Inspection on 19/01/07 for 36 Shooters Avenue

This inspection was carried out on 19th 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 but made no statutory requirements on the home.

Other inspections for this house

36 Shooters Avenue 15/07/08

36 Shooters Avenue 16/05/07

36 Shooters Avenue 25/10/05

36 Shooters Avenue 31/05/05

36 Shooters Avenue 07/01/05

36 Shooters Avenue 19/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 36 Shooters Avenue 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG Lead Inspector Robert Bond Key Unannounced Inspection 19th January 2007 10:00 DS0000017578.V325248.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 DS0000017578.V325248.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. DS0000017578.V325248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 36 Shooters Avenue Address 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG 020 8907 8270 020 8427 0458 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) Quality Family-Based Community Care Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000017578.V325248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No admissions until requirements met as per Notice dated 24th June 2005. That no more service users are admitted to the home, until such time as the registered person can demonstrate that requirements imposed on the home by the Commission for Social Care Inspection have been met or are being met satisfactorily as deemed by the Commission. Date of last inspection 25th May 2006 Brief Description of the Service: 36 Shooters Avenue is a care home providing personal care and accommodation for three people who have a learning disability. There were no vacancies in the home at the time of the inspection. The home is owned and run by Quality Family-Based Community Care (QFBCC), a local private and independent care service provider. The home has 24-hour staffing, including one staff member sleeping-over at night. It has been operating since 2001. The home is located within a residential area of Kenton, part of the London Borough of Harrow. The home is close to local shops and bus links, whilst tube links are around twenty minutes’ walk away. Parking restrictions do not apply on the road outside the home. The home’s drive can accommodate two vehicles. The premises are an adapted two-storey building. Two of the bedrooms are on the first floor, with the other on the ground floor. All are single rooms, fully furnished, and with built-in wash basins. The home has one bathroom with adapted shower facility, and toilets on each floor. Access to the first floor is by the stairs only. The home has a kitchen, a lounge, and a large rear garden that is shared with the next-door care home, also operated by QFBCC. The rent quoted in the Service Users’ Guide is £891.80 per month plus fees for the provision of care as determined by the Registered Provider according to service users’ needs. DS0000017578.V325248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the course of the inspection, the Inspector interviewed the Deputy Manager, met two other members of staff and met two service users. The Inspector toured the premises and examined a range of records. Residents of the home are referred to as Members by the Care Home but are called Service Users within this report because that is how they are referred to by the Care Home Regulations. The home was fully occupied by service users. The Deputy Manager reported that the home had one support staff vacancy, and that another support worker is on long-term sick leave. Gaps in the staffing rota were being filled by the Proprietor and members of her family. A relief support worker is being sought. There is no Registered Manager in place. This inspection was a ‘key’ inspection that assessed the homes performance against the key National Minimum Standards (NMS) created by the Department of Health for care homes for younger adults. In all, the Inspector assessed 27 standards. The Inspector found that 8 of the anticipated outcomes for the NMS assessed were fully met, 13 were only partially met, and 6 were not met. This led the Inspector to make 32 requirements. The previous CSCI inspection report dated 25th May 2006 contained 27 requirements. A Statutory Requirement Notice was issued by the CSCI on 7th November 2006 in order to seek compliance with unmet requirements. The Proprietors and Registered Manager have made progress in meeting the requirements made in May 2006 in that 13 of the 27 requirements have been fully met. Others have been partly met. However 10 requirements remain partially or fully unmet, and have been restated within this report. The home continues to function overall at an unacceptable standard and aspects of the Statutory Requirement Notice dated 7th November 2006 have not been complied with by the timescale that was set (5th December 2006). The CSCI will undertake a further management review to consider the appropriate action to take. What the service does well: The referral process for prospective service users includes a full assessment and a visit to the care home. Service users living in 36 Shooters Avenue are enabled to make choices to assist them to live as normal a life as possible. Risk assessments have been undertaken. Individual care plans are in place in the form of a series of objectives that service users