilities. The support worker confirmed that he had received a job description when starting his work. There is evidence that people are enabled and encouraged to do things for themselves where possible, for example making their own cup of tea and washing up afterwards. There is evidence that promoting independence is central to the work with people using the service. Staff have induction when commencing work at the home. Staff training records evidenced some training, though records of training undertaken were not comprehensive. Staff have previously undertaken training in fire safety, first aid, moving and handling and supervision skills, however training records must be brought up to date. It has been noted during this inspection that records of staff training were not fully available to satisfy requirements made at the previous inspection. The new manager who has been in post for three months has undertaken a training needs audit which has been sent to the relevant training officer in HILT responsible for organising the training. Some staff training records or certificates were available, however these were not comprehensive on the day of inspection. The manager provided dates of training scheduled for staff subsequent to the inspection in areas including medication, adult protection, first aid and working with people with learning disabilities, in particular, who have autism. As the new manager has started this process, training undertaken by staff will be further examined at the next inspection. Staff are enrolled on NVQ Level 3 courses. The home has various employment related polices in place, including recruitment and selection and equal opportunities. Staff employment files checked contained all necessary documents, including CRB checks and employment references, and ID. It was noted however that one staff file had a typed reference without a company stamp or complement slip or verification of the authenticity of the reference. See recommendations. With a permanent manager in place all staff now have regular and recorded supervision sessions and an annual appraisal. These evidenced discussions around training needs, performance and issues related to people using the service. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 25 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): 37-43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home continues to promote beneficial outcomes to people using the service. A newly appointed permanent manager with required skills and experience to perform her duties has brought more stability and leadership to the home. EVIDENCE: The home presents as having a warm and friendly atmosphere and a service which is responsive to meeting the needs of the people who live in the home. Following an unsettled period of management during the last year, a new permanent manager has been in post over the last three months. The manager Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 26 is undertaking her Registered Managers’ Award due to be completed shortly and informed that she intends to put in her application to become the Registered Manager of the service. The manager presents as being approachable, skilled and experienced in the field of social care and in management with relevant previous experience of management in residential homes prior to her management position in this home. The manager appears to have taken on board areas where improvements to the service may be needed. It was stressed that areas identified as requiring improvement in future inspection reports must be adequately responded to and within timescale if requirements are given to demonstrate that the service responds well to meeting the needs of people using the service. The home has copies of previous inspection reports available to view and there was evidence that the home has monthly unannounced Regulation 26 visits. Reports of these visits were available in the home, however the reports do not always promptly available to the home. See recommendations. The home has all necessary policies and procedures in place. These were of a generally satisfactory standard (with the exception of the adult protection procedure as stated elsewhere in this report). Other policies include equal opportunities, medication and recruitment and selection. All of these appear to be in line with National Minimum Standards. However all the homes’ policies and procedures, including the Statement of Purpose and Service Users Guide must be updated to include the new contact details of the CSCI for any correspondence or communications. Records within the home were stored securely, staff and service users can access their records as appropriate. Fire extinguishers are situated around the home. These were last serviced in May 2007. The home tests its fire alarms on a weekly basis and regular fire drills are held. The home had in date safety certificates for PAT testing and gas and water safety checks, however the electrical installation certificate was carried out in February 2003 and expired in February this year. See recommendations. COSHH products were stored securely and the home tests fridge and freezer temperatures daily. However, hot water temperatures could not be viewed as the log could not be placed at the time of inspection, however the support worker and manager informed that water temperatures are undertaken on a daily basis. Water tested in bathrooms appeared to be at a comfortable temperature. The home had in date employer’s liability insurance cover in place. Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 27 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 3 4 3 5 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 3 1 3 3 3 2 3 3 3 Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 28 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 A cupboard is required to be installed for the storage of Controlled Drugs that meets the requirements of the Misuse of Drugs Regulations 1973. The registered person must ensure that the home seeks and records the wishes of service users on the arrangements to be made in the event of their death. Timescale for action 14/07/08 2. YA21 15 18/06/08 3. YA23 13 The timescale of 30/09/7 has not been met. The registered person must 18/06/08 ensure that the home has an adult protection procedure which is in line with current legislation. The timescale of 30/09/07 has not been met. The registered person must ensure that the following maintenance issues are addressed: Radiators around the home must have appropriate protective coverings in place to reduce the risk of scalding. bathroom door. DS0000010267.V361299.R01.S.doc 4. YA24 23 18/06/08 Downs Park Road (93) Version 5.2 Page 29 5 YA35 18 1 (c) The timescale of 31/10/07 has not been met. Training records must be available in the home which demonstrate that staff receive adequate training to effectively carry out their duties. 18/06/08 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 YA8 YA24 Good Practice Recommendations Ensure that minutes of all residents’ meetings are up to date and available. Decorate the bathroom on the second floor to create a more homely atmosphere. Find an alternative storage location for the staff cabinet in this bathroom or have in place a different storage cabinet which does not detract from the homely appearance of the bathroom. Ensure that evidence is available that staff references are checked for their authenticity when letters are received without headed paper or complement slips. Ensure that Regulation 26 visit reports are made available to the manager after the site visits. 3 4. YA34 YA39 Downs Park Road (93) DS0000010267.V361299.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Contact Team 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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