Inspection on 22/01/07 for 137a Tentelow Lane

This inspection was carried out on 22nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

137a Tentelow Lane 10/07/07

137a Tentelow Lane 05/12/05

137a Tentelow Lane 16/05/05

137a Tentelow Lane 16/12/04

137a Tentelow Lane 13/07/04

137a Tentelow Lane 09/09/03

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 137a Tentelow Lane Norwood Green Southall Middlesex UB2 4LW Lead Inspector Sarah Middleton Unannounced Inspection 22nd January 2007 09:30 137a Tentelow Lane DS0000027763.V322656.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 137a Tentelow Lane DS0000027763.V322656.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. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 137a Tentelow Lane Address Norwood Green Southall Middlesex UB2 4LW 0208 893 6634 0208 893 6634 mettlelus@aol.com http/www.milburycare.com/home.html Milbury Care Services Limited 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) Manager post vacant Care Home 4 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the named service user, who is registered blind, can remain in the home so long as the home is able to meet the service user’s assessed needs and care plan. The establishment must inform CSCI when the service user no longer resides at the home. 5th December 2005 Date of last inspection Brief Description of the Service: 137a Tentelow Lane is a home for four female service users with learning disabilities. One has a hearing and sensory impairment, in addition to a learning disability. The owner and care provider is Milbury Care Services. The home is a four bedroomed, semi-detached house, located on a busy road between Southall and Hounslow. There are local shops nearby and Southall, Ealing and Hounslow shopping centres can be accessed by car. There is a car and a larger people carrier for the house as there are no trains or bus routes close by. The adjoining house (137b) is for four male service users, whose Registered Manager is currently the Manager Designate for 137a Tentelow Lane, where four female service users live. 137a has four single bedrooms. One is on the ground floor and has its own shower. There is a shared toilet nearby. One first floor bedroom is en-suite, with its own bath. The two further bedrooms on the first floor share a bathroom and toilet. The office and sleeping in room for staff is located on the first floor. The lounge, dining room, kitchen and laundry room are located on the ground floor. There is a rear garden, which is mostly lawn with a patio area. There is parking at the front of the property for both houses. There is a joint staff team for 137a and 137b Tentelow lane, and staff work between the two houses. 137a is staffed twenty-four hours a day. Fees range from £1,100-£1,300 per service user, per week. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out as part of the regulatory process. A total of seven hours was spent at the home. The Manager Designate was not present at the inspection and so the Deputy Manager assisted with the inspection process. The Manager Designate is now in the process of applying to become the Registered Manager of 137 A Tentelow lane. The Inspector viewed service users files, staff employment files and maintenance records. In addition, three service users and two members of staff were spoken with as part of the inspection. There were no visitors at the time of the inspection. There were no service user vacancies. There were one or two staff vacancies currently being filled by either permanent or bank members of staff. Staff had assisted the four service users to complete surveys and three comment cards had been completed by family members. One comment card, from a family member, had commented on the heating being too high in a service users room and this was brought to the attention of the Deputy Manager, see further on in the report relating to this subject. What the service does well: The home offers the service users stimulation and occupation on a daily basis. Service users preferences and abilities are taken into consideration when providing activities for them. The staff team is stable and service users often have the opportunity to receive one to one support to from a member of staff. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to explore more equipment and items for the service user who has a visual impairment, such as Brail reading materials, as they had stated they could read Brail. The home had not improved on care plans from the last inspection. Care plans are vital when considering and recording an individual’s needs. These documents also need to show how the home is able to meet those identified needs and evidence how they have involved the service user and/or their representatives when developing and reviewing the care plan. The environmental risk assessment was not available at the inspection. This must be completed to ensure all aspects of the home have been assessed and recorded, highlighting any possible identified risk areas. Where the temperature of the water is deemed to hot, action must be taken to ensure service users are not put at risk and that the problem is solved as soon as possible. Where there are certain areas of the home where the heating is too hot, for example, the ground floor toilet and first floor bedroom, this problem must be notified to the relevant persons and dealt with accordingly. The handles missing from various kitchen cupboard doors and from the unit in the dining room must be replaced. If staff are to provide nail care to service users, then they must receive training on providing this form of personal care support from an appropriately trained professional. Furthermore, where staff are out of date on mandatory training and additional/specialist training, then every attempt must be made to address this shortfall. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 7 The home must be able to provide a summary or report that highlights the work, improvements and reviews that have taken place in the home. The report should aim to incorporate any relevant views from service users and family members, along with future aims and objectives for the forthcoming year. This report must be available for the CSCI, service users and/or their representatives. 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. 137a Tentelow Lane DS0000027763.V322656.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 137a Tentelow Lane DS0000027763.V322656.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed prior to admission into the home, thus ensuring the home is confident it can meet those identified needs. EVIDENCE: The home’s pre-admission documentation was not available for inspection. The Inspector was informed that the home has a pre-admission assessment that is used for prospective service users. The Inspector viewed a social services assessment on one of the most recent admissions into the home and this offered a basic overview of the prospective service user’s needs. The Deputy Manager described how they, along with the Manager Designate and Operations Manager met with this service user to ascertain their needs and abilities. Visits were then arranged for the service user to spend time in the home and to meet with the other service users and members of staff. The Inspector advised the Deputy Manager that any documents, such as preadmission information should be kept in the service users file to ensure the home can evidence the pre-admission process. There have been no new admissions into the home for over two years. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from having their needs clearly identified and recorded onto care plans. Furthermore, their views and contributions should also be added onto the care plans, to ensure they have had a role in deciding what is important in their life. Service users are encouraged, where possible, to make decisions about their lives. Service users are able to take risks and documentation is in place outlining those identified risks. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home had a previous requirement regarding improving the information detailed on service users care plans. The Inspector viewed a sample of care plans at this inspection and found there had been no significant improvement. On one care plan there was only two identified needs recorded, relating to cleaning a hearing aid and protecting the service user from the sun. The Inspector spoke with the Deputy Manager about the lack of information regarding the service users needs. The information viewed did not give any clear indication of the individual’s needs, such as social, health or communication needs. The Inspector re-stated the requirement for care plans to be written in more detail. Furthermore, a requirement was also made for the home to consult with and record service users views about how they see their needs. The home had written essential lifestyle plans that were personal and had some information relating to each service user, such as their preferred routines, things to do to keep them safe, and likes and dislikes. This document was seen as good practice and did offer some insight into the needs of the individual service user. The Deputy Manager acknowledged the need to have care plans written in more detail and will discuss this with Management and the staff team. Samples of daily records were viewed. Overall these were written in a more positive language, although some records did not give sufficient information, such as why a service user had been screaming or shouting and whether the member of staff had tried to establish if there was something wrong. It was strongly recommended that staff consider carefully what they are writing and whether it provides sufficient information for other members of staff. The Inspector also brought to the attention of the Deputy Manager the general layout of the individual files. It was confusing to find current information, as there were no sections divided. A strong recommendation was made for service user files to be well maintained with only relevant or necessary information stored in them. Service users meet with their keyworkers and one service user stated members of staff ask for their opinions. Those service users asked stated they feel listened to and included in the daily aspects of the home, such as choosing meals and activities. Service users do not have independent advocates, although all have contact with family members. One service user is a spokesperson for people with learning disabilities and visits a centre to provide support and speak out for those who are unable to. The service users living in the home are not able to manage their finances. Staff are aware of individual service user’s abilities and support them accordingly. The Inspector viewed a sample of risk assessments and overall these were satisfactory. These assessments covered areas such as moving and handling, falls and safety when out in the community. One service user had a new risk assessment in place for when they are out with staff in the community. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 12 This arose from a complaint the service user had made, see Standard 22 for further information. The Inspector discussed with the Deputy Manager about the dates when these documents were originally written, as some of these were written a few years ago, although all had been signed and dated when reviewed, which is approximately every six months. It is seen as good practice to consider re-writing documents relating to service users, so that there is clear evidence that all of the service users needs are fully considered and amended or updated where necessary. 