and staff have signed up DS0000017578.V325248.R01.S.doc Version 5.2 Page 6 to. Medication is suitably administered, with appropriate records being kept. Leisure activities are made available, in the home and in the wider community. Links with family and friends are maintained. Service users’ rights are respected. Varied meals are provided, including fresh fruit. Service users are supported in having their personal and health care needs met. A satisfactory complaints procedure is in place. Staff members are NVQ trained. What has improved since the last inspection? What they could do better: The Registered Provider must appoint a Registered Manager for the home, and must seek a variation to the registration of the home so that service users with a sensory impairment may continue to be accommodated. DS0000017578.V325248.R01.S.doc Version 5.2 Page 7 The Statement of Purpose must be updated to reflect these changes, and must also contain the Registered Provider’s address. The objectives that form part of service users’ care plans must be reviewed at least monthly. The frequency of formal reviews must be audited. Activities must be provided to service users in line with their activity programme unless there is a good reason not to provide the activity. The reason must be recorded. All service users must receive adequate amounts of food and drink, without over long periods between meals. The home must maintain sufficient records to demonstrate these matters. The weight of service users must be taken and recorded on a regular monthly basis. Service users must be provided with a copy of the home’s complaints procedure in a format they can read, including Braille where appropriate. The home’s procedure concerning the Protection of Vulnerable Adults must show how and to whom any allegations of suspected abuse must be made. All staff who work in the home must be trained in applying the home’s and the London Borough of Harrow’s Protection of Vulnerable Adults policy and procedure. The refurbishment of the kitchen must be completed so that walls and skirting boards are made good. The patio must be cleared of rubbish. The rear garden fence must be repaired. All service users should be provided with a lockable storage space for valuables, unless a risk assessment indicates otherwise, which must be recorded in the care plan and agreed by the service user. The non-provision of this facility to a service user who is partially sighted or blind could be construed as discrimination. The smell of urine in the upstairs toilet must be eradicated. Evidence must be supplied to demonstrate that the washing machine and other plumbing meets the Water Supply (Water Fittings) Regulations, 1999. DS0000017578.V325248.R01.S.doc Version 5.2 Page 8 The Proprietor is required to supply the CSCI with a written explanation about how the roster provides sufficient staffing to meet the needs of service users throughout the week. Care homes must retain for inspection information and documents relating to the recruitment and checking of everyone who carries on, manages or works at a care home. The home must have in place clear records of training undertaken, a needs analysis of each staff member’s training needs, a training plan for the home as a whole for the year ahead, and a dedicated training budget. The training records must show the dates and extent of mandatory training, and when it is next due for each member of staff. The Proprietor must send the CSCI an evidenced report on how the mandatory training of staff has been achieved. The training of staff members in dealing with challenging behaviour, and in spotting and reporting potential abuse of service users has not been provided within the timescale set within a Statutory Requirement Notice. The system of formal professional recorded supervision of staff has broken down completely and must be reinstated. The care home is required to have in place a Registered Manager. A quality assurance system is required that involves collecting the views of service holders and other interested parties so that a development plan for the year ahead can be written. The owner is expected to undertake her own internal monitoring of the service and to report her findings in writing monthly to the manager and to the CSCI. Staff members must read all the home’s written policies and procedures and must sign a dated record stating that they have read and understood each of the policies and procedures. More attention must be paid to good record keeping. Regular health and safety audits to identify potential hazards within the care home must be undertaken. The fire safety risk assessment must take into account the needs of each service user. The CSCI requires the home’s certified accounts for the years 2004/05 and 2005/06. DS0000017578.V325248.R01.S.doc Version 5.2 Page 9 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. DS0000017578.V325248.R01.S.doc Version 5.2 Page 10 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 DS0000017578.V325248.