Inspection on 30/10/06 for 3 Clareville Road

This inspection was carried out on 30th October 2006.

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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Clareville Road 01/10/07

3 Clareville Road 25/04/06

3 Clareville Road 30/01/06

3 Clareville Road 07/11/05

3 Clareville Road 14/07/05

3 Clareville Road 27/09/04

3 Clareville Road 04/05/04

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Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Clareville Road (3) 3 Clareville Road Caterham Surrey CR3 6LA Lead Inspector Helen Dickens Key Unannounced Inspection 30th October 2006 12:45 Clareville Road (3) DS0000013483.V316861.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 Clareville Road (3) DS0000013483.V316861.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. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clareville Road (3) Address 3 Clareville Road Caterham Surrey CR3 6LA 01883 340181 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) The Regard Partnership Limited To Be Confirmed Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 18-65 YEARS Two named individuals may be accommodated who are 17 years of age. Of the ten service users accommodated two named service users currently in residence may also fall within the category MD Mental Disorder in addition Of the ten service users accomodated two named service users currently in residence may also fall within the category MD mental Disorder in addition to LD Learning Disability. 25th April 2006 Date of last inspection Brief Description of the Service: 3 Clareville Road, Caterham is a detached three storey house within the Regard Partnership Ltd, developed to provide accommodation for 10 service users with learning disabilities. The home is sited in a residential road with similar properties, and is within walking distance of local shops and amenities in the town centre of Caterham. Service users’ bedrooms are situated on the ground and upper floors. There is a toilet on the ground floor, and all bathing and showering facilities are situated on the upper floors. This limits the homes suitability for less mobile service users. Communal and recreational areas are situated on the ground floor. Weekly charges per person range from £1223 to £1892. Holidays, clothing, and ‘one to one’ support are extra and these are negotiated with the placing authority. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was the second key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. The inspection was carried out by Mrs. Helen Dickens, Regulation Inspector. Mr. Richard Clayton, the new Manager who took up his post in February, represented the establishment. A partial tour of the premises took place and the manager and one resident staff were interviewed. The inspector met three other service users who were present in the home. A number of documents and files were sampled during the course of the inspection. The inspector would like to thank the service users, the staff, and the manager, for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Assessment and care planning documents have shown further improvement since the last inspection and all the service users now have a new support plan. The plans and other documents are now kept on one file which was a recommendation from the last inspection. There were some good examples of service users having more involvement in the day to day running of the home, and the home environment looked better cared for. The kitchen was cleaner and the food well kept. Record keeping has also improved since the last inspection. Some decorative work has been carried out including a new floor covering fitted in the dining room, some carpets and decorating in resident’s rooms, and the garden looks better. Clareville Road (3) DS0000013483.V316861.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. Clareville Road (3) DS0000013483.V316861.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 Clareville Road (3) DS0000013483.V316861.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. Resident’s individual aspirations and needs are assessed prior to admission to this home. EVIDENCE: Three resident’s files were sampled and all had sufficient pre-admission assessment information from which to devise a suitable care plan. Those residents admitted since the new manager has been in place have had an assessment carried out by the manager plus information on file gathered from other relevant professionals including the care manager’s community care assessment. Resident’s admitted prior to the new managers appointment did not always have pre-assessment information on file and where this was the case, the manager was asked to ensure an assessment was carried out for these residents and this has now been completed. The latest resident to be admitted came for a pre-admission day at the home and the manager said the resident was involved in a meeting when the decision about the placement was made. This resident was spoken to and confirmed they were happy at this home. Clareville Road (3) DS0000013483.V316861.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): 6,7,8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents have a care plan which is generated from a comprehensive assessment of their needs though further work needs to be done to meet this Standard in full. Residents are supported to make decisions about their day to day lives and have some opportunities to participate in the life of the home. Residents are also supported to take risks as part of an independent lifestyle. EVIDENCE: The care planning system has improved further since the last inspection and the new manager said that all residents now have a support plan in place. Three of these were sampled and it was noted that the care planning documents were kept together for each resident which made access more straightforward. At the April 2006 inspection the manager said that service users/relatives had not yet signed all these plans, but would be doing so soon. Though there had been more involvement from residents and some parts of some plans were now signed off by the resident in question, more work needs Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 10 to be done to complete this task. The plans were not yet in a resident-friendly format and this would also need to be considered to meet this Standard in full. At the April 2006 inspection the manager demonstrated how he was improving