137a Tentelow Lane DS0000027763.V322656.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities to suit their interests and abilities. Many of these activities are in the local community. Service users are supported to maintain social relationships with their family and/or friends. Service users rights are respected and recognised by the members of staff. Menus and meal provisions provide service users with a nutritious and well balanced diet that suits their cultural needs as well as their individual preferences. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 14 EVIDENCE: One service user attends the local college and has been receiving travel training from the local Mencap group. The aim was for this service user to travel to and/or from College independently. This support has concluded and the home, the service user and Mencap are now considering the risks. For other service users the other local College was unable to offer courses to meet their needs. The home explored other Colleges and met with College staff, however there were no courses available to access. Some service users attend a day centre, whilst others work a few hours a week cleaning. All service users have structured activities in place; some of these are one to one with a member of staff, whilst other activities are with other service users, such as bowling and attending the leisure centre for swimming. The older service user often receives one to one from a member of staff and is encouraged to walk every day to maintain good health. A reflexologist visits the home to offer massage and treatment to those wanting this activity. Various resources are accessed via public transport or by using the homes own transport. Cinemas, restaurants and places of worship, such as the local church are accessed. One service user had also been visiting the local temple, although they were asked not to attend by those from the temple, due to the specific behaviour displayed by the service user. The Inspector viewed a staff external activity document that is used to monitor what member of staff has gone out with a service user. This is to ensure that the activities and time away from the home is shared out fairly between the staff team. The home tries to ensure that service users are occupied as much as they wish or are able to be. Contact with family varies, some service users have regular contact with family, whilst with others it is more sporadic. One service user becomes anxious and excited when they know they are visiting their family, in the past this often led to behaviour that challenged the service. The home now has a procedure for this individual service user, visiting family, whereby they do not tell this them too far ahead of time, thus avoiding anxious or excitable behaviour. The Deputy Manager stated that this new alternative way of working seems to be working and the previous behaviour has decreased, as the service user is less stressed. The home can and do support service users to visit family and they encourage family members to visit the service user at the home. Some service users can read a few words, whilst others are not able to read; therefore personal mail is read to them. All service users can have privacy and lock their bedrooms, some choose to use this facility, whilst others choose to keep doors unlocked. Staff were seen to interact with service users and not exclusively amongst themselves. One service user confirmed they are able to spend time with others or alone and that this decision is respected. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 15 The Inspector was informed that the preparation and cooking of main meals is shared between the home and the registered home directly next door to the home. Staff are allocated to cook a meal and go to the kitchen of the home that is scheduled to prepare and provide the meal. Meals are then sent to the home that has not cooked for that day. The Inspector queried why the two separately registered homes do not cook and provide meals for each home, instead of having staff, on occasion, move into the other home and kitchen to make a meal. The Inspector was informed that this system has been in place for a while and the Deputy Manager stated that it works, as it is shared equally amongst the staff team. Service users living in both homes choose the menus. This aims to provide variety and enable service users to express preferred meals. The menus viewed showed a range of meals and the Inspector was informed that fresh produce is used throughout the weekly meals. Sometimes staff have to suggest meals, as some of the choices are unhealthy or repetitive. Menu ideas are recorded in order to have different meals offered to service users, in particular these ideas are used where service users are unable to state what they would like to eat. Recipe books were seen in the kitchen, which also provides variety to menu suggestions. One of the service users is diabetic and meals are provided to suit this dietary requirement. Cultural meals are also offered to meet the particular preferences of some of the service users. One service user commented on some of the foods available to them that meet some of their cultural needs. Another service user stated they were very happy with the different meals offered to them and confirmed that being a vegetarian was respected and noted by the members of staff, who provide meat free meals for them. The kitchen was viewed and was found to be clean and tidy. Fridge and freezer temperatures had been taken and were within an appropriate range. Alternative meals eaten that are not on the set meal, or if service users eat out in the community, are recorded, in order to monitor the diet of all service users. Some service users are able, with supervision, to make drinks and snacks, whilst others can chop and prepare some things for the meal, again with staff supervision. The Inspector noted that some handles were missing from the kitchen cupboard doors; see Standard 24 for further details. 