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective and current service users do not have adequate information to make an informed choice as the home’s Statement of Purpose is not complete and the current registration of the care home is not sufficient. Prospective users’ individual aspirations and needs are not being assessed as the home has no vacancies and is not allowed to fill vacancies at present. EVIDENCE: The Inspector examined the home’s Statement of Purpose and the Service Users’ Guide. He found that the Statement of Purpose was not up to date and was not in line with the Care Home Regulations as it did not include an address for the Registered Provider. The name and qualifications of the Registered Manager quoted in the Statement of Purpose were those of the Registered Provider, who is not the Registered Manager. There is no Registered Manager in post. The Inspector noted that one of the existing service users is blind, but the home is not registered to accommodate service users with sensory impairment. When these matters are corrected, the Statement of Purpose (and Service Users Guide) will have to be amended. See Requirements 1, 2 and 3. DS0000017578.V325248.R01.S.doc Version 5.2 Page 12 No new service user has moved into the care home since the previous CSCI inspection. Indeed there is a registration condition in place forbidding any new admissions for the time being. Consequently the Inspector did not assess the quality of assessments undertaken on prospective service users, as none have been undertaken in recent times. DS0000017578.V325248.R01.S.doc Version 5.2 Page 13 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are adequately aware that their assessed and changing needs and personal goals are well identified in their individual plans, but reviews of care objectives must be more frequent. Service users are satisfactorily able to make decisions about their lives, with the necessary assistance provided. Service users are suitably supported to take risks as part of an independent lifestyle that is encouraged. EVIDENCE: The Inspector examined in detail (case-tracked) the care file of one service user. He found that the individualised care plan was a series of goals or objectives that were selected from a list of 25 possible topics, and which were personalised and amended according to individual need and progress. Examples of objectives included ‘cleaning teeth’, ‘preparing dinner’, and ‘changing the duvet cover’. The objectives are therefore promoting independence and relate to daily living. Each objective is clearly written up, DS0000017578.V325248.R01.S.doc Version 5.2 Page 14 and the service user and the staff members of the home sign their consent to aiming to achieve the objective. Thus service users are shown to be involved in the care planning process. Progress in achieving the objectives is supposed to take place monthly. This is the task of the Office Manager (for 34 and 36 Shooters Avenue), who is also the designated Reviewing Manager. Unfortunately the review process has fallen behind and has not taken place since November 2006. See Requirement 4, which is restated. The last formal review of the care of the service user who the Inspector casetracked was held on 19th June 2006. The care home prepared a detailed summary review of the care objectives, and the service user’s mother attended the meeting. The Inspector, when he requested it, was not shown any evidence of the auditing of the frequency of formal review meetings, hence Requirement 30 is restated. The Inspector examined minutes of a service user group meeting held on 12th January 2007. Independence is clearly promoted and risk assessment and risk management form part of the care planning process. DS0000017578.V325248.R01.S.doc Version 5.2 Page 15 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 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. According to individual activity programmes, service users have an adequate range of activities to attend, but further evidence is required concerning actual attendance. The activity programme contains sufficient community events. Family contacts are promoted but visitors are few. Service users rights and responsibilities are sufficiently recognised. Service users eat in suitable surroundings but further evidence is required concerning the amount of food and drink, and the times of serving. EVIDENCE: When the Inspector arrived at the care home at 10.15 am, one service user had gone to the Irish Club as per his activity programme, whereas the other two service users were still in bed. The Deputy Manager reported that they both had ‘days off’ from their usual activities and had chosen to lie in. At lunchtime (12.15 pm), one service user had finished her breakfast of toast, but DS0000017578.V325248.R01.S.doc Version 5.2 Page 16 the other service user was still eating a boiled egg. If this meal was their lunch as well as their breakfast, it may be that service users are not receiving a sufficient number of meals each day, and at the correct frequency. The CSCI require a report from the Registered Provider to detail the reasons why no activity was provided for two of the service users on the morning of 19th January 2007, what activity was scheduled to take place in the service users’ activity plans, who decided that the service users should lie in and why, how this decision was recorded, and exactly what the service users had to eat and drink and at what times during the whole of that day. See Requirements 5 and 6. The activity plan examined indicated that the service user in question attended Welldon Day Centre, Barnet College, went on outings, and visited the cinema, pub, and