Inspection on 03/03/08 for Dunton Road, 71-73

This is the latest available inspection report for this service, carried out on 3rd March 2008.

CSCI found this care home to be providing an Good service.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunton Road, 71-73 01/12/05

Dunton Road, 71-73 03/08/05

Dunton Road, 71-73 02/03/05

Dunton Road, 71-73 27/07/04

Dunton Road, 71-73 30/03/04

Dunton Road, 71-73 27/01/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Dunton Road, 71-73 71-73 Dunton Road Bermondsey London SE1 5TW Lead Inspector Keith Izzard Unannounced Inspection 3 March 2008 11:15 rd Dunton Road, 71-73 DS0000007100.V359939.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 Dunton Road, 71-73 DS0000007100.V359939.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. Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunton Road, 71-73 Address 71-73 Dunton Road Bermondsey London SE1 5TW 020 7232 0016 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) yemi.ojumu@threecs.co.uk Three C`s Mrs Yemi Ojumu Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Dunton Road, 71-73 DS0000007100.V359939.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: 7 27th June 2006 Date of last inspection Brief Description of the Service: The home provides care for up to seven people with mental health issues. This home is made up of seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues as it is on the ground floor. There is no lift in the home. The bedrooms meet the space requirements of the standards as does the communal space. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. The home is close to several bus routes into central London and the surrounding area. The Old Kent Road, which offers shopping facilities, pubs, restaurants and a large supermarket is close by. There are a number of smaller shops and a Post Office in Dunton Road. On the day of the inspection there were no vacancies The home makes the reports of the Commission’s inspections available in the staff office. Dunton Road, 71-73 DS0000007100.V359939.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 site visit for this unannounced inspection was completed over a period of six hours on 3rd March 2008. We were assisted by four members of staff the manager and a regional manager, all of whom provided information in a constructive and helpful manner. All but two of the residents were seen as one was on holiday and another visiting a relative. The service was last inspected in February 2006. At the previous inspection 23 requirements were made of which 21 had been complied with two partially complied with and one not complied with. This is a commendable response from the new manager and her staff team. The inspection included a review of information received about the service, a tour of the premises, a detailed examination of written records, including care plans, talking to and observing two residents’ interaction with members of the staff team. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: Residents were involved in the day-to-day running of the home. They were also encouraged to speak up and to say what they wanted and they did this at the regular residents meetings. Residents either attended day centres or took part in other regular activities. They had received good health care and medication was safely dealt with. The home was comfortable and spacious and their bedrooms were personalised and full of their personal possessions. Three residents who were spoken to said that staff treated them well. The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. Good attention was given to meeting resident’s individual needs and also to provide residents with leisure and social activities. Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The following requirements were made: Care plans and reviews of care plans, including” CPA” reviews, must all be signed by residents. An extractor fan must be installed to expel stale smoke from the smoking room. The carpet in the hallway stairs area must be replaced and sturdy curtain rails installed throughout the home. The kitchen units and work surfaces must be replaced to ensure adequate cleaning and maintenance of good hygiene. The Registered Individuals must ensure that both management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained. This was the subject of two previous requirements, not complied with by 31/03/06 & 31/08/06. The manager must ensure that there is an annual survey of the views of service users, their relatives/ advocates and any professionals involved with service users. This survey must be made public and a copy sent to CSCI. The following recommendations were made: Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 7 The home should undertake its own six monthly review of care plans and ensure that updating assessment reports completed by staff members are always dated and signed. The manager should ensure that updating assessment reports completed by staff members are always dated and signed. It is recommended that the manager has the flexibility to commission training from other external sources if specific needs are identified that could be met in this way. The manager was advised to request an inspection from the London Borough of Southwark Environmental Health Office, as one had not occurred for some time. The manager was advised to request an inspection from the London Borough of Southwark Environmental Health Office, as one had not occurred for some time. It is recommended that the combined post of chef/cleaner be reviewed to consider whether this particular dual role is acceptable. It is recommended that records of fire drill records clearly state all staff members and residents who were in attendance at the time and detail any significant outcomes. 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. Dunton Road, 71-73 DS0000007100.V359939.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 Dunton Road, 71-73 DS0000007100.V359939.