Inspection on 20/09/04 for 40 Fir Tree Road

Care Homes For Adults (18 ­ 65)Fir Tree Road (40)40 Fir Tree Road Banstead Surrey SM7 1NGUnannounced Inspection20th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Fir Tree Road (40) Address 40 Fir Tree Road, Banstead, Surrey, SM7 1NG Email address Tel No: 01737 379242 Fax No:Name of registered provider(s)/company (if applicable) Community Integrated Care Name of registered manager (if applicable) David Render Type of registration Care Home No. of places registered (if applicable) 8Category(ies) of registration, with (number of places) Learning disability (3), Learning disability over 65 years of age (5), Physical disability (2), Physical disability over 65 years of age (4) Registration number H090000201 Date first registered Date of latest registration certificate 9th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 9th September 2003 Yes NO 25/5/04 If Yes refer to Part CFir Tree Road (40)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 320th September 2004 9.45am Peter BenthomID Code075672Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Judith Conteh - ManagerFir Tree Road (40)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementFir Tree Road (40)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Fir Tree Road (40). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Fir Tree Road (40)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The home is registered as a care home only within the service user category: Learning disability (LD) and Learning disability over 65 years of age. The home is registered to accommodate a maximum of seven Service Users and is managed by Community Integrated Care. The Home is a large detached house with extensive grounds to the front and rear and is situated on a busy main road, near to Banstead town centre. The service aims to provide a safe and homely environment that enables Service Users to develop to their maximum potential and where they are treated with dignity and respect. The staff aim to ensure that Service Users are very much an integral part of the homes operation despite their profound disabilities. The home provides a good standard of accommodation to its Service Users.Fir Tree Road (40)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) 1 Choice of Home (Standards 1-5) The standards assessed were met. The home had an updated statement of purpose, which accurately depicted the services provided by the home. 2 Individual needs and choices (Standards 6-10) Of the standards assessed one was seen to be partly met. The service user plans in place were comprehensive but must be updated and reviewed on a more regular basis to ensure that they accurately depict service users needs. Please see requirements. 3 Lifestyle (Standards 11-17) The standards assessed were met. . The home provided a high level of individualised support to service users. This was a commendable part of the homes operation. The menus provided were appetising and well presented using fresh foods where possible. Links with service users friends and family were well developed and maintained by the operation of the home. 4. Personal Health care and Support (Standards 18-21) The standards assessed were met. Service users health needs were well met. The home has a positive and supportive relationship with the local surgery. 5. Concerns, Complaints and Protection (Standards 22-23) The standards assessed were met. The home has a robust complaints procedure. There has been one Vulnerable Adult investigation following the injury of one Service User which was satisfactorily concluded. A revised risk assessment has been put in place for this Service User and it was examined on the day of the inspection. 6. Environment (Standards 24-30) Of the standards assessed one was found to be unmet. Generally the home followed the guidance set out in these standards. The home is well maintained and furnished to a high standard. It offers spacious and wellequipped accommodation to its service users. A plan for total refurbishment and re-decoration of the premises has been submitted to CSCI and work is to commence on the 26th September 2004. 7. Staffing (Standards 31-36) Fir Tree Road (40) Page 6 The standards assessed were met. There is a commitment from Community Integrated Care to provide staff with continual training and development. The acting manager has reviewed all staff training needs and is in the process of accessing appropriate training. Two new members of staff have been appointed since the last inspection and written references and CRB checks have been applied for. The new staff will have immediate access to the companys induction programme. Staff have received training in the protection of vulnerable adults but this needs to be updated. Please see requirements. 8.Conduct and Management of the Home (Standards 37-43) The standards assessed were met. Generally the management of the home was well implemented and met the standards outlined in this section. The registered manager has now left the service and the acting manager has been appointed as manager. An application for registration has not as yet been received by CSCI in realtion to the new manager. Please see requirements.Fir Tree Road (40)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Fir Tree Road (40)Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 18 (1) [c] (i) YA23 Staff training in the protection of vulnerable adults must be updated and evidence of training undertaken by staff to be available for inspection The service user plans in place were comprehensive but must be updated and reviewed on a more regular basis to ensure that they accurately depict service users needs. The manager must submit an application for registration as manager to CSCI without delay 31 December 200426 (a) (b)YA6.1031 December 2004 With immediate effect 20.09.0438 (1)(2)YA37RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard *PART BFir Tree Road (40)INSPECTION METHODS & FINDINGSPage 9 The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES NO NO NO NO NO YES NO NO YES YES NO NO NO YES NO YES 6 X X NA NA YES YES 12 X 22/9/04 9.30 3The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: Fir Tree Road (40) Page 10 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Fir Tree Road (40)Page 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 1225.96 1225.96 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Personal toiletries and holidays 3 Key findings/Evidence Standard met? The statement of purpose was well written and covered most of the criteria set out in Schedule 1 of The Care Homes Regulations 2001. The document is specific as regards the range of need that the servce caters for.