the library. The Deputy Manager reported that home has use of a car but a shortage of drivers for it. However staff members accompany service users on the public bus, and use is made of Dial-a-ride. The Inspector noted one of the service users reading a Braille book. The Deputy Manager reported that service users assist in running the care home by for example tidying their rooms or making their beds. Review notes confirm the involvement of one relative, but the Inspector noted from the Visitors Book that no-one had signed in during the previous 4 week period. The Deputy Manager confirmed that no visiting had taken place during this time as service users had ‘gone home for Christmas’. The Inspector noted that MENCAP periodically visited the home. The Inspector examined a sample menu, which was satisfactory. Frozen foods are stored in a freezer at 34 Shooters Avenue. Meals are served at a table in the joint lounge and dining room, which is a suitably pleasant place to eat. In this room was a bowl of fresh fruit, which is commended. DS0000017578.V325248.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users receive good personal support in the way they prefer and require. Service users’ physical and emotional health needs are satisfactorily met, but the record of weight is not being maintained sufficiently well. Service users are adequately protected by the home’s medication procedure. EVIDENCE: The Inspector found that details of service users’ personal care needs and how to meet those needs were recorded in sufficient detail in their care files. The Inspector overheard support staff assisting service users to get washed and dressed. A member of the support staff was heard to knock on doors and to treat service users with respect. Service users were seen to be well groomed and appropriately dressed. The Inspector found that service users’ health care needs, and how they were being met, were recorded in their care files. Details of health related DS0000017578.V325248.R01.S.doc Version 5.2 Page 18 appointments were seen by the Inspector, such as use of a chiropodist, an optician, and visits to a clinic for dressing an ulcer on a service user’s heel. A chart is used for each service user to record their weight and monitor any change on a monthly basis. The example the Inspector examined had not been completed since 18th November 2006 (two months before), and the October 2006 entry was also blank. See Requirement 7. The Inspector examined the medication storage and record keeping. No errors or omissions were noted. Correction fluid had not been used as previously. Boots the Chemist undertake auditing of the system. DS0000017578.V325248.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. Service users can feel satisfied that their views are satisfactorily listened to and acted upon, but one service user does not have a copy of the complaints policy in a format that she can read. Due to an inadequate procedure, and a lack of staff training, there is insufficient evidence to say that service users are adequately protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints policy, which is satisfactory. The home’s Service User Guide contains a service user friendly version of the home’s complaints procedure. However as one of the service users is blind, previous requirements have been made by the CSCI that she be provided with a copy of the home’s complaints procedure in Braille. The Inspector noted that an email had been sent by the home to Harrow Association for the Blind on 19th October 2006 requesting this Braille document. The Deputy Manager reported that the document had not been received, and as no good reason was available for non-receipt of the document, and as no chasing up had been undertaken by the home, Requirement 8 is restated. The Inspector examined the home’s complaints log. No complaints were recorded and no complaints were made to the Inspector by service users. The Inspector examined the home’s Protection of Vulnerable Adults policy and procedure. The procedure must be expanded as it does not indicate how and to DS0000017578.V325248.R01.S.doc Version 5.2 Page 20 whom allegations of abuse should be made. The nationally agreed arrangement is that allegations of abuse must be reported by the management of care homes to the Safeguarding Adults Co-ordinator in the local Social Services Department (London Borough of Harrow) for action, and to the local office of the CSCI (Harrow) for information. See Requirement 9, which is restated. The Deputy Manager reported that staff in the home had not yet received POVA training. See Requirement 10, which is restated. DS0000017578.V325248.R01.S.doc Version 5.2 Page 21 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. Service users live in an environment that is comfortable but not sufficiently homely or safe due to rubbish on the patio, broken garden fences and dangerous cleaning chemicals being stored where service users could easily access them. The home is not sufficiently clean and hygienic as the upstairs toilet smelt of urine. EVIDENCE: The Inspector toured the premises, and asked to see into the service users’ bedrooms. He was shown into the bedrooms by the Deputy Manager without permission being sought from the service users, who were downstairs at the time. The bedrooms were seen to be suitably equipped, furnished