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&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information is provided to enable residents to make an informed choice prior to admission to the home. Residents’ needs are assessed to ensure that their needs can be met. EVIDENCE: Standard 1 There was a previous requirement that the Registered Manager must ensure that all service users are issued with the up-to-date service user guide and a copy of the housing association’s tenants’ handbook. We saw copies of both the Service User Guide and updated Statement of Purpose; both documents complied with this Standard. Standard 2 The personal care files of two service users were examined. These included detailed referrals comprising assessments completed as part of the care management process and reports from professionals such as psychiatrists, and Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 10 other therapists. Both the files included a care plan and the provider stated that the care planning and risk assessment process starts before admission to the home and takes up to one month to fully complete. Both service users had clearly been involved in the setting up of their care plans and had signed them. There was a previous requirement that the Registered Individuals must ensure that the staff team and potential referral sources are clear about the admission criteria and levels of need the home can work with. Goals for development had been clearly identified and the process by which care staff members would achieve them and reviews of care clearly scheduled with input from both Community Psychiatric Nurses and care management. Dunton Road, 71-73 DS0000007100.V359939.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users care plans show that they have been involved in their compilation however the CPA reviews of care plans must be signed personally by individual residents. Service users are supported to make their own decisions. Risks are identified and managed safely. EVIDENCE: Standard 6. Two care files and individual plans were examined in respect of both residents case tracked. Individual plans were comprehensive and involved both residents and their representatives, including family or advocates and other professionals involved, as appropriate. These plans are reviewed annually with outcomes clearly stated and agreed by all participants. However, it was noted Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 12 that annual CPA reviews of care were not personally signed by residents, this must occur in order to evidence their agreement with the ongoing care plan. See Requirement 1 It is further recommended that the home undertakes its own review six monthly, between annual reviews, inviting all professionals and relatives involved and record any apologies for non attendance should this frequency not be sustainable for some relatives or involved professionals. It was also noted that a number of updating assessment reports on residents, compiled by staff members had been well completed but not signed and dated the manager acknowledged this should be done. See Recommendations 1 & 2 Records seen were, otherwise comprehensive and up to date and records included appropriate risk assessments. Where risks were identified procedures and care plans reflected how these were being managed, for example some residents only go out when accompanied by a staff member or relative, because of concerns regarding their vulnerability, this being part of an agreed CPA programme. Standard 7 Service users are encouraged to make decisions wherever possible in respect of activities, food, domestic tasks, the décor and layout of their rooms, their personal appearance and clothes they choose to wear. One service user interviewed stated that she had chosen the colour scheme for her room and her and had helped decorate the room. Two residents’ rooms were seen and both all were personalised. Standard 9 Independence is promoted where possible. Risk assessments were available in both residents’ care files and are readily available for all staff members in order to assist with the identification and implementation of individual needs of residents. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of service users, as identified in Standard 6 above. Evidence was available from the service user’s records examined and from discussion with both service users that they are enabled to express choice in what they do. Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 13 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 14 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. Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences EVIDENCE: Standards 11-14 All residents have an individual programme of appropriate and stimulating activities within and outside of the home. Good efforts had been made by staff members in providing weekly programmes of activities for residents, that overall have improved since previous inspections. Residents are encouraged to attend local centres for activities and in-house there is a music group and an art group. Two residents attend day centres one of which is an AfricanCaribbean day centre and therefore meeting cultural needs. Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 15 All residents receive either a week’s holiday or the equivalent in day trips and additionally other day trips are provided for all residents. Most service users can come and go from the home as they choose but where they are not able to as advised by their individual risk assessments they are supported by staff members to go out and be part of the local community. Standard 15 Families are involved in the home as much as possible and can visit when they choose. We noted that commendable efforts had been made by staff members to re-establish family contact for one resident estranged from her family for some time. One resident also maintained an ongoing relationship outside of the home and had received appropriate and caring support and guidance in this respect from staff members. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. Clear instructions are readily available on an individual basis for any reduced fat or low sugar diets applicable to service users and culturally appropriate food provided as required. Dunton Road, 71-73 DS0000007100.V359939.