137a Tentelow Lane DS0000027763.V322656.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way that they prefer and need. Service users health needs are met, however, service users would benefit if their individual health needs were recorded clearly on to their care plan. Medication systems are in place to safeguard service users. EVIDENCE: Staff support the service users with their personal care needs. The level of support and supervision varies, depending on the needs of the service user. Some like to have privacy and space and are able to wash independently, whilst others need the full assistance from staff. The Deputy Manager informed the Inspector that service users purchase their own clothes, with support from staff. One service user, who was asked, said they go out to choose their own clothes, with support form staff and were hoping get some jeans soon. Times for getting up and going to bed vary. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 17 Service user go to different hairdressers, depending on their needs, one attends a hairdressers specifically for people with Afro hair. Only female members of staff provide personal care to the female service users. The Inspector was informed that medical appointments are recorded onto a medical/appointment form. This form enables staff to record any relevant information relating to the visit. All service users have GP’s and have recently had routine heart checks following referrals from the GP, this was standard practice and not due to any service users having heart conditions. The Deputy Manager stated that the service user with diabetes has their nails cut by a professionally trained person, whilst the other service users nails, if required are cut by members of staff. The Deputy Manager informed the Inspector that the home had requested training for staff, but so far this had not occurred. See Standard 35 with regards to training for staff. This Standard has not been met and is a joint requirement with Standard 6, as there were no detailed care plans in place that outlined individual service users health needs. All staff attend medication training prior to administering medication. The Inspector viewed a medication competence form that is signed by the Manager Designate when they feel the member of staff has the skills and knowledge to administer medication. The majority of medication is delivered in a blister pack and then medication for each week is placed into a doset box. The Deputy Manager explained the reason for taking medication out of the blistered pack was that it avoided mistakes occurring, as some medication is loose and could cause confusion. The home has checked with the Pharmacist and the Inspector was informed that the Pharmacist stated this practice is fine to use and does not affect the efficacy of the medication currently being used in the home. The Inspector viewed a sample of medication administration records and these had been completed correctly. Liquid medicines had dates of opening written on them. Service users are not able to self-medicate and there were no controlled drugs in the home. The Inspector counted a sample of loose medication although it was difficult to cross reference the amount that should have currently been in the home as several past medication administration records had to be looked at to ensure no mistakes had occurred. Those medications counted were correct. Currently the home does not have a system in place to check and record any checks on medication, in particular where there is loose, unblistered medication. The Inspector made a strong recommendation for the home to develop a system in order for Management to carry out and record spot checks on all of the medication in the home. By implementing a system to check medication, the home can quickly identify any errors and act accordingly to remedy the problem. Staff will also be made aware that medication will be monitored and mistakes will lead to Management taking the necessary action to protect the service users. 137a Tentelow Lane DS0000027763.V322656.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. Service users can be confident that their concerns and views are listened to and would be acted on. Systems are in place to protect service users from abuse. EVIDENCE: The home had recently received a complaint from a service user. Appropriate measures were taken to record the complaint and notify the CSCI. The Manager Designate acted swiftly in looking at how to support this service user, who had stated that some staff were walking ahead too fast and were not supporting them, as they would have liked to be supported, when they were out in the community. As mentioned earlier, there is now a procedure in place that this service user is asked, when they have been out with a member of staff, regarding how they found the support that was offered and whether the service user was happy. All staff received training from Management as to how to effectively and safely support this service user when out in the community. The Inspector viewed the complaints record and found this had been completed satisfactorily. The Inspector also met with the service user who had made the complaint. They said they were now happy with how staff supported them and walked with them when outside. Other service users were asked if they knew who to complain to or raise a concern and they stated they would talk to either their keyworker or Management. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 19 There has been no protection of vulnerable adults investigations. Staff receive training on this subject and are aware of the need to report any concerns to Management. The home has the local authority’s safeguarding adults policies and procedures. Service users finances were not viewed at this inspection. 137a Tentelow Lane DS0000027763.V322656.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, 26, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from the home having appropriate heating and safe water temperatures in all areas of the home, handles on kitchen units and furniture. Service users would also be safeguarded if environmental risk assessments were completed. Service users bedrooms offer them the privacy and space to spend time away from others. The service user with a visual impairment would benefit from having equipment and materials that meets their individual needs. Service users benefit from a clean and odour free home. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Inspector discussed with the Deputy Manager the family member’s comment regarding one of the service user’s bedrooms being too hot. The Inspector also went into the ground floor small toilet and found this to be very hot. Radiators have covers on them to protect service users, however this problem has been ongoing and had not been resolved. The Inspector made a requirement that the heating should be at a safe and comfortable temperature in all areas of the home. The water temperatures had been taken on the morning of the inspection and it was found that in the ground floor bedroom the washbasin and shower water temperatures were too hot. The Inspector made a requirement for this issue to be addressed immediately and the Deputy Manager spoke several times to the relevant person to come and visit the home as soon as possible to look at and fix the heating and water problems. No confirmed dates for such a visit had been arranged by the end of the inspection. In the meantime the service user, who has the capacity to understand risks, was informed not to use their washing facilities in their room until further notice. The Inspector checked with this service user who confirmed they understood they were not to use the water in their bedroom as it was to hot. The differences in heating and water temperatures needs to be addressed, so that all can be confident that these safety issues do not keep arising. The Inspector also noted that on several kitchen cupboards handles were missing and handles were also missing on the unit in the dining room. A requirement was made for these to be replaced. The Deputy Manager could not locate an environmental risk assessment on various areas of the home that could prove hazardous. This had been a requirement at the last inspection and as this was not available this was re-stated at this inspection. One service user showed the Inspector their bedroom. This was spacious and personalised, with the service users music in their room. They stated they were happy with the bedroom. The service user with a visual impairment received an Occupational Therapist visit and assessment, although this was provided at a much later date than was requested. The Manager Designate had made several attempts to obtain this assessment when the service user initially moved into the home, however they received no response for several months. During the Occupational Therapy assessment the service user was provided with a few items, such as a level indicator, that informs the service user when the cup is full of liquid. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 22 The Inspector was informed that this service user had previously told the Deputy Manager they could read Brail. Later, during the inspection, this service user stated they could not read Brail. The Inspector discussed with the Deputy Manager the need to provide equipment and materials in order to meet this specific need. A requirement was made for Brail reading materials to be provided to establish if the service user can read Brail. Furthermore the home should make contact with the local community team to ascertain how to receive regular information about items for people with a visual impairment, as there are various pieces of equipment available and made for the benefit of people with this specific need. The laundry room was not viewed at this inspection. The Inspector was informed that the drier is now located in the garden shed. Overall the home was clean and tidy at the time of the inspection. 137a Tentelow Lane DS0000027763.V322656.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): 32, 33, 34, 35 & 36 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 being supported by a competent and qualified staff team, who receive one to one support and supervision from Management. Recruitment procedures are robust and aim to safeguard service users. Service users would be further safeguarded and appropriately supported if training in all mandatory subjects were up to date and included specialist training, such as nail care. EVIDENCE: The Deputy Manager explained that the home is meeting its target of having the minimum of 50 of staff with an NVQ. Staff can study for an NVQ level 3 or 2 and are encouraged to do so once they have completed the Learning and Disabilities Award Framework. The staff team work in both Tentelow lane 137a and 137b. The staff team is a mixture of ages, gender, backgrounds and experiences. Those staff observed interacted positively with the service users and those service users asked stated the staff were caring and supportive. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 24 There are some staff vacancies, but this has not had an impact on the service users or staff, as the Manager Designate, is keen to recruit members of staff as initially bank staff. This practice enables both the member of staff and Management to see how they fit into the home and whether they have the skills to meet the needs of the service users. Then, if there is the opportunity and all are agreed, the bank staff member is offered a permanent position within the staff team. The home has never used agency members of staff. The permanent members of staff, who are able to work some overtime hours, usually fill vacant staff hours. The staff team meets every month and members of staff are encouraged to contribute to these meetings. The home considers and recognises individual members of staff contributions to the home and towards service users and awards those who have made a positive contribution. Those members of staff asked stated there were sufficient numbers of staff working on each shift, with often a floating member of staff to support both homes. The Inspector viewed a sample of staff employment files. These contained completed application forms, photographs, Criminal Record Bureau checks and signed health declarations. The Inspector noted that for one bank member of staff, there were two references, but there was a note to say their recent employer was on holiday and therefore a reference was sought from another employer. The Inspector made a strong recommendation for one of the references to be from the most recent or current employer. This is important as it offers current views regarding the applicant. The Inspector viewed the training staff had attended and identified that some members of staff were out of date, for example one member of staff was out of date for fire training, which is mandatory. A requirement was made for all training, in particular mandatory training to be booked and to be up to date for all members of staff, including the Manager Designate. In addition, a requirement was made for staff to only carry out nail care on service users when they have received appropriate training by an accredited trainer in nail care. This needs to occur to ensure staff are confident and competent to carry out this personal care task correctly and safely. The Deputy Manager stated that the Manager Designate was currently designing an individual training profile for each member of staff, so that it would be easy at a glance to see what training has been completed and what is outstanding. The introduction of this document is seen as good practice. The Inspector viewed an induction booklet that is worked through by new members of staff and signed off by the staff member and Management. This looks at various subjects such as policies and procedures, principles of care and the needs of the service users. The Deputy Manager confirmed that new members of staff have several days to shadow existing staff to see their work practice and to learn more about the home and service users. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 25 The Inspector also spoke with the Deputy Manager regarding the new Mental Capacity Act 2005 becoming legislation in April 2007. The Deputy Manager was not aware of this new legislation and the Inspector spoke briefly about the main aim of the act and the possible impact it would have on the home, as the home will need to carefully consider service users abilities to give consent for all aspects of their daily lives. The Deputy Manager was advised to make further enquiries about training for Management and subsequently all members of staff regarding how this will affect the home and how it will be introduced to the home. Staff informed the Inspector that they receive supervision and that is it a useful form of support. The Inspector was informed that notes are taken of these sessions, although these notes were not viewed at this inspection. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 26 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well managed. Service users would benefit if a summary of the reviews and developments of the home are made available to them and their representatives. The various shortfalls regarding the heating and water temperatures could affect the health and safety of the service users. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 27 EVIDENCE: As stated earlier, the Manager Designate is in the process of applying to become the Registered Manager of the home. He has worked in the home for many years and is aware of the needs of the both service users and members of staff. Staff spoke positively regarding how they feel able to approach the Manager Designate and all Management if they need advice or support. The Deputy Manager stated that the Manager Designate is currently studying for an NVQ level 4. The Manager Designate’s training file was not viewed at this inspection. The home has systems in place to monitor the running of the home and to obtain service users and their representatives views. The Inspector viewed a quality assurance report, where various areas regarding the home were explored, such as environment, food and management. The home held an open day for family members to meet with the Operations Manager and to contribute their views. In addition, monthly Regulation 26 visits occur and the CSCI receive these reports. The Inspector discussed with the Deputy Manager about providing a summary or small report showing in a more easy read for service users and family members, about the improvements and changes the home has made, service users views about the home, any shortfalls