and decorated except that one service user had no lockable space. The Deputy Manager responded that although one service user had a lockable box to store valuables, the other service user was blind and hence no box was provided. DS0000017578.V325248.R01.S.doc Version 5.2 Page 22 This omission raises concerns of possible discrimination. The service user in question was seen by the Inspector to make her way around the home unaided, and it is possible she could locate and use a lockable cabinet or box within her bedroom. Hence the Proprietor must consider as part of the care planning process and risk management process whether it is possible for the service user to be provided with a lockable space for her personal valuables in line with normal practice. If the risk assessment indicates it is not advisable to provide that facility, this and the reasons for the decision must be recorded in the care plan, and agreed by the service user. See Requirement 32. The Inspector found the home overall to be adequately decorated and furnished overall. The lounge/dining room is a pleasant room to spend time in. The kitchen has recently been refurbished but the work has not been finished in that walls and skirting board have not been made good. The Deputy Manager reported that the walls are going to be tiled. See Requirement 11. The kitchen contains a washing machine and tumble drier. The Deputy Manager reported that service users do not experience incontinence and hence soiled laundry is not being washed in a food preparation area. The Proprietor is required to submit to the CSCI written evidence obtained from a professional that the washing machine and other plumbing within the premises complies with the Water Supply (Water Fittings) Regulations of 1999. See Requirement 31. The Inspector found within an unlocked kitchen cupboard ‘Mould Killer’, ‘Appliance Descaler’, and ‘Oven Cleaner’. In an unlocked cupboard under the stairs, the Inspector found ‘Paint Stripper’. All these chemicals are injurious to health and their containers are marked as such. These materials come under the C.O.S.H.H. Regulations and must be kept securely. An immediate requirement has not been made on this occasion as the materials were locked away in the presence of the Inspector. Requirements concerning this aspect of the home being unsafe for service users are contained in the Health and Safety section of this report. Previous CSCI inspections have identified the need to clear the back garden of rubbish, and although this has been largely undertaken, the patio was seen to have a large quantity of broken or waste items stored upon it. This is a health and safety hazard for service users. Requirement 12 is restated. The rear garden fence was seen to have blown down in several places. This creates security and health and safety hazards for service users. See Requirement 13. In most areas the home was clean enough, but the upstairs toilet smelt of urine and hence efforts must be made to eradicate the smell and keep it clean. Requirement 14. DS0000017578.V325248.R01.S.doc Version 5.2 Page 23 DS0000017578.V325248.R01.S.doc Version 5.2 Page 24 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 poor. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff members who are competent and sufficiently trained in terms of NVQs, but not in terms of required specialist training. There is insufficient evidence to judge whether service users are adequately protected by the home’s staff recruitment practice, as insufficient records were available for inspection. Staff members are not appropriately trained in order to fully meet service users’ individual and joint needs, as certain mandatory training has not been provided. The Deputy Manager and other staff are not receiving formal supervision, to the likely detriment of service users. EVIDENCE: The Deputy Manager reported that one support worker had left since the last CSCI inspection, and another support worker had gone on long term sick leave. The Inspector asked about recruitment and was told that no one had been recruited but that the Proprietor was advertising for a relief support worker with a driving licence and an NVQ level 2 award. The Deputy Manager added that nobody had applied as yet. DS0000017578.V325248.R01.S.doc Version 5.2 Page 25 The Inspector examined the current staff rota. Sufficient staff were rostered to be on duty as the Proprietor and her family covered the shifts as necessary. On the day of the inspection, one of the Proprietor’s daughters, who was working as a support worker, was seen in both adjacent care homes. See Requirement 15, which is restated as the CSCI have not received from the Proprietor the required explanation about how the roster provides sufficient staffing to meet the needs of the service users throughout the week. A search for a copy of this document was made at 34 and at 36 Shooters Avenue by both the Deputy Manager and the Office Manager but it could not be located. As no staff recruitment had taken place in recent times, and as the extent of staff records within the home was very limited, the Inspector was unable to verify that suitable references and CRB’s had been obtained on every one who works in the home. A valid CRB was seen for one long time support worker who had transferred from a QFBCC care home that had closed, but her references