decision making opportunities for service users. The service user’s meeting held on the evening of that inspection gave good examples of how residents were being given some involvement in menu planning and choosing outings. This has improved even further with residents becoming more involved in shopping, menu planning and cooking. The home have stopped using the summer/winter 4 weekly menu cards which were institutional and have adopted a more flexible approach. The home have purchased a laminator to enable them to produce resident-friendly documents which will last longer. However, the picture format menus which the manager has started to construct have not progressed very far as there are insufficient clip-art images available, and those that are available do not always depict the food item in an easily recognisable way. Further work needs to be done and this was discussed with the manager. A recommendation on this matter will be repeated from the last inspection. Standard 8 covers participation and this has also improved since the last inspection. In addition to food, shopping and menu planning as outlined above, residents have also been involved in choosing some of the new décor for the home, and in particular for their own rooms, and are now being involved in gardening (as some are doing gardening at college). The home will need to do more work on resident-friendly formats in order to fully involve residents and should review the current arrangements for the quality monitoring questionnaires which go only to head office and opinions are then ‘pooled’ with the rest of the Regard quality information giving no indication of the level of user satisfaction at Clareville Road. This is discussed further under Standard 39. In April 2006 it was noted that though there were some risk assessments in place, overall, risk management plans needed more work. It was difficult to ascertain if service users had been given good information on which to base their decisions with regard to taking risks, as per Standard 9. On the day of this inspection in October, arrangements for managing risk were much improved. It was noted that risk management strategies were in place on the three resident’s files sampled. One resident with challenging behaviour had clearly been involved in these risk management strategies and had signed them off in the support plan. They had been up-dated following recent episodes of challenging behaviour and when visiting this resident in their room they volunteered to show the list of behaviour management strategies they were currently using and identified their favourite methods. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to take part in educational and social activities and be part of the local community, though documentation on these matters was not available for inspection. Family links and friendships are supported and service users were treated with respect by staff. Meals offer some choice and variety and residents now have more involvement. EVIDENCE: These Standards were not fully reassessed during this visit as some aspects were found to be satisfactory at the April 2006 inspection. It was noted at the April 2006 inspection that in examining care plans and speaking with staff it was clear that residents do have educational opportunities and a number of them attend college on a regular basis. On the day of the inspection in October some residents were on their way out to Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 12 college. A plan of weekly college attendance was also examined which confirmed which residents attended on which days. Notes from the service user’s meeting and care planning documents highlighted opportunities within the local community and staff collected relevant information on such activities. One resident interviewed confirmed he was currently going to college for IT training and gardening on two days per week. The manager has instituted a scheme of achievement awards for residents and the resident interviewed in their room had chosen to display this on their wall. The activities plan for residents was missing and therefore it was not possible to check which classes residents were attending and check on their progress. The manager said this would be found and returned to its proper place. At the April 2006 inspection it was noted that service users were supported to maintain family and friendship links and staff were familiar with the needs and level of involvement of the main relatives/friends in relation to each service user. However, comment cards sent to relatives prior to this October inspection highlighted some concerns including information arriving too late, and communication and staffing issues which were discussed with the manager. Service users were observed to be treated respectfully by staff and the manager knocked on every service user’s bedroom door, even though the majority were thought to be out. Staff were interacting positively with service users during the inspection and residents were seen to turn to staff for assistance when needed. Resident’s choices were respected and one resident showed the inspector their ‘do not disturb’ sign and outlined when they used this. During the inspection one resident declined to show the inspector their room and staff respected their wishes. Another was using their ‘do not disturb’ sign so staff did not even knock on that resident’s door. Arrangements for meals have improved since the last inspection. The kitchen is much cleaner than it was at the previous inspection and the metal gate dividing the kitchen has been removed and a breakfast bar put in its place. The manager says breakfast in the dining room is laid out ‘hotel’ style with residents helping themselves to a variety of cereals and toast; some residents make their own toast and drinks. The old laminated menus have gone and new menus with resident’s preferred meals (ascertained at the house meeting) are now used. The residents assist with choosing the menus, doing the shopping, and preparing the food within their abilities and with support from staff. Some residents have had the advice of a dietician and the manager knows how to access further advice as necessary. The dietician suggested photographs of the foods residents could choose from and the manager said the home will now buy a camera for this purpose. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support to service users is provided in a respectful manner by staff. Service users physical and emotional health needs are met. The administration of medication has also improved. EVIDENCE: These Standards were not fully reassessed as were they were found be satisfactory at the previous inspection in April 2006. At that inspection the support to service users was observed to be provided respectfully, and personal care provided in the privacy of each resident’s own room. A key working system is in place in this home. Assistance needed was documented on care planning documents and further work has been done in order to provide a comprehensive and current picture of each service user’s needs. Residents were observed to be dressed in their own individual style and additional support from specialist workers was sought and documented on resident’s files. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 14 Healthcare needs were documented on service users files and there was evidence of residents being assisted to access healthcare services with support from staff. For example, the dietician spoke to staff and some residents on healthy eating and exercise, and a physiotherapist advised on gentle exercise and recommended some sports venues. The manager said they were taking a more holistic approach to a healthy lifestyle. At the April 2006 inspection it was noted that medication administration had improved over the last 6 months and Requirements made at the CSCI pharmacy inspection carried out in November 05 have been met. A list of staff authorised to give medicines was available and updated annually; service user records contained a photograph and there were no unexplained gaps observed. Protocols were in place for medicines administered ‘as required’. Since this inspection a medication error had been reported to CSCI but this had been dealt with in a timely and efficient manner by the home. The inspector was concerned about the policy for administering medication with two staff members and the manager outlined the division of responsibilities. The policy itself and the manager’s outline regarding the respective responsibilities of both members of staff differed and advice was sought from the CSCI pharmacy inspector on this matter. A requirement will be made in this regard. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s views are taken into account in this home, and the majority of staff have undergone training in protecting vulnerable adults. However, more work will need to be done to meet this Standard in full. EVIDENCE: At the April 2006 inspection it was noted that a complaints procedure is in place and attempts have been made to put this into a more user-friendly format. The resident’s meeting notes contained details of discussions with residents regarding the procedure and staff had identified that residents would need to have this issue highlighted to them again until they fully understood their right with regard to complaints. No complaints had been received since the last inspection. During this inspection in October 2006 it was also noted that no complaints had been received by the home since the previous inspection. Very few preinspection comment cards had been returned to CSCI but of those which were returned, one relative was not aware of the complaints procedure, and another had raised some concerns about lack of communication and insufficient staff. The manager should ensure all stakeholders are aware of the complaints procedure and about how to raise issues regarding the home. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 16 In April 2006 a Requirement was made that all staff must familiarise themselves with the home’s policy on protection of vulnerable adults and the training records now show that all but one staff member (who has been away for some months), and the manager, have now had the ‘Regard’ training on this issue. To meet this Standard in full the manager must complete his own training and ensure that all relevant reportable incidents are reported as discussed below under Standard 37. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff work hard to provide a homely environment for residents but more work needs to be done to meet this standard in full. The home needs to review its practices with regard to cleanliness and hygiene in order to fully protect residents. EVIDENCE: At the April 2006 inspection it was noted on a tour of the premises that a refurbishment plan was underway; some service users rooms had been decorated, and one bathroom had been painted. On the day of that inspection, new floor coverings were being laid in the dining area. Some parts of the home were nicely decorated and comfortable, including some service users bedrooms. New radiator covers were both tasteful and provided a safe covering for hot radiators. However, much work still needed to be done. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 18 At this inspection in October 2006 there had been more improvements including providing curtains at a window where they had been missing, partially clearing the cellar, removing the iron gate which separated the dining and kitchen areas, and providing a ‘breakfast bar’ type divider instead. Some carpets had been deep-cleaned and some floor coverings replaced. Most parts of the establishment looked homely and comfortable however, some areas of the home still had torn wall paper, peeling paint and one bathroom room had torn privacy screening on the window. One service user’s bedroom furniture that needed attention, including one chest of drawers with a drawer missing had, according to the manager, been repaired but was now damaged again. The vacant room has been redecorated and had a new carpet fitted but a radiator cover will need to be in place before a resident can move into this room. At the previous inspection it was noted that not all hand washing areas had individually dispensed soap and paper towels and some basins had water which was not maintained at around 43C as set down in the Standards. On this inspection in October those water temperatures tested were within acceptable limits and hand washing areas had individually dispensed soap – one however still had no paper towels and there was no evidence of a paper towel holder having being fitted as the wall had no holes or marks. Alternative arrangements will need to be made as soon as possible. The kitchen area had improved considerably with a new floor covering and was generally cleaner than at the previous inspection. The garden which previously