Inspection on 05/02/07 for 137b Tentelow Lane

This inspection was carried out on 5th February 2007.

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

Other inspections for this house

137b Tentelow Lane 26/07/07

137b Tentelow Lane 06/02/06

137b Tentelow Lane 19/05/05

137b Tentelow Lane 28/01/05

137b Tentelow Lane 27/05/04

137b Tentelow Lane 03/02/04

137b Tentelow Lane 10/09/03

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 137b Tentelow Lane Norwood Green Southall Middlesex UB2 4LW Lead Inspector Sarah Middleton Unannounced Inspection 5 February 2007 09:35 th 137b Tentelow Lane DS0000027764.V322658.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 137b Tentelow Lane DS0000027764.V322658.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. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 137b Tentelow Lane Address Norwood Green Southall Middlesex UB2 4LW 0208 893 6635 0208 893 6635 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) Mr Charles NII Ashong Mettle Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: 137b Tentelow Lane is a home for four male service users with learning disabilities. The owner and 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 house car for both 137b and the adjoining care home, (137a). There are no bus or rail routes close by. The adjoining house is for four female service users. There is a joint staff team for 137a and 137b Tentelow Lane. 137b 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 lounge, dining room, kitchen and laundry room are located on the ground floor. The office is on the first floor. There is a rear garden, which is mostly lawn with a patio area. There are parking spaces for both homes to the front of the house. Fees range from £950-£1,200 per service user, per week. 137b Tentelow Lane DS0000027764.V322658.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. The inspection took place between 9.35am-3.50pm. Four service user surveys were completed and one family member survey was completed. Overall feedback was positive. Two members of staff and one service user were spoken with as part of the inspection process. There were no visitors at the time of the inspection. There were no service user vacancies. The Registered Manager, Deputy Manager and a senior member of staff assisted with the inspection process. The Inspector would like to thank all those who contributed to the inspection. What the service does well: What has improved since the last inspection? Risk assessments are completed on any areas identified as a potential risk and these are reviewed on a regular basis. Staff were being more vigilant in recording the meals service users were eating when out in the community. The dining room flooring had been replaced with new and practical flooring. There were photographs of staff on the sample of staff employment files viewed. The testing for Legionella and the Portable Appliance testing were both up to date. 137b Tentelow Lane DS0000027764.V322658.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. 137b Tentelow Lane DS0000027764.V322658.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 137b Tentelow Lane DS0000027764.V322658.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): 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 are assessed prior to their admission into the home. EVIDENCE: The Inspector was informed by the Registered Manager that some of the admissions into the home, several years ago, had not been as organised and planned as he would have wanted. The Inspector discussed with the Registered Manager the importance of planning and assessing prospective service users, to ensure the home can be confident that it can meet the identified needs of the prospective service user. There has not been an admission into the home for the past five years. Visits would be encouraged to enable the prospective service user and their representatives to meet with the other service users and members of staff. The Inspector viewed a blank pre-admission assessment that would be used by the Registered Manager. This covered a range of subjects such as, relationships, finances, personal care, health and social needs. The Registered Manager stated they would be the person who would initially assess any prospective service user. The Inspector was satisfied that the Registered Manager would ensure that the home would not accept emergency admissions without appropriate information and plan for sufficient time to assess the prospective service user. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 9 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. Service users are supported and encouraged to make decisions about their daily lives. Risk assessments are in place to care and support service users to lead safe and as independent lives as they are able to. EVIDENCE: Samples of care plans were viewed. One service users care plan outlined various needs, such as personal care, assisting the service user in the community and supporting the service user to maintain positive relationships. Overall care plans did not indicate health needs, social interests or record the needs of each service user. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 10 This has been a requirement at the last inspection and was made a re-stated requirement at this inspection. The Inspector spoke with the Registered Manager regarding the need to ensure members of staff know what is an appropriate care plan and that all information relating to any type of identified need must be recorded. This information would then inform staff to effectively support the service user and ensure their needs were being met. The care plans that are in place are reviewed every six months and keyworkers meet with service users every month. Essential lifestyle plans were viewed and these provided an overall picture of the service user, including their likes, dislikes and preferred routines. The Inspector saw these as good practice as they demonstrate that staff have considered what is important to the individual service user. The Deputy Manager showed the Inspector that the home has recognised the need to expand the care plans and has started to update some of the service users care plans. The Inspector is hopeful that the home will now act and work towards providing more detailed care plans. Daily records were viewed and these gave a general impression of what the service users had been doing and any particular incidents or behaviours that had occurred. The Registered Manager has spoken with members of staff about the language used when writing about the service users and overall this had improved. Three of the service users use various forms of communication. One service user uses Makaton and some symbols, whilst others can say one or two words. Staff described how they use different ways to try and understand what service users want or need. Some service users will take members of staff to what they want, whilst others might point or make gestures. The Deputy Manager informed the Inspector that he would be seeking advice and information from the local Speech and Language Therapist, who could offer professional input to the staff team. Overall staff stated that service users are encouraged to make decisions and have choices throughout their daily lives. This could be from choosing the meals they want, clothes they want to wear or activities they take part in. None of the service users have advocates but the majority of them have regular contact with family members. The Inspector spoke with Management about the possible benefits for service users if they had an independent advocate. This additional form of support can prove useful, if family members have views regarding the service user that might not be what the service user wants. Service users are not able to manage their own finances. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 11 The Inspector viewed some risk assessments. These are reviewed on a regular basis and new risk assessments are developed as needs and risks change. These assessments covered a range of subjects such as travelling in the community, using the home’s transport and bathing. The risks are recorded along with ways to support and minimise the potential risk to the service user. The Inspector spoke with the Registered Manager with regards to the difference between recording needs onto a care plan and highlighting potential risks and hazards onto a separate risk assessment. It is possible that the information can overlap onto both documents, as a risk could also be deemed as a need. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are in place, both at the home and in the community. These provide occupation and stimulation to meet individual’s preferences. Service users are supported to maintain social relationships. Service users rights and choices are respected and promoted by the home. The meal provision offers service users a well balanced diet, which promotes positive health. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 13 EVIDENCE: The Inspector was informed that the service users are active throughout most days. Various places are visited and accessed, such as, day centres, leisure centres and bowling. Those service users with a particular faith are supported to attend church services or the local mosque. One service user goes to a cinema where Asian films are shown. The home keeps a record of the staff that takes part in activities to ensure there is a fair balance within the staff team. The home went on one large group holiday, with the service users who live in the adjoining, separately registered care home. The Deputy Manager stated this had worked out well as service users could interact with each other and all had one to one support from a member of staff. One service user spoken with stated they were happy with the activities they took part in. Service users were seen to be going out and about throughout the inspection. All service users require support and guidance from a member of staff. As stated earlier, community resources are accessed and some activities are provided on a one to one basis or in small groups. Overall family contact with service users is as regular as service users and family members wish it to be. Where service users need to visit family in the family home, then staff take the service user and wait outside, so that service users can have private time with family members. Service users can see family or any visitor in private or in the communal areas of the home. The Inspector was informed that service users could lock their bedrooms. Two service users can read and receive their personal mail. The Inspector was informed that the other service users have their personal mail read to them. Staff were seen to interact with service users in a sensitive manner, throughout the inspection. One service user spoke about not being able to be alone in the kitchen, as in the past they had threatened to harm staff with a knife. This service user had insight and described the reasons why they had limited access to the kitchen. Staff confirmed they supervise all service users in the kitchen due to the potential risks. The Inspector viewed a sample of menus. All service users, including those service users who live in the adjoining registered care home, choose a meal each week. The menus incorporate service users preferences and staff include fresh produce into these meals. The cooking is shared amongst the two homes and the member of staff allocated to cook a meal on a particular day cooks in either of the two kitchens. The lunch was seen to come over from the other home on the day of the inspection. Each meal was individually wrapped to stop it from getting cold. Those staff asked stated that this system works, as it frees up time for staff to support and be with service users. One member of staff described how staff encourage service users to make their own drinks and snacks. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 14 Meals are recorded, including when service users are eating out in the community or if they eat something as an alternative to the set menu. This enables staff to monitor the diet of individual service users. In order to meet the service users cultural needs, specific restaurants are visited that cater for service users differing cultural backgrounds, such as Caribbean and Asian. The kitchen was viewed and this was found to be clean and tidy at the time of the inspection. Fridge and freezer temperatures had been taken on a regular basis and were within an appropriate range. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal care support in private and in the way that they prefer. Service users health needs are met, however, service users would benefit if their individual health needs were recorded clearly on to their care plan. Robust medication systems are in place to safeguard service users. EVIDENCE: The Inspector was informed that one service user needs full supervision and support with regards to their personal care. Where possible, personal care is given by a male member of staff. On the rare occasion that personal care is provided by a female member of staff, it is clearly recorded who gave the personal care and why. This is then monitored by Management. It is only where there are no male members of staff available, that this situation would arise. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 16 Other service users require differing levels of encouragement and support when managing their personal care. All personal care is provided in private. The service user spoken with stated they could go to bed and get up when they want to. All service users have access to health professionals, such as GP’s, Psychiatrists and Speech and Language therapists. Staff record medical appointments and treatments onto a form. This is seen as good practice as it enables staff to monitor the health of individual service users. As noted earlier in the report, care plans had not been written in sufficient detail to show service users needs. A requirement made at the previous inspection related to clearly identifying individual health needs on care plans. This had not been carried out and is a re-stated requirement. The Inspector spoke with the Registered Manager about highlighting and recording health needs so that staff are fully aware of these needs and how these are to be met. The Inspector viewed a sample of medication administration records and found that these had been completed correctly. The home receives medication in blister packs and each week places medication into a daily doset box. Medication that loses its efficacy is kept in its original box. The service users are not able to self-medicate. There were no controlled drugs in the home. The Inspector spoke with a service user who occasionally receives medication to calm them down. This service user described how they feel out of control at times and that this prescribed medication helps to relieve some of the anxiety they feel. They showed an awareness into how they can behave when feeling frustrated or upset and that this behaviour is not acceptable for those living and working in the home. The Inspector discussed the use of medication to calm service users with the Registered Manager. He was confident that staff do not over use this form of medication when looking to support a service user who is becoming out of control. In addition, the Registered Manager reads through reports and daily reports to ascertain if the situation could have been handled differently and will speak with staff if he identifies alternatives measures that could have been taken. The Inspector was satisfied that the home considers various options to support service users appropriately. Staff receive training prior to administering medication. Staff have a competence test on their knowledge of medication before the Registered Manager confirms they are able to administer medication. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those service users able to feel confident that their views and complaints would be listened to and acted upon. Systems are in place to protect service users from abuse. EVIDENCE: The home has received one complaint since the last inspection. The Inspector viewed the complaints book where complaints are recorded. This complaint had been fully recorded and dealt with by the Registered Manager, who met with the family member who had made the complaint. This case is now closed. One of the service users informed the Inspector that if they were unhappy with something they would discuss this with the Registered Manager. The Registered Manager acknowledged that for the other three service users making a complaint would be more difficult, due to their communication needs. The complaints procedure is freely available and was in the dining room on the wall. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 18 There has not been any protection of vulnerable adults investigations, (POVA). The home ensures that members of staff receive training on this subject, so that they are fully aware of action to take in the event of a POVA concern. Those staff asked stated that they would inform Management if they had any suspicions that abuse was taking place in the home. The home has the Local Authority’s policies and procedures on safeguarding adults. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 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 a home that is more well maintained. Service users bedrooms offer them the space to be alone with their personal possessions around them. Overall the home was clean and free from odours. EVIDENCE: The Inspector carried out a tour of the home and samples of rooms were viewed. The dining room carpet had been replaced with practical flooring. The flooring in the bathroom on the first floor and in the service users bedroom on the first floor had not been replaced. This had been identified at the last inspection and a re-stated requirement was made for this to be addressed. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 20 Service users had new carpets in their bedrooms, however one bedroom door on the first floor had difficulty in closing. This door needs attention so that the service user can easily open and close their bedroom door. A requirement was made for this shortfall to be addressed, as this had been a problem for several months. The Registered Manager showed the Inspector a sample of emails that he had sent to the maintenance department to address the bathroom flooring and the service users bedroom door. The Inspector acknowledged that there can be difficulties in getting work completed on the home, however areas needing attention must not be ignored by those responsible for the upkeep of the home. The Inspector also noted that the washbasin in the main bathroom on the first floor had cracks in it. This washbasin needs replacing and a requirement was made. This main bathroom would benefit from the whole suite being updated and replaced and the bathroom being decorated to offer service users a more pleasant room to bathe in. The Inspector also saw that in several areas of the home, for example on the hall landing and in the living room, there were different paint colours on the walls. It would seem there had been marks noticed and attempts had been made to cover them up, however the wrong paint was used, making the marks on the walls stand out even more. Rooms needing to be redecorated must be done so professionally and a requirement was made for this work to be carried out. The Registered Manager needs to carry out regular maintenance checks so that these shortfalls are identified and resolved. The Inspector viewed a sample of bedrooms. These had new carpets, as stated above and were spacious and personalised. Service users are able to spend time in their bedrooms as they so choose. Staff and service users maintain the cleanliness of the home and at the time of the inspection the home was clean and free from any odours. Staff receive training on infection control and health and safety. The laundry room is located in a separate room. Each service user has a specific day to wash their personal items. The drier is now located in the garden shed. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 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 competent and effective staff team who work together in the interests of the service users. The recruitment procedures are robust and aim to safeguard service users. Staff receive appropriate training in order to meet the needs of the service users. EVIDENCE: The majority of the staff team have either obtained an NVQ or are in the process of studying for this qualification. The needs of the service users vary, and as highlighted earlier in the report, staff over time have got to know the service users and aim to understand their individual preferences and dislikes. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 22 Staff admitted that it could be difficult to always know what a service user is trying to communicate to staff. However staff informed the Inspector they were aware of the varied abilities of each service user and that if a service user could not speak or hear, they still had the ability to understand questions and dialogue from the staff team. Where staff are unsure of what a service user is trying to tell them, then advice is sought from other members of staff or by a process of elimination, through asking the service user a series of questions. This then often addresses what the service user wanted. One member of staff stated they are trying to learn Makaton so that they can communicate with one of the service users who use Makaton as a form of communication. Overall those staff asked stated the staff team work well together. Good communication and working in the interests of the service users are the aims of the staff team. Monthly team meetings take place and staff can contribute to the agenda. All staff, including bank members of staff, are encouraged to attend these meetings. Workshops are also run during these meetings, where members of staff present a subject to the staff team and discussions then take place regarding the presentation. The Inspector viewed the rota and found there were suitable numbers of staff working at any one time. The home has not used agency members of staff for many years. The Registered Manager has a regular team of bank staff who cover vacant hours or when staff are sick or on holiday. The staff team comprises of a mixture of ages, gender and backgrounds. This mix reflects the cultural and gender composition of the service users. The home has a staff team who work in both the home and the adjoining separately registered care home. There are two Deputy Managers and one senior member of staff who work between the two homes. The Inspector viewed a sample of staff employment files. These contained completed application forms, photographs, health declarations, references and Criminal Record Bureau checks. Currently the Registered Manager is in the process of developing individual training profiles on each member of staff. This aims to show the training that staff have attended and those courses that are booked for the forthcoming year. Training is up to date for all members of staff and bank staff are also able to attend training. The Inspector discussed the trainers used, as some of the training is now held on one or two days, for example, Protection of vulnerable adults, infection control and moving and handling are all on one day. The Inspector queried whether this type of training in such a short period of time could fully train members of staff, in particular new members of staff, with little or no previous care experience. The Inspector made a strong recommendation for the type of training to be reviewed to ensure it is provided by accredited trainers who are thoroughly covering the topics in the space of time currently being used. The senior member of staff is waiting for training on supervision so that they will then be able to offer one to one support and supervision to support workers. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 23 Those staff asked stated they had received a detailed induction, where they had time to read policies and procedures, service users files and shadow existing members of staff. New members of staff work through an induction booklet that is only signed off by Management once they are satisfied that the new member of staff is competent and has grasped the initial information needed to work in the home. 137b Tentelow Lane DS0000027764.V322658.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 managed home. Service users and their representatives would benefit from having a quality assurance summary made available to them. This would enable them to know the work the home has been doing and future aims and objectives. The maintenance and health and safety records viewed protected Service users health and safety. 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Registered Manager has worked in the home for many years and is in the process of studying for an NVQ level 4. This he aims to finish by the summer 2007. Staff feedback was positive regarding the Management support offered in the home. The home has various systems in place to review the running of the home. Monthly Regulation 26 visits take place and the reports are forwarded on to the CSCI. In addition, an open day is held for family members to meet with the Operations Manager and to feedback any comments they feel able to with regards to the home. An overall report is then produced to include comments from service users and family members. The Inspector discussed with the Registered Manager, the need to develop a service user friendly summary/report of the improvements and ongoing work the home has made over the past year and include areas still to be addressed. This summary/report should include any relevant comments from service users, along with future aims and objectives. The Registered Manager acknowledged the need to produce something that is personal and shows the work all members of staff do to offer a good service for the service users. A requirement was made for this summary/report to be developed and produced. The Inspector viewed a sample of health and safety records. The testing for Legionella and Portable Appliance Testing were up to date. Water temperatures had been taken on a regular basis and were within an appropriate range. The fire equipment had been serviced and regular weekly checks are carried out on the fire alarm and emergency lighting. When fire drills are held, one service user, who has a hearing impairment, has a flashing light in their bedroom that is set off, when the fire alarm goes off. One service user breaks one of the fire boxes on the top floor landing area. This is currently sealed off and the new parts have been ordered. The Registered Manager explained that this is an ongoing problem. This is the only fire box that this particular service user is interested in. The Inspector made a strong recommendation for the local fire officer to visit the home to see if this fire box could be moved to an alternative location, as this might stop the service user smashing it. This visit would also be important as the fire regulations were updated in the latter part of 2006 and this might have implications on the home. The Registered Manager stated he would arrange for a visit as soon as possible. Fire drills/practices had been held at regular and different times of the day and evening, involving all members of staff. 137b Tentelow Lane DS0000027764.V322658.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 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 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 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 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 3 x 137b Tentelow Lane DS0000027764.V322658.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. Standard YA6 Regulation 15 Requirement Care plans must detail service users identified needs. These care plans must show how these identified needs are to be met. (Previous timescale 30/03/06 not met). Service users individual health needs and how these are to be met must be clearly evidenced in care plans. Previous timescale 30/03/06 not met). Timescale for action 31/03/07 2. YA6 YA19 12(1)(b) &15 31/03/07 3. YA24 23(2)(b)(d) The flooring for both bathrooms on the first floor must be replaced. Previous timescale 31/05/06 not met). 23(2)(b)(c) 23(2)(b)(c) 23(2)(d) The washbasin in the first floor main bathroom must be replaced. The service users bedroom door on the first floor must be fixed, so that it closes easily. Areas needing to be decorated must be done so in a professional way. DS0000027764.V322658.R01.S.doc 09/04/07 4. 5. 6. YA24 YA24 YA24 31/05/07 01/03/07 31/05/07 137b Tentelow Lane Version 5.2 Page 28 7. YA39 24(2) A quality assurance 30/09/07 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. 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. Refer to Standard YA35 Good Practice Recommendations It is strongly recommended for the type of training provided on some areas, to be reviewed. This is relevant where several subjects are covered in a short period of time. Training needs to thoroughly cover all relevant issues relating to a topic and train and inform staff appropriately. It is strongly recommended for the London Fire and Emergency Planning officers to carry out an inspection of the home, in light of the recent changes to fire regulations. 2. YA42 137b Tentelow Lane DS0000027764.V322658.R01.S.doc Version 5.2 Page 29 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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