were not available for inspection. The Care Home Regulations, Schedule 2, specify the information and documents that must be available for inspection in respect of persons carrying on, managing or working at a care home. See Requirement 16. The Deputy Manager reported that she had an NVQ qualification. The Inspector asked to see the home’s training records and was shown the certificates obtained by the Office Manager during November 2006 in Food Hygiene and in Health and Safety. Several staff members had been scheduled to also undertake First Aid training but the records in the home were confusing about when this had taken place. A letter confirming the dates for First Aid training showed the date as 1st November, and in handwriting the date was also shown as 31st November. Since November does not have 31 days, the Inspector asked to see the home’s diary, appointment book, or daily notes for 2006 so that he could obtain from that record the correct date of the First Aid training. No such daily record of events for 2006 could be produced. See Standard 41 for the requirement made. The Office Manager subsequently reported that the First Aid training had taken place on 30th November 2006. The Inspector enquired about the mandatory training courses and training in Challenging Behaviour and in Adult Protection that had been required in previous CSCI inspection reports and in a Statutory Requirement Notice dated 7th November 2006. The Deputy Manager was not able to produce clear evidence that all the mandatory training had been undertaken as necessary by all staff members as the home did not have in place satisfactory training records for each member of staff, and for the home as a whole. See Requirement 17, which is restated and which requires a training plan and a dedicated training budget. Requirement 18 stipulates that each staff member must have a training needs analysis undertaken as part of their appraisal. The Deputy Manager stated that staff appraisals had been started. Requirement 19 requires the Proprietor to provide a written report to the CSCI naming the DS0000017578.V325248.R01.S.doc Version 5.2 Page 26 current staff employed at the care home (including the Proprietor and her husband if they undertake management or support worker shifts) and indicating the dates on which named person undertook their mandatory training, including: fire safety training, food safety, first aid, manual handling, medication, COSHH, and health and safety. The Deputy Manager reported that the training in Challenging Behaviour had not taken place as the trainer required a minimum of four trainees, and one staff member had left her employment. The Deputy Manager added that training in Adult Protection had not taken place either. No dates or alternative training arrangements had been made as far as the Deputy Manager was aware. See Requirement 20. The Statutory Requirement Notice dated 7th November 2006 has not been fully complied with. The Inspector asked to see the home’s record of formal staff supervision. The Deputy Manager was unable to produce the records, saying that one support worker had left and one was on long-term sick leave. The Inspector therefore asked to see the record of her supervision by the Proprietor. The last entry was dated 28th March 2006. See Requirement 21. The Proprietor is not undertaking the Regulation 26 visits and reports that are required and which often form part of the supervision process of the manager in other care homes. See Requirement 24. DS0000017578.V325248.R01.S.doc Version 5.2 Page 27 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, 40, 41 42 and 43. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not sufficiently well run and to the benefit of service users as evidenced by the number of requirements. There is no Registered Manager in post. Self-monitoring, review and development processes involving service users are not adequately refined, and auditing the home by the Proprietor in the form of Regulation 26 visits and reports is not taking place. Service users’ best interests are not sufficiently safeguarded by the homes policies as the POVA policy is inadequate, staff have not been trained in it, and staff have not yet read all the policies and signed that they have understood them. Some record keeping is not satisfactory, to the possible detriment of service users. The health, safety and welfare of service users are not satisfactorily promoted and protected. Management is not sufficiently accountable or competent as evidenced by their failure to meet previous CSCI requirements. DS0000017578.V325248.R01.S.doc Version 5.2 Page 28 EVIDENCE: The home does not have a Registered Manager in place, and is currently being managed by the Deputy Manager, who is also the Registered Manager for the next door care home. The Proprietor has submitted proposals for the future management of the home in her action plan following the previous CSCI inspection, but the proposals do not include the required Registered Manager post. See Requirement 22. The Inspector noted minutes of a staff meeting that took place the previous week. The home obtains service users’ views when creating and reviewing care plan objectives, and via service users’ meetings. There is not however a Quality Assurance process in place, as previously required. See Requirement 23. The