had large patches of bare lawn was much improved though the shed the manager had said was being erected had not materialised. The manager said they were still considering what to do with the garden area but that in the summer some residents had been involved in gardening and potatoes had been planted. Only one bare area remained on the lawn and this was at the rear of the garden under a large tree. At the previous inspection in April 2006 a Requirement was made for the home to review its practices with regard to cleanliness. Though on this visit in October the home looked cleaner and there was a vast improvement in cleanliness in the kitchen area which had a new floor covering and had been deep cleaned, there is still no cleaning rota and the manager said that care staff and residents are expected to keep the home clean. Residents were said to help with some household tasks, but again, this was not documented. The manager was asked again to make more formal and regular cleaning arrangements to ensure the home is maintained in a clean and hygienic state. Plastic aprons and gloves have been provided and are sited discreetly throughout the home for use by staff. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent workforce and though arrangements for staff training and recruitment have improved, further work is needed. Supervision of care staff has also improved and now meets this Standard in full. EVIDENCE: At the April 2006 inspection residents were observed to be comfortable with the manager and staff at this home. The two staff interviewed at that time were approachable to residents and motivated, and assisted inspectors to communicate better with service users, as some residents at this home do not communicate verbally. Staff files showed a variety of relevant training courses attended by staff. However, it was noted then that crucial protection of vulnerable adults training was needed in order to ensure that service users were safeguarded at all times and this has since been completed, except for the manager and one staff member who has been away for some months. The manager confirmed that 7 of the 14 care staff employed at this home have NVQ2 or above, and five other staff are currently enrolled on NVQ courses. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 20 It was also noted in April 2006 that staff recruitment had improved considerably since the last inspection and all four files sampled contained the necessary documentation including an enhanced criminal records bureau check. The files were in a standard format which made it easier to check what had happened with regard to each employee. Not all files had a checklist at the front, and one had a checklist which was only partially completed. Some files had the same documentation in a different section, and it wasn’t clear whether one staff member had received a new contract due to a change in employment arrangements. Currently only the manager will be involved in recruitment though the new deputy will receive training in recruitment procedures and techniques. This Standard was not reassessed during the October visit. In April 2006 the manager had started identifying the relevant training courses required by individual staff members and this has now been completed; however, as required at the April 2006 inspection, there is still no overall training plan for the home as a whole – though this work is ongoing and significant progress has been made. At the April 2006 inspection, staff records showed that staff had received supervision until December 2005 though prior to that they had received fewer than the required number of sessions per year. The manager said staff supervision is being restarted and would happen on a monthly basis. Records checked during this inspection in October showed that supervision was now happening on a regular basis with each staff member receiving either a formal supervision meeting, or an ‘observation’ supervision each month. The manager highlighted that the month of September had been the exception when few staff received supervision due to the demands of the service. However, even taking this into account, the staff are on course to receive 6 formal and documented supervision sessions within 12 months as set down in this Standard. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager continues to make improvements but more work needs to be done to meet these Standards in full. EVIDENCE: The new manager continues to make improvements at this home and these are detailed elsewhere in the report. However, the manager is still not registered with CSCI and though he agreed to arrange for his CRB check within one week of this inspection in October (and therefore set the application in progress), it still remains the case that this service has been operating without a registered manager for over a year. The manager said he will be Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 22 undertaking the NVQ4 in care as currently he only has the RMA in management. The manager has overall responsibility for ensuring that CSCI Requirements are met in a timely fashion (37.3) and some Requirements remain outstanding from the previous inspection in April 2006. In particular, on the day of the inspection in April 2006 it became clear that a reportable incident had occurred several days previously, and had not been reported under a Regulation 37 notice. A Requirement was made in this respect. On the return visit in October 2006 it was brought to the attention of the manager that very few Regulation 37 notices had been received at all from the service and when checking the home’s records, at least four incidents had been recorded in the home but the notices had not been received by CSCI. Until the problem has been resolved, the manager was advised to follow up all faxed notices with a telephone call to confirm these had arrived. It was also noted that the pre-inspection questionnaire which was sent to the service in August had also not been received at CSCI – managers are usually given two weeks to complete this documentation. The manager said he remembered completing this but not sending it off and he agreed to locate it or request a new one by the end of the week in which this inspection was carried out. It was noted at the April 2006 inspection that quality assurance issues are currently the focus of attention at this home and the the day before that CSCI inspection, the The Regard Partnership’s quality assurance