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 2 Key findings/Evidence Standard met? The Service Users guide is in the process of being updated by the new manager. There is currently one Service User vacancy and the manager has undertaken to prepare the document and forward it to CSCI before the admission of the new Service User. The Inspector was advised that this will take place after the major alterations to the premises have been carried out.Fir Tree Road (40)Page 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home had a clear philosophy of care, which the management was able to discuss with the inspector. As yet the data provided by the home about the skill mix of staff did not enable the inspector to assess whether this would meet the collective and individual needs of service users. This will be reviewed at future inspections. However the discussions undertaken and practice observed on the day of inspection indicated that staff skills were complimentary to the needs of service users.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The procedures discussed with the management were considered to meet the criteria set out in this standard. Service users have the opportunity to visit the service prior to admission and the manager reported that she would carry out a full assessment of need in relation to any new prospective Service User.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? Service users had contracts with the home but these were held by CIC. There was no evidence of contracts or terms and conditions being provided to the service user. A contract/ terms and conditions should be provided to each service user. Again it is important to consider the communication needs of service users when compiling this contract/ terms and conditions Please see recommendations.Fir Tree Road (40)Page 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The service user plans includes all aspects of the individuals life, such as physical care; health needs; leisure and behaviour. Each individual had an ongoing reviewed individual plan developed with him or her and his or her representative.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Fir Tree Road (40)Page 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The inspector noted that the management ensured that service users views were realistically incorporated into the daily routines of the home and decisions about the day-to-day operation of the home, given their level of dependency and their communication difficulties.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Risk assessments are completed on all service users and a general risk assessment has been completed on the premises incorporating Health and Safety aspects. It was evidenced that risk assessments are made on according to the needs of the service user and are reviewed regularly.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Fir Tree Road (40)Page 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionStandard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionFir Tree Road (40)Page 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Staff support Service Users to become part of, and participate in community activities. Good communication is maintained with the neighbours of the home and the community is respectful and supportive of the home.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? All Service Users have varied and individually designed activity programmes which were sampled on the day of the inspection.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Staff attempt to maintain links with Service Users families. Any visitors could be entertained either in the service users own room or in the garden. Friends are invited to visit. The home has maintained some good family links. No restrictions were reported in terms of visiting times.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The daily routines and house rules do promote independence and individual choice and freedom of movement. All Service Users participate in the running of the home in as far as they are realistically able to. There is freedom of access to all parts of the home and all Service Users are very involved with each other on an almost continual basis, yet are free to enjoy the personal space of their bedrooms.Fir Tree Road (40)Page 17 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Menus viewed during the Inspection showed a good variety of healthy meals that had been chosen by the Service Users. Service Users are assisted with eating by staff and make it clear to staff their particular likes and dislikes despite their profound communication difficulties.Fir Tree Road (40)Page 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Personal support is given in private, and Service Users choose which clothes they want to wear. Guidance is given by staff regarding personal hygiene.