Proprietor is not undertaking Regulation 26 visits and producing monthly reports for the manager of the home and for the CSCI. This process is a key element in the self-monitoring of services. See Requirement 24. The Inspector examined the home’s set of policies. As reported elsewhere in this report, the Protection of Vulnerable Adults procedure is not complete. Neither is there a policy on Challenging Behaviour. The previous CSCI inspection required the owner to ensure that there is documentation to show that staff members have read the home’s policies. The Deputy Manager explained that a system is being established whereby staff members sign to confirm that they have read and understood the policies, but the Inspector found that no-one had yet signed the pro-forma that had been created. Requirement 25 is therefore restated. The previous CSCI inspection report required that judgemental terminology be avoided when describing service users’ behaviour. The Inspector was shown evidence of where records had been changed accordingly. However in other areas the Inspector found record keeping to be lacking. Examples quoted already in this report are gaps in the weight records of service users, gaps in the monthly reviews of service users’ objectives, confusing records concerning when First Aid training took place, a lack of proper training records, an absence of any diary, appointment book or daily records for 2006, a lack of staff recruitment records, and an inability to find a copy of a report allegedly already submitted to the CSCI. Requirement 26 is therefore that more attention must be paid to good record keeping. DS0000017578.V325248.R01.S.doc Version 5.2 Page 29 In terms of health and safety, reference has already been made to a substantial breach of the C.O.S.S.H Regulations. Although the absence of safe storage of chemical cleaners was corrected whilst the Inspector was present, the incident highlights the lack of health and safety awareness amongst staff in the home, and a lack of health and safety auditing by the management of the home. Hence Requirement 27, which requires the management to set up a regular system of health and safety audits, such as the use of a check list of potential hazards that is completed weekly. The use of a system of self-audits will build upon the work already undertaken to assess health and safety generally within the care home. The Deputy Manager reported that fire safety training took place on 26th September 2005, but that the use of health and safety videos for in-house training purposes has been abandoned. A fire safety report from the Fire Service is awaited. The Inspector examined the home’s fire safety risk assessment together with the Office Manager who had undertaken it. The Inspector explained why the requirement was not yet met as the assessment did not include the needs of service users who might for example need special assistance in terms of responding to an alarm or in evacuating the building in a hurry. Requirement 28 is restated. The Inspector saw evidence of regular smoke alarm tests, fire alarm tests, and home evacuations. The recording of fridge temperatures was satisfactory. The CSCI have received the Registered Person’s certified financial accounts for the year 2003/04, but none for subsequent years, hence Requirement 29 has been made. The management structure of the home is unclear. The home is being managed by the Deputy Manager, who is the Registered Manager for the home next door. There is no Registered Manager. The two homes together have an Office Manager, and QFBCC has a General Manager. The Proprietor has proposed having a Deputy Care Manager and a Reviewing Manager, but there is no potential Registered Manager identified. NMS 43 requires that clear lines of accountability exist within the care home, and with any external management, so that the management arrangements are clearly understood by staff and service users. DS0000017578.V325248.R01.S.doc Version 5.2 Page 30 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 2 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 1 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 2 33 x 34 2 35 1 36 1 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 2 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 1 x 1 2 2 2 1 DS0000017578.V325248.R01.S.doc Version 5.2 Page 31 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA1 YA1 YA1 Regulation 4(1)©Sch1(1) 8(1) 4(3)(b) Requirement The Statement of Purpose must include the address of the Registered Provider. The Registered Person must appoint a Registered Manager. The Registered Person must seek from the CSCI a variation to the registration of the home to enable them to accommodate service users with sensory impairment. The Registered Person must ensure that as per the home’s policy on service user objectives, monthly reviews of key objectives take place and are recorded. THIS IS RESTATED AS THE PREVIOUS TIMESCALES OF 15/10/5, 15/12/05 AND 09/11/06 HAVE NOT BEEN MET. The Registered Person must supply to the CSCI a report concerning activities that should have been provided to service users DS0000017578.V325248.R01.S.doc Timescale for action 01/03/07 01/04/07 01/03/07 4. YA6 15(2)(b) 01/03/07 5. YA12 16(2)(m) 01/03/07 Version 5.2 Page 32 on 19/01/07. 