officer carried out a ‘mock inspection’ at Clareville Road. This resulted in an action plan and arrangements for monitoring progress. The partnership also carries out monthly Regulation 26 monitoring visits. Service user’s meetings also provide an opportunity for their views to be aired. An annual development plan has also been produced for this home. It was noted at the April 2006 inspection that a nationwide survey by the Regard Partnership showed overall good results but there was no way to determine from the general leaflet (containing the feedback), how this applied to individual homes. At the October 2006 inspection this was discussed again with the manager but a more relevant breakdown of this survey was still not available. The home must include feedback from their own residents in order to meet Standard 39 in full. It was noted at the April 2006 inspection that the new manager takes health and safety matters seriously and a number of issues highlighted on that day were either remedied immediately (warning tape was put on a small step which might be a hazard to visitors); or given priority for that day, for example the fitting of soap dispensers was carried out during the afternoon. A number of shortfalls on that day have since been rectified including flushing through unused shower heads to avoid legionella, professionally cleaning the kitchen, including walls and tiles, and more regular recording of fridge and freezer temperatures. One fridge thermometer was not working on the day of the previous inspection and this was the case again in October though there Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 23 were records showing the temperature of the fridge had been recorded until earlier in the month, when the thermometer broke, and a new thermometer had since been ordered. Food items in the kitchen fridge which had been opened were all dated and labelled and the kitchen was generally cleaner and food was well kept. The hazardous substances cupboard was found to be securely locked. However, procedures still need to be put in place to ensure the correct hygiene management of all areas of the home, and there is still no cleaning rota, and ad hoc arrangements are unsatisfactory. One bathroom had no paper towel holder or paper towels for staff and residents to dry their hands – this affects the health and safety of residents and staff alike. The accident book had large gaps between incidents and it was discovered that there were three different accident books. In addition, old accident reports were not being removed to a central file to protect confidentiality and advice was given on this matter. The manager must review arrangements for recording and monitoring accidents and incidents within the home. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 24 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 25 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(1)(2) Requirement The registered person must ensure that each service user has an individual plan of care that includes the signature of the service user/representative to signify their agreement with the care plan and risk assessments, and that these documents are presented in a useraccessible format. There must also be documentary evidence regarding service users educational and social activities, including their goals and progress. (Partially met from 30/01/06 and 28/02/06). The registered person must review practice to ensure that staff are clear that when two staff are administering medication, both must read the chart and the blister pack, as both DS0000013483.V316861.R01.S.doc Timescale for action 30/12/06 2. YA20 13(2) 31/10/06 Clareville Road (3) Version 5.2 Page 26 3. YA23 13(6) have the responsibility for the safe administration of medication, as per the home’s policy. The registered person must ensure that all staff receive training on protection of vulnerable adults issues. (Partially met from 25/04/06) The responsible individual must ensure that the decorative and maintenance shortfalls identified under this Standard are dealt with in a timely fashion. (Outstanding from 25/06/06). The responsible individual must review the cleaning arrangements (including drawing up a rota) for this home paying particular attention to the kitchen and toilets. (Outstanding from 25/05/06) The registered person must carry out a training needs assessment for the staff team as a whole. (Partially met from 30/05/06). The manager must be registered with CSCI. The registered person must review reporting of notifiable events to CSCI as set out in this Regulation. Notifications must be made in a timely fashion, i.e. without delay. DS0000013483.V316861.R01.S.doc 30/11/06 4. YA24 23(2)(b)(d) 30/12/06 5. YA30 23(2)(d) 16(2) (j) 30/11/06 6. YA35 18(1)(a) 30/11/06 7. 8. YA37 YA37 8(1) CSA Section 11 37(1)(2) 30/12/06 31/10/06 Clareville Road (3) Version 5.2 Page 27 9. YA39 24(2)(b) 10. YA42 16(2)(j) 11. YA42 17(1) Schedule 3 12. YA42 24(A) (Outstanding from 25/04/06) The home must include feedback from their own residents as part of their quality assurance processes in order to meet Standard 39 in full. The registered person must ensure that all hand washing facilities are furnished with paper towels, or other hygienic means for residents and staff to dry their hands. (Partially met from 25/04/06) The registered person must put in place a system to maintain clear records of accidents and incidents at the home, and have regard to confidentiality and data protection regulations when storing this information. The registered person must produce and send to CSCI an improvement plan detailing how, and when, the issues highlighted in this report will be dealt with. 30/12/06 31/10/06 31/10/06 30/11/06 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 YA6 Good Practice Recommendations It is recommended that service users’ responsibilities for housekeeping tasks are specified in their individual plans. DS0000013483.V316861.R01.S.doc Version 5.2 Page 28 Clareville Road (3) 2. YA17 3. YA22 It is recommended that the format of menus is more userfriendly. It is also recommended that a daily record of what each resident has eaten should be kept. (Outstanding from the last inspection). The registered person should ensure that all stakeholders are aware of how to raise issues and access the complaints procedure. Clareville Road (3) DS0000013483.V316861.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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