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 &21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive flexible personal support. The physical and mental healthcare needs of service users were met. The medication system for the home was well organised and recorded. EVIDENCE: Standard 18 Neither service user case tracked requires physical assistance with their personal care other than some prompting by staff members to adequately maintain personal hygiene, and encouragement by staff members to boost self esteem and personal appearance. All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. Two service users interviewed commented that staff members treated them appropriately and assisted them with personal care when necessary. A previous requirement to ensure that care Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 17 plans in the area of personal care are reviewed so that they set realistic goals for service users was complied with. Standard 19 All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained with the local mental health team to support staff with meeting service users’ needs. Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example, individual therapy, CPN, Psychiatrist and Dietician. Standard 20 Both residents interviewed stated that they were happy for staff members to assist them with their medication and did not express any desire to self medicate. In one instance this would not be advisable in any case. The medication system was examined and was appropriately organised; medication was stored in a locked cabinet and quantities and dosage of medication tallied with the MAR sheets examined. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist; Boots had also provided regular audits and training for staff members. It was pleasing to note that a number of previous requirements to do with medication madder at the previous inspection had all been complied with. Dunton Road, 71-73 DS0000007100.V359939.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. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. Only two minor complaints had been made to the provider since the previous inspection and whilst these had been dealt with satisfactorily the manager was advised how recording could be better organised. See Recommendation 3 No have any complaints had been received directly by the Commission. Some residents have the capacity to raise concerns and three residents we interviewed commented that they were happy within the home and had no complaints but would know who to complain to if they ever needed to do so. The complaints procedure is prominently displayed within the home and produced in easily understandable language, as well as within the updated Service user Guide. Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 19 Standard 23 The home had policies and procedures in relation to adult protection and as whistle blowing policy. No allegations of abuse had been made to the provider or the Commission since the last inspection. The home had a copy of the London Borough of Southwark Safeguarding Adults Protection Procedures and all staff members had read the procedures and signed a document to evidence this. Those staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. All staff had received training this area, although one was booked for a refresher course, and it this area had been discussed in team meetings, thereby complying with a requirement made at the previous inspection. Dunton Road, 71-73 DS0000007100.V359939.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and pleasant environment although some attention is needed to refurbishment in some areas. The home was clean and hygienic but kitchen units need replacement to facilitate effective cleaning and hygiene. EVIDENCE: Standard 24 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 21 The home was clean, bright and comfortable. Bedrooms were spacious and personalised, and there was ample communal space for service users. However, the smoking room must be provided with an extractor fan. See Requirement 2 The carpet on the stairs and hallway requires replacement and sturdier curtain rails are required throughout the home. See Requirement 3 It was recommended that the combined post of chef/cleaner be reviewed to consider whether this particular dual role is acceptable. See Recommendation 4 Standard 30 The Home was clean and tidy on the day of the inspection, and liquid soap and towels was available in the bathrooms and toilets. The kitchen work surfaces were clean and tidy with utensils and equipment appropriately stored. All cleaning materials were locked away and subject to COSH procedures. The kitchen cupboards and work surfaces must be replaced in order to comply effectively with hygiene requirements, as they were in a poor state of repair and difficult to clean effectively. See Requirement 4 The manager was also advised to request an inspection from the London Borough of Southwark Environmental Health Office, as one had not occurred for some time. See Recommendation 5 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 22 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): 31,32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clarification is still required of job descriptions for the benefit of both residents and staff members. The home’s recruitment practices were satisfactory. Staff training was comprehensive and a high level of staff members qualified at or above the minimum Standard requirement had been achieved. EVIDENCE: Standard 31 There was a previous requirement made regarding clarification of job descriptions, please see Standard 37. See Restated Requirement 5 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 23 Standard 32 From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite skills, attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions. Standard 34 Two personnel files were examined for staff members and recruitment practice were found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Proof of identity and photos were included on the personnel files and also evidence obtained of the physical and mental fitness of workers had been complied with. Two members of care staff were interviewed and both stated that they had received a thorough recruitment and induction programme when they commenced working at the home. Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. At this inspection we were informed that all of the care staff have achieved NVQ level 2, thereby exceeding the required level of 50 required to be trained to this level. The manager provided evidence of a training plan for the year 2008-2009 and this was comprehensive. All staff members had received induction and foundation training and had, in place, an individual training and development plan and an annual appraisal. It was noted that the training provided was confined to that provided by the local authority and it is recommended that the manager has the flexibility to commission training from other external sources if specific needs are identified that could be met in this way. See Recommendation 6 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 24 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. Service users benefit from a well run home. Surveys of residents’, relatives’ and professionals’ views on the running of the home must be conducted annually and made publicly available. Regulation 26 visits were conducted monthly and reports retained within the home. The health and welfare of service users is promoted and protected. EVIDENCE: Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 25 Standard 37 The Registered Manager is very experienced and has the necessary NVQ4 qualification. Staff members interviewed stated that the manager is approachable and supportive, had a good rapport with residents and they would not hesitate to discuss any concerns about the home or the welfare of residents with her. Residents interviewed were equally positive. Communication within the home was of a good standard with team meetings held regularly and the manager, overall, complies with the requirements of Standard 37. However, there was a previous requirement that the Registered Individuals must ensure that both the manager and deputy management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained to the staff team. The manager stated that this had not yet been fully completed although this was in progress. This is a restated requirement and must be implemented as soon as possible. See Restated Requirement 5 Standard 39 Residents are involved in regular weekly meetings and are encouraged to express their views on the running of the home and the service provided for them. The recorded minutes of the meetings provided evidence that residents are encouraged to participate in this process. However, the home must ensure that there is an annual survey of the views of service users, their relatives/ advocates and any professionals involved with service users. This survey must be made public and a copy sent to CSCI. See Requirement 6 Visits to check on the quality of service provided by the home had been made by the Responsible Person, on a regular monthly basis, as required. The reports of these visits were readily available for inspection within the home, as required. Standard 42 A number of records to do with safety and maintenance were seen by the Inspector and were found to be up to date and well recorded and in accordance with information supplied within the pre inspection questionnaire. The manager confirmed that all staff had annually updated fire training. The Inspector recommended that records of fire drill records clearly state all staff members and residents who were in attendance at the time and detail any significant outcomes. See Recommendation 7 Dunton Road, 71-73 DS0000007100.V359939.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 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 3 X 3 X 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 X 2 X 2 X X 3 X Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 27 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. 2 3 Standard YA6 YA24 YA24 Regulation 15 24 (2) p 24 (2) b Requirement Care plans and reviews of care plans, including” CPA” reviews, must all be signed by residents. An extractor fan must be installed to expel stale smoke from the smoking room. The carpet in the hallway stairs area must be replaced and sturdy curtain rails installed throughout the home. The kitchen units and work surfaces must be replaced to ensure adequate cleaning and maintenance of good hygiene. The Registered Individuals must ensure that both management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained. Previous requirement: Unmet timescales 31/03/06 & 31/08/06 The manager must ensure that there is an annual survey of the views of service users, their relatives/ advocates and any professionals involved with DS0000007100.V359939.R01.S.doc Timescale for action 01/06/08 01/08/08 01/08/08 4 YA30 23 c 01/08/08 5. YA37 18 (1) (a) 01/08/08 6. YA39 12 (1) (2) (3) & (4) & 24 01/08/08 Dunton Road, 71-73 Version 5.2 Page 28 service users. This survey must be made public and a copy sent to CSCI. 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. 4. Refer to Standard YA6 YA6 YA22 YA22 Good Practice Recommendations The home should undertake its own six monthly review of care plans and ensure that updating assessment reports completed by staff members are always dated and signed. The manager should ensure that updating assessment reports completed by staff members are always dated and signed The manager should ensure that any complaints are recorded to clearly indicate whether they are substantiated or partially substantiated or not substantiated. It is recommended that the combined post of chef/cleaner be reviewed to consider whether this particular dual role is acceptable. The manager was advised to request an inspection from the London Borough of Southwark Environmental Health Office, as one had not occurred for some time. It is recommended that the manager has the flexibility to commission training from other external sources if specific needs are identified that could be met in this way. It is recommended that records of fire drill records clearly state all staff members and residents who were in attendance at the time and detail any significant outcomes. 5. YA30 6. YA35 7. YA42 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Dunton Road, 71-73 DS0000007100.V359939.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!