6. YA17 16(2)(h)Sch4(13) The Registered Person must supply to the CSCI a report concerning the food and drink provided to service users on 19/01/07. 12(1)(a) The Registered Person must ensure that service users’ weight is recorded monthly. 22 Service users must be provided with a copy of the complaints process within their rooms, in Braille if necessary. THIS IS RESTATED AS TIMESCALES OF 15/10/05, 15/12/05 AND 09/11/06 HAVE NOT BEEN MET. 13(6) The Registered Person must ensure that the home’s POVA procedure shows how allegations of abuse are to be reported. 13(6) The Registered Person must arrange the training of all staff working in the care home in the POVA reporting procedure. 23(2)(b) The refurbishment of the kitchen must be completed 23(2)(o) All excess, waste, and broken items must be disposed of or removed out of communal areas of the home [including the patio]. THIS IS RESTATED AS PREVIOUS TIMESCALES OF 15/2/05 AND 1/8/05 ARE ONLY PARTIALLY MET. 23(2)(o) The rear garden fence must be reinstated in order to create a safe environment for service users. 23(2)(d) The smell of urine in the upstairs toilet must be eradicated. DS0000017578.V325248.R01.S.doc 01/03/07 7. YA19 01/02/07 8. YA22 01/04/07 9. YA23 01/03/07 10. YA23 01/04/07 11. 12. YA24 YA24 01/04/07 01/03/07 13. YA24 01/03/07 14. YA30 01/03/07 Version 5.2 Page 33 15. YA33 18(1)(a) 16. YA34 Sch2,19 17. YA35 18(1)(c) 18. YA32 18(1)© 19. YA35 18(1)© 20. YA35 18(1)© The owner must provide explanations about how the rosters provide sufficient staffing to meet the needs of service users throughout the week. THIS IS RESTATED AS PREVIOUS TIMESCALES OF 22/2/05 AND 1/8/05 HAVE NOT BEEN MET. The home must maintain for inspection all the information and documentation used for recruitment and checking of staff that are required in Schedule 2. The home must have a training and development plan, with a designated training budget. THIS IS RESTATED AS THE PREVIOUS TIMESCALE OF 1/6/04 HAS NOT BEEN MET. All staff members must have a training needs analysis undertaken as part of their appraisal. The Registered provider must provide the CSCI with a written report with evidence on how the requirement concerning mandatory training contained in the Statutory Requirement Notice dated 7th November 2006 has been met. All staff must receive up to date external training on challenging behaviour and adult protection. THE TIMESCALE OF 5TH DECEMBER 2006 SET IN THE STATUTORY NOTICE DATED 7TH NOVEMBER 2006 HAS NOT BEEN MET. DS0000017578.V325248.R01.S.doc 01/04/07 01/04/07 01/04/07 01/04/07 01/03/07 01/04/07 Version 5.2 Page 34 21. YA36 18(2) 22. YA37 8 23. YA39 21, 24 24. YA39 26 25. YA40 18(1)(c), (2) 26. YA41 17 27 YA42 13(4)(a) The Registered Person must ensure that all staff receive formal supervision at least six times per year and have an annual appraisal. The Registered Person must appoint and submit to the CSCI for registration the name of that person so that they may become the Registered Manager. A system of regular reviewing, and improving, the quality of care provided at the home, including through consultation with service users and their representatives, must be set up. Reports of such reviews must then be supplied to service users and their representatives, and the CSCI. THIS IS RESTATED AS PREVIOUS TIMESCALE OF 01/09/03 HAS NOT BEEN MET. The Registered Person must undertake visits and produce monthly reports for the manager and for the CSCI as per this regulation. The owner must ensure that there is documentation to show that staff have read the home’s policies. THIS IS RESTATED AS THE TIMESCALE OF 01/12/05 HAS NOT BEEN MET. More attention must be paid to record keeping and the omissions identified in this report must be corrected. An audit of the potential hazards in the care home must be undertaken on a regular basis. DS0000017578.V325248.R01.S.doc 01/03/07 01/03/07 01/05/07 01/03/07 01/04/07 01/04/07 01/03/07 Version 5.2 Page 35 28. YA42 23(4) 29. YA43 25 30. YA6 15 31. YA30 13(4)© 32 YA24 23(2)(m) The fire-safety risk assessment must be improved upon, as it was seen to miss a number of potential hazards including the needs of each service user. THIS IS RESTATED AS THE PREVIOUS TIMESCALE OF 01/09/04 HAS NOT BEEN MET. A copy of the accounts for the financial years 2004/05 and 2005/06, including details of the running costs of the home, rent, payments under a mortgage, and expenditure on food, heating and staff wages, must be sent to the CSCI. A copy of the business and financial plans for the home must additionally be kept at the home. The owner must audit when the last formal review meeting was for each service user and ensure that these reviews are undertaken at least every 6 months. Summary records of the meetings must also be kept. THIS IS RESTATED AS THE PREVIOUS TIMESCALES OF 15/10/05 AND 09/11/06 HAVE NOT BEEN MET. The Registered Person must supply to the CSCI a written report from a professional confirming that the plumbing arrangements within the care home comply with the Water Supply (Water Fittings) Regulations, 1999. All service users are to be DS0000017578.V325248.R01.S.doc 01/04/07 01/03/07 01/04/07 01/04/07 01/03/07 Page 36 Version 5.2 provided with a lockable space for their personal valuables. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000017578.V325248.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000017578.V325248.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!