identified and any future aims and objectives for the forthcoming year. The main quality assurance report is not easy to understand for service users; neither does it look at the actual work the home has been doing to provide a high quality service user for those living in the home. The Inspector made a requirement for the development of a short document summarising all of the above. This report should then be made available for both service users and the CSCI. The Inspector viewed a sample of maintenance and health and safety records. The fire equipment had been inspected and was up to date. The Inspector made a recommendation for the Manager Designate to contact the London Fire and Emergency Planning officer to arrange a visit to the home, as new fire Regulations were introduced in 2006. The Inspector also made a recommendation for the Manager Designate and the fire officer to check the home’s current fire risk assessment to ensure it is detailed enough and complies with the new legislation. The current fire risk assessment looks at ensuring checks are in place, such as the cooker being off, fire doors not being wedged open and that emergency lighting is working. The fire drills/practices are held regularly throughout the year, although times had not been noted of when these occurred. Therefore it was not clear if any night- time fire drills had occurred. The Inspector re-stated a recommendation that times should be evidenced on the documentation used and that some of the fire drills need to be held at night so that all members of staff are able to respond effectively in the event of a fire. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 28 The gas safety record, Portable Appliance testing and the testing for Legionella were all up to date. Procedures are in place, such as de-scaling showerheads and checking taps for limescale to prevent Legionella from being present in the most vulnerable areas of the home. Standard 42, has not been met, due to the earlier requirements relating to the central heating and water temperatures, as these shortfalls could affect the health and well being of the service users. See Standard 24 for further details. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 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 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 2 x 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 30 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 YA6 YA19 Regulation 15 Requirement Timescale for action 31/03/07 2. YA6 15 3. YA24 13(4) Care plans must clearly indicate the service users needs and how these are to be met in respect of their health and welfare. (Previous timescale 28/02/06 not met). Consultation with service 31/03/07 users when devising and reviewing their care plans should be recorded onto the care plans. Environmental risk 28/02/07 assessments must be in place and reviewed on a regular basis to ensure there are no unidentified hazards that could pose a risk to service users, staff and visitors. (Previous timescale 28/02/06 not met). Missing handles on the kitchen cupboard doors and unit in the dining room must be replaced. The heating problems, where certain rooms are too hot, must be resolved so that the DS0000027763.V322656.R01.S.doc 4. YA24 23(2)(b) 28/02/07 5. YA24 YA42 23(2)(c)(p) 12/02/07 137a Tentelow Lane Version 5.2 Page 31 6. YA24 YA42 7. YA29 8. YA35 9. YA35 10 YA39 temperature is the same level in all areas of the home. 13(4)23(2)(c) Service users must be protected from areas where the temperature of the hot water is deemed too hot. The differences in water temperatures must be resolved. 12 (1) (a) The home must make every attempt to provide equipment or materials to meet the needs of the service user who has a visual impairment, for example providing reading materials in Brail. 13(4)(c) Staff must be trained, by a suitably qualified professional, to provide nail care to service users. 18(1)(a)(c)(i) Staff must be up to date with mandatory training and receive additional/specialist training in order to meet the needs of the service users. 24(2) A quality assurance summary/report must be available for the CSCI and service users and or their representatives. This must briefly outline improvements the home has made and areas still to be addressed. 12/02/07 31/03/07 31/03/07 31/05/07 30/09/07 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 YA6 YA6 Good Practice Recommendations It is strongly recommended that daily records provide sufficient information and details relating to a service user. It is strongly recommended that service users files be maintained in a concise, clear and consistent way. DS0000027763.V322656.R01.S.doc Version 5.2 Page 32 137a Tentelow Lane 3. YA20 4. 5. 6. 7. YA34 YA42 YA42 YA42 It is strongly recommended that a robust system be introduced to monitor, record and carry out spot checks on medication, in particular where there is loose medication that is not placed into doset boxes. It is strongly recommended that one of the references sought by the Registered Provider is that of the current or most recent employer of the applicant. It is strongly recommended that the time of fire practices/drills be recorded, to ensure these include nighttime practices/drills. It is strongly recommended that the London Fire and Emergency Planning officers carry out an inspection of the home, in light of the recent changes to fire regulations. It is strongly recommended that during the above Fire officers visit, the home’s fire risk assessment is looked at, by the fire office and Manager Designate and amended/updated where necessary. 137a Tentelow Lane DS0000027763.V322656.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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