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 1X3 Key findings/Evidence Standard met? A Service User recently contracted a fracture and was taken to the local Accident and Emergency unit. There was some delay in referring the Service User for treatment and as a result the matter was referred under the local authority multi-agency protection of vulnerable adult procedures for investigation. The matter has now been satisfactorily concluded and a full review of the Service Users risk assessment has taken place since.Fir Tree Road (40)Page 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The health care records for service users adequately recorded their needs. The management should ensure that any changes to service users medication is properly documented at the time of the change. No service users manage their own medication on account of their dependencyStandard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Fir Tree Road (40)Page 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? There have been no complaints since the last inspection. The home has a complaints procedure in place in line with CIG policies and procedures. All Service users have been supplied with a copy in pictorial format.Fir Tree Road (40)Page 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX2 Key findings/Evidence Standard met? The service has an adult abuse policy in place. Staff had received training in the protection of vulnerable adults. The Local Authority multi-agency procedures for protecting vulnerable adults were in place at the service. A whistle blowing policy has been introduced. However training needs to be updated to include all staff especially those who have recently been recruited. Please see requirements and also refer to comments under standard 19.Fir Tree Road (40)Page 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The standard of decoration and overall maintenance of the interior and exterior of the premises is adequate. However some communal areas require redecoration and communal carpets in the hallway, stairs and landing need to be replaced as soon as possible. A requirement was made during the last inspection regarding the replacement of worn and stained carpets and this is now in hand with a programme of total refurbishment and redecoration. It was reported that this work will commence on the 26/9/04.Fir Tree Road (40)Page 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was met. YES NO NO 7 1 0 0 Standard met? 3 7 71 0 0 0Fir Tree Road (40)Page 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Fir Tree Road (40)Page 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Service Users had the equipment that they needed in order to maximise their independence. This equipment includes mobile hoists and lifting equipment and the home has a passenger lift to enable Service Users to access the first floor with assistance from staff.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The premises were clean and tidy and free from any mal odours. Laundry facilities were viewed and were adequate for the size of the home and the needs of the Service Users.Fir Tree Road (40)Page 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? There are appropriate training opportunities in place for staff. There are arrangements in place for all staff to have regular access to training and a commitment from the organisation to provide staff with NVQ training. Four members of staff have NVQ Level 2.Fir Tree Road (40)Page 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 7 X X X 4 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? There are currently sufficient staff employed to meet the needs of the service user group, who are all of high dependency. Staff are able to work on a one to one basis with Service Users.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? CIC currently manages recruitment. Two written references are required for all staff and Criminal Records Bureau checks will be carried out on all future staff. The manager is involved in all aspects of staff recruitment and equally importantly staff induction programmes.Fir Tree Road (40)Page 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not assessed at this inspection.0Fir Tree Road (40)Page 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The manager is qualified to NVQ Level 3 and is currently studying for NVQ Level 4 and the Certificate in Management. She was appointed as manager of the service on 16/7/04 and therefore must submit her application for registration without further delay. Please see requirements.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Fir Tree Road (40)Page 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? The Inspector viewed the following records during this Inspection : Service Users Care Plans, Service Users Medication Records, the Staff Rota, Menus, Training Records and Staff Records. These records were in good order.Fir Tree Road (40)Page 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Staff were noted to receive training in matters of health and safety and ample information was available to advise staff as to safe practice, including lifting and the handling of corrosive materials. There is a Health and Safety procedure in place.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed at this inspection.Fir Tree Road (40)Page 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateMr P Benthom Mrs W KamaraSignature Signature SignatureFir Tree Road (40)Page 33 Public reports It should be noted that all CSCI inspection reports are public documents.Fir Tree Road (40)Page 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 22 September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Fir Tree Road (40) Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Fir Tree Road (40)Page 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Fir Tree Road (40)Page 37 Fir Tree Road (40) / 20th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000013494.V185208.R01© This report may only be used in its entirety. 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