Inspection on 10/10/06 for 54 Leylands Road

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

54 Leylands Road 15/05/07

54 Leylands Road 16/01/06

54 Leylands Road 22/08/05

54 Leylands Road 09/11/04

54 Leylands Road 29/06/04

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

CARE HOME ADULTS 18-65 54 Leylands Road 54 Leylands Road Burgess Hill West Sussex RH15 8AL Lead Inspector Mrs M McCourt Key Unannounced Inspection 10th October 2006 11:40 54 Leylands Road DS0000014663.V308805.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 54 Leylands Road DS0000014663.V308805.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. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 54 Leylands Road Address 54 Leylands Road Burgess Hill West Sussex RH15 8AL 01444 870546 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) Sussex Oakleaf Housing Association Limited Mr Prabhooraj Unmar Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: 54 Leylands Road (previously registered as Peppers) is a care home registered for up to six service users in the category of mental disorder (excluding learning disability or dementia), one of whom can be in the category of mental disorder over 65 years of age (excluding learning disability or dementia). The registered provider is Sussex Oakleaf Housing Association Limited, for whom the Responsible Individual is Mr Neil Perkins. The registered manager is Mr Prabhooraj Unmar. The current scale of monthly charges range from £1,024.87 to £1,118.65. This information was obtained from the Pre-Inspection Questionnaire. Additional charges are made for personal items. 54 Leylands Road is a detached property, with accommodation provided over two floors. In addition there are extensive grounds that can be easily accessed by the residents. The home is located in a residential area of Burgess Hill, with easy access to nearby bus and train services. The Service Users Guide and Statement of Purpose can be located at the home, and are accessible to Service Users, staff, relatives and anyone else interested in the service. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Tuesday 10th October and Wednesday 11th October 2006, spanning two days and lasted a total of eight and a half hours. Pre-inspection planning took approximately two days. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Three staff members and the Registered Manager were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with two Service Users accommodated at the home. Policies and procedures were examined during the site visit. What the service does well: The home actively encourages Service Users to attend regular resident’s meetings, where a variety of issues are raised and taken forward to the next meeting. Service Users are very able and can make choices about their daily lives. There were good examples of how staff work hard to support individuals to accomplish set goals. One resident living at the home has been supported with a particular goal, details of which are in the body of the report. With assistance and support from his keyworker, he has been able to improve the quality of his life and achieve what he had set out to do. Medication records and storage was excellent. The Inspector found no gaps in signing and written records were up to date and accurate. The storage of medication was very tidy and orderly. The Registered Manager is a RMN who is very ‘hot’ on medication issues and who holds in-house training regularly. Staff are supervised whilst they are being inducted for at least several weeks, until the Registered Manager is confident that the person is competent. The environmental tour found the home to be clean, bright and comfortable. The Inspector looked at a sample of bedrooms, and these were found to be personalised to suit individual taste. The Garden is being well maintained by a gardener, and there was an array of flowering plants and an ornamental 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 6 pond. To the side of the building there is an allotment area where fruit and vegetables are being grown. The Inspector saw some large pumpkins that had been grown and were being stored in the green house. Staff and Service Users benefit from a supportive management structure, and it was noted that the deputy manager had worked hard to maintain the smooth running of the home in the Registered Manager’s absence. What has improved since the last inspection? What they could do better: During the course of the visit, the Inspector learned that the TV in the lounge is switched off every evening at 11pm, unless someone is watching a film, and then it is permitted to stay on until midnight. In addition Service Users must vacate the kitchen by 11pm so that staff in the sleeping-in room are not disturbed. The Inspector was of the opinion that this practice infringes on Service Users’ rights. Complaints are at times received from Service Users, but are not then entered in the home’s complaints log. The Inspector advised the manager that any complaints, regardless of how minor, should be recorded, otherwise the home is not seen to be taking its own policies/procedures seriously. Records examined during the inspection found that despite Adult Protection training being highlighted in a previous report, there are still gaps with some staff not having attended the course. There had been two staff booked to go on training in April 2006, but it was postponed. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. Staff training was highlighted at the previous inspection. At that time medication training and manual handling training were outstanding. In addition the majority of staff had not received the expected amount of mental health related training or Adult Protection training. Due to staffing and management issues over the past few months, training is still to be addressed. Core training and development issues also need to be looked at. The Inspector was told that although the company offers in-house training, courses 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 7 are sometimes cancelled and the manager is unable to release staff due to costs incurred by covering their shifts. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. It came to the attention of the Inspector that a support worker post has been reduced. The result would be that one member of staff would be left to work alone for two short periods of time throughout the day. The Inspector considered that this would leave the staff and Service Users vulnerable and for that reason this is unacceptable given the high needs of the client group. 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. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The quality in this outcome area is good. The judgement has been made using available evidence, including a visit to the service. Prospective Service Users individual needs are assessed prior to admission. A Statement of Purpose is available to Service Users and visitors. Contracts between the home and the Service User, detailing breach of contract, are in place and were found to be signed and dated. EVIDENCE: Statement of Purpose and Service Users Guide are available at the home. As all residents can read well, it is not necessary for either of them to be in any other format. An independent living plan is completed for individuals on admission to the home. One looked at was due to be reviewed in March 2006, but had not been and some care plans were also over due their review date. In addition the care plan looked at had not been signed by the Service User and although the Inspector was told that the person had refused to sign it, there was no 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 10 evidence of a statement documenting his refusal either. A care plan meeting is held every six weeks to discuss pertinent issues. A risk assessments matrix is in place covering behaviour, medication, health, safety and the welfare of Service Users. However, whilst it is a good example, it had not been reviewed since April 2005. Individual risk assessments are done as and when identified. CPN reviews are carried out every three months and the Inspector looked at notes from one meeting dated August 2006 with the next one planned for November 2006. Contracts were in place and the Inspector looked at two, both of which were signed and dated. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. The quality in this outcome area is adequate. The judgement has been made using available evidence, including a visit to the service. Service Users are supported to take risks as part of an independent lifestyle, but risk assessments need to be reviewed on a regular basis. Although Service Users are supported to make decisions, individual rights are not respected as much as they could be. EVIDENCE: The Inspector spoke with a Service User who said that he is involved in the review of his care plans on a regular basis. The resident has lived at the home for 9 years, although he wants to work towards living independently. He told the Inspector that the staff are ‘alright’, although he believes that some of his concerns are not taken seriously. He said that he has an advocate but does 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 12 not know their name or what they are doing for him. Details of the advocate were found in his personal file and the Registered Manager told the Inspector that he was in possession of minutes from a finance meeting, at which the advocate was present. The Service User told the Inspector that he does manage to go out and about several times a week to the cinema, shops and so on. He also said that there is not enough for him to do, and he would like to drive again but cannot due to the medication he is currently taking. Service Users meetings take place on a regular basis and the Inspector looked at the minutes for meetings held in May, July, Aug and Sept of this year. Subjects discussed include a variety of issues and those raised are taken forward to the next meeting. Service Users are very able and can make choices about their daily lives. However, the Inspector learned that the TV in the lounge is switched off every evening at 11pm, unless someone is watching a film, and then it is permitted to stay on until midnight. In addition Service Users must vacate the kitchen by 11pm so that staff in the sleeping-in room are not disturbed. The Inspector was of the opinion that this practice infringes on Service Users’ rights. One Service User uses a local advocacy group for advice on finances. At least two advocacy contact details are on prominent display within the home. Risk management strategies are documented but need reviewing on a more regular basis. Occupational therapy reports had been carried out in May 2005, but not followed up since that time. Written procedures for unexplained absences are in place, providing a clear process for staff to follow and are found within the Emergency On-call Procedure manual. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 and 17. The quality in this outcome area is good. The judgement has been made using available evidence, including a visit to the service. Service Users are encouraged to take part in appropriate activities and are encouraged to access their local community, but it is often difficult to motivate people due to their illness. Service Users self cater and are encouraged to eat healthily. EVIDENCE: Currently, very few of the residents accommodated at the home attend educational courses or opportunities to develop life skills. This is partly due to the nature of their health problems, which makes it difficult to motivate at least four of the Service Users, and the affects of medication is also a factor. One Service User has however managed to achieve an NVQ level 1 in art at Lewes College previously. Another Service User is a volunteer and another works part time at a resource centre in Burgess Hill. Service Users do have 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 14 access to a drop in centre, run by MIND and one of them attends on a fortnightly basis Residents have access to a ‘Get together’ club held weekly in Haywards Heath. A Service User spoken with confirmed that he does receive visitors sometimes and is able to see them in private if he chooses. Service Users also hold keys to their own rooms. The Registered Manager told the inspector that one of the Service Users has a dual diagnosis, but there is no social worker involved in his care. The home has tried to involve a designated social worker, but a CPA meeting is held each year instead. As previously highlighted, Service Users are asked to leave the lounge and kitchen at a designated time each evening. Five Service Users self cater and the remaining one has meals provided to him by staff. The inspector sampled lunch with residents and was presented with a mushroom, ham & cheese omelette, which was well presented and tasty! 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The quality in this outcome area is good. The judgement has been made using available evidence, including a visit to the service. The home provides Service Users with both physical and emotional support, with assistance from other health professionals if necessary, although more frequent reviewing of health issues should take place. Medication procedures are excellent with no discrepancies found. EVIDENCE: Flexible regimes for getting out of bed, mealtimes, activities and so on are usually respected. The home has a keyworker system in place, but due to some recent staffing problems, there have been gaps in key working duties. The Registered Manager is working to rectify these issues. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 16 A diary system and weekly white board is used to plan health appointments and specific activities. CPA, psychiatric and OT assessments were seen to be in place. Monitoring and reviewing of specific health conditions is not regular enough, but again, this may be due to the staffing problems the home has recently experienced. One Service User does receive regular support meetings held every four to six weeks, and these are attended by his care manager, the Registered Manager and his family. The Inspector was told how one of the residents living at the home has been supported to lose weight and live a more healthy lifestyle. Together with regular exercise and support from his keyworker, who devised a diet plan and exercise regime, he has managed to lose an amazing amount of weight and become much fitter and therefore happier. Medication is stored in a locked metal cabinet and located within the office that is also kept locked. On examination of MAR sheets the Inspector found no gaps in signing and written records were excellent. The storage of medication was very tidy and orderly. Two staff count out the tablets or check the medication to be administered for each resident. One will then administer the medication. Each week staff do a stock take of all the medication, record the quantities and then sign to confirm it has been done. The Registered Manager is a RMN who is very ‘hot’ on medication issues and who holds in-house training regularly. Staff are supervised whilst they are being inducted for at least several weeks, until the Registered Manager is confident that the person is competent. The Inspector was told that all staff are made to read policies and to read the information sheets on all medication, noting the contra indications. They must also learn about ordering, stock checks, administration, disposal and what to do when problems arise. When the staff member is deemed competent they are issued with a certificate to allow them to administer. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is adequate. The judgement has been made using available evidence, including a visit to the service. The home does have good policies and procedures in place, however Service Users do not feel their views are listened to, and more needs to be done to ensure their concerns are acted on. All concerns, regardless of how minor, should be recorded in order to track outcomes. Staff knowledge of adult protection procedures would benefit from appropriate Adult Protection training. EVIDENCE: The Commission for Social Care Inspection has not received any complaints in respect of this service. A clear and straightforward complaints procedure is in place and is displayed prominently on the notice board. It has recently been updated, and there is now one formal policy and one less formal one. A book is used to log complaints. No complaints have been recorded since 2005. However, complaints are regularly received from Service Users (about the restrictions on the lounge, money issues and so on) but despite this they have not been entered in the complaints log. The Inspector advised the manager that any complaints, regardless of how minor, should be recorded. A Service User had told the Inspector that he had complained several times to the Registered Manager about issues he has within the home. The manager confirmed this to be true, but had not recorded any of them. The Inspector 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 18 discussed the importance of putting concerns in to writing, otherwise the home is not seen to be taking its own policies/procedures seriously. There is one copy of the West Sussex County Council Adult Protection procedures available, and this is located within the office. Service Users spoken with confirmed that they would speak to the manager if they had any concerns or problems. Records examined during the inspection found that despite Adult Protection training being highlighted in a previous report, there are still gaps with some staff not having attended the course. There had been two staff booked to go on training in April 2006, but it was postponed. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. The quality in this outcome area is good. The judgement has been made using available evidence, including a visit to the service. Service Users live in a homely, comfortable and safe environment. It is nicely decorated throughout and is well maintained. EVIDENCE: 54 Leylands Road is a large detached house with accommodation provided over two floors. It is surrounded by its own gardens and in addition has a large area designated to car parking. Communal space is plentiful, consisting of lounge, kitchen/diner, office, conservatory that is used as an activity room, and a good size garden area. The Garden is being well maintained by a gardener, and there was an array of flowering plants and an ornamental pond. To the side of the building there is an allotment area where fruit and vegetables are being grown. The Inspector saw some large pumpkins that had been grown and were being stored in the green house. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 20 The environmental tour found the home to be clean, bright and comfortable. The Inspector looked at a sample of bedrooms, and these were found to be personalised to suit individual taste. An inventory of Service Users’ furniture was seen on personal files. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. The quality in this outcome area is adequate. The judgement has been made using available evidence, including a visit to the service. Service Users are supported and protected by the home’s recruitment policy and practices. Service Users’ individual needs are met by a well-managed staff team, although staff must be able to access the necessary training required in order to offer effective support. EVIDENCE: Staff training was highlighted at the previous inspection. At that time medication training and manual handling training were outstanding. In addition the majority of staff had not received the expected amount of mental health related training or Adult Protection training. Due to staffing and management issues over the past few months, training is still to be addressed. Core training and development issues also need to be looked at. The Inspector was told that although the company offers in-house training, courses are cancelled and the manager is unable to release staff due to costs incurred 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 22 by covering their shifts. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. There are seven staff currently employed to work at the home. Two staff work the morning shift, two staff work the afternoon shift and during the night there is one waking staff member and a sleep-in for back up. The home has recently reduced staffing numbers by one support worker post. The result being that one member of staff is covering the shift for brief occasions for two periods of time each day. This proposal would be unacceptable given the high needs of the client group. Supervision contracts are in place between supervisor and supervisee. Those looked at had been signed. Staff are not receiving regular supervision sessions due to recent management and staffing issues. Inductions for new staff are in the form of a list of subjects that are signed and dated by the line manager when they have been covered. Recruitment records were looked at and were found to contain all the necessary documents to ensure the safety of Service Users, including application forms, 2 written references and CRB checks. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. The quality in this outcome area is adequate. The judgement has been made using available evidence, including a visit to the service. Staff and Service Users benefit from a supportive management structure, and it was noted that the deputy manager had worked hard to maintain the smooth running of the home in the Registered Manager’s absence. Annual quality assurance systems are in place, but the Registered Manager should ensure the views of Service Users, staff and relatives are sought, on a more regular basis. Health and safety awareness could be greatly improved by regular staff training. Regulation 37 incidents must be forwarded to the Commission for Social Care Inspection. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager is Mr P Unmar. Mr Unmar had been absent from the home for a period of time. Mr Graham Mann, deputy manager, has been acting up and running the home on a day-to-day basis. Mr Unmar has recently returned to work, and is phasing back to full duties. He has managed the service for five years and is a qualified RMN, having worked within the mental health field for 30 years now. The organisation holds an annual Service Users forum and there is a central event, attended by Service Users accommodated in any Sussex Oakleaf establishment. The meetings are Service User lead and incorporate workshops that cover a range of issues pertinent to individuals. An annual questionnaire survey is carried out and the results from that are published. The Registered Manager said that he tried to implement a family/carers support group but there was a poor attendance level and it has not been repeated since. Regulation 26 visits are carried out. The Inspector became aware of a regulation 37 incident that had not been reported to the Commission for Social Care Inspection. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. Mandatory training has been difficult to achieve due to the Registered Manager’s sickness absence and finances. Some health & safety training has not been provided by the organisation, such as infection control. 1st aid training has been undertaken by all staff now, with staff having attended the one day course, obtaining their certificate. Two members of staff have attained the four-day qualification. Mental health training has still only been attended by two staff members. The Inspector looked at the accident log. There have been no reportable accidents since 2003. The home also has an incident folder for all serious events, for example; assault, threats, damage to property and so on. The last one entered was dated 16.7.05, which was also sent to the Commission for Social Care Inspection. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 25 Fire training is provided every three months. Fire equipment testing was last tested in July 2006. Fridge freezers were clean, tidy and in good order but jars opened had not been dated, including mayonnaise, mustards, spreads and so on. 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 1 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 x 3 3 2 x x 2 x 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA22 Regulation 22(3) Requirement The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. Timescale for action 31/12/06 2. YA23 13(6) The registered person shall make 31/03/07 arrangements, by training staff or by other measures, to prevent Service Users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall ensure that the persons employed to work at the care home receive (i) training appropriate to the work they are to perform; and (ii) suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of Service Users ensure that at all times suitably qualified, competent and experienced persons are working DS0000014663.V308805.R01.S.doc 3 YA32 18(1) (c) 31/03/07 4 YA33 18(1) (a) 31/12/06 54 Leylands Road Version 5.2 Page 28 5 YA43 37 at the care home in such numbers as are appropriate for the health and welfare of Service Users. The registered persona shall give notice to the Commission for Social Care Inspection without delay of the occurrence of – (g) any allegation of misconduct by the registered person or any person who works at the care home. 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations 6.6 – The Plan is drawn up with the involvement of the Service User together with family, friends and/or advocate as appropriate, and relevant agencies/specialists. 6.10 – The Plan is reviewed with the Service User (involving significant professionals, and family, friends and advocates as agreed with the Service User) at the request of the Service User or at least every six months and updated to reflect changing needs and agreed changes are recorded and actioned. 16 – 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). 16.8 - Service Users have unrestricted access to the home and grounds; Service Users’ visitors have access subject to individual and collective Service User consent. 36.4 – Staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice. 39.6 – Feedback is actively sought from Service Users (with support from independent advocates as appropriate) about services provided through e.g. anonymous user satisfaction questionnaires and individual and group discussions, as well as evidence from records and life DS0000014663.V308805.R01.S.doc Version 5.2 Page 29 2. YA16 3. 4. YA36 YA39 54 Leylands Road 5 YA42 plans; and informs all planning and review. 42 – The Registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. (see section 42.2) 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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 54 Leylands Road DS0000014663.V308805.R01.S.doc Version 5.2 Page 31 - 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. 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