Inspection on 28/02/07 for 72 Croydon Road

This inspection was carried out on 28th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 72 Croydon Road 72 Croydon Road Beddington Surrey CR0 4PB Lead Inspector David Pennells Key Unannounced Inspection 28th February 2007 11:30 72 Croydon Road DS0000067692.V331388.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 72 Croydon Road DS0000067692.V331388.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. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 72 Croydon Road Address 72 Croydon Road Beddington Surrey CR0 4PB 020 8686 5693 TBA 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) www.caremanagementgroup.com Care Management Group Limited Mrs Lydia Canrom Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection - New service - first inspection Brief Description of the Service: 72, Croydon Road (variously known as ‘Croydon Road’ or ‘Beddington’ is situated just within the boundaries of the London Borough of Sutton on a main link road (the A232) between Croydon and Carshalton / Sutton. Busses pass the home and bus stops are close by. The nearest train station is Waddon - a short walk away - with trains running into West Croydon and up to London, whilst connecting with Sutton in a westerly direction. There is limited parking on the driveway at the front of the building - but free parking on the side road, which is just a few steps away from the house itself. The house is located conveniently close to a local park (Waddon Ponds), and also is within a relatively short distance of the ‘Valley Park’ and major Purley Way shopping and leisure complexes. The house is a substantial, detached family sized property with single, ensuite accommodation for up to six people who will use the service, and it has reasonably good communal space - and a substantial back garden with a garden shed. A kitchen and office complete the accommodation. The service provided caters for six service users with learning disabilities and, in the main, associated challenging behaviour. There were three male and three female people using the service at the home at the time of the inspection, the three females being white British, with one white British male, an African male and a Vietnamese British male. One person uses the service predominantly at weekends and during holidays, attending a boarding college during the weeks of term time. The home’s declared intention - as stated in the Statement of Purpose begins: “72, Croydon Road will aim to provide progressive and holistic care (maintaining a therapeutic input) to adults with autism, leaning disabilities, psychological needs, associated mental health issues and some behaviours of a challenging nature. 24-hour therapeutic and progressive support will be offered, promoting independent thought and normalisation within a calming and homely environment.” 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced, and was conducted from 11.00am to 6.30pm on an ordinary weekday. On arrival, the home’s manager was out - at Head Office, but returned to the home at about 12.30pm and assisted the inspector, as appropriate, with the rest of the inspection process. This was the first key inspection to the home since its opening, and the inspector was keen to observed how the service had ‘bedded down’ - there now being a full complement of people using the service, and the staff team therefore also staring to become established. As the house is owned and managed by a care home company which runs a number of similar establishments throughout the local area - and was therefore familiar to both the Commission and the assigned Lead Inspector, the inspector had monitored the home’s progress through checking of the submitted Regulation 26 visit reports (the reports of the visits of the company’s representative) and other feedback about the service. This previous feedback, associated with feedback from relatives, from care managers and health and mental health care professionals have, alongside the visit to the home, informed the assessment process for this first key inspection. The home’s service has a ‘head start’ - in that policies and procedures, documentation, maintenance, reporting lines, staff training and general support services are already provided by a well established company / network of CMG workers alongside the home’s manager and staff team. Feedback from relatives and professionals was generally very positive about the service - especially bearing in mind the relatively recent opening of the home. One set of relatives had raised a number of concerns about issues specific to their relative - many of which reflected, perhaps, ‘teething troubles’ for the home - and they continue to pursue some issues with the home and the supporting placing authority concerning the service provided for their relative. Other relatives indicated that they had not had to make a complaint, that they felt the home was providing an adequate service with sufficient staff generally, and were kept informed / involved about their loved one at the home - and were all ‘so far’ satisfied with the standard of the service. What the service does well: The home appears to be establishing itself well and, with the background support from the CMG managing organisation, the general processes and approach to the service is good. Clearly there is still need for the community the people who use the service, the staff and the entire ‘population’ to come together - but there were clear signs that this cohesion was evolving. It is hoped that, now the home is ‘full’ and staffing is complete, that the stability with the consolidation of approach this will bring - will arise naturally. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 6 The management approach to the house was caring and positive; the staff members met, whilst still clearly needing additional training, were growing together in both understanding and the performance of their task. The inspector believes that the home will improve positively from being a ‘new’ establishment to a ‘mature’ one quite quickly. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comprehensive Statement of Purpose which ensures that all necessary information about the service is available both for people who use the service and others enquiring about the home. Prospective users of the service can be confident that they will have the opportunity to find out about the home, to visit (including staying for short periods) and – through assessment and consultation - be assured that the home can meet their needs, prior to making a firm decision to settle. Service users will receive a contract in a communication strategy suited to their needs - and this seeks to ensure that all ‘terms and conditions’ are known and recognised from the point of confirmation of the contract. EVIDENCE: The Statement of Purpose for the home is a comprehensive document holding all necessary information as required by the revised Standards, Regulations & Schedules. Important elements – such as the service user contract (standard 5) can be presented, where appropriate, in a ‘Symbols’ style – to enable users of the service to engage with this part of the document as much as possible. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 9 The Complaints procedure is also clearly stated in the symbols style. The Service User Guide is being created at present, reflecting the growing ‘culture’ and expanding service within the home. Referrals to the home require full and concise information to be provided; admissions are based on a full needs assessments undertaken by the registered provider at a regional level and involving the home’s manager, and relying on information provided by a social worker / care manager from the relevant placing Local Authority. Bromley, Brighton, Essex and Hammersmith & Fulham boroughs currently make / fund placements in Croydon Road. Fees charged vary from £1,500 to £1,800 per week. The service user group’s ages span from 18 to 27; it is possible that some members of this community may eventually move on as they settle into adulthood. There is a gender balance in the home, there being three males and three females using the service. Of the six, four are of white British descent with one male of African and one male of British Vietnamese descent. The introductory phase to the home - including site visits - gives the person the chance to see if they feel ‘at home’, and staff the chance to ensure that they are able to offer an appropriate service, along with assessing compatibility with other service users in this small community of six distinct personalities with widely varying needs. At the opening of the home, two people arrived at the home at about the same time in September 2006, two in October and finally one in November and one in December 2006. One male person attends a residential school during term-time weekdays and is generally absent from the home from Monday morning to Friday teatime each week. A second person attends a college environment each day. The home’s admission policy is conditional to a ‘trial’ basis. In keeping with good practice, all the other service users would be consulted / observed about the possibility of the prospective new service user eventually moving in on a permanent basis - and the permanence is then confirmed after a thorough review. Relative’s feedback responses showed that some people were finding it more difficult to settle in the home than others; expectations of the home’s service were still being worked through - and the registered provider, assigned care managers and the home were assisting relatives with this process. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can expect to be provided with a care plan that addresses their specific needs and aspirations of the individual; this being developed as far as is practicable with the involvement of service users, and / or their representatives in the decision-making. Consultation with service users relies on both direct contact and also a broader approach of checking with relatives and carers as well as professionals. Risk assessments form a fundamental part of the care planning process, enabling independence and self-determination for service users within a framework of safety and protection considerations. Service users and relatives / friends can be assured that information about service users is kept in line with best practice and data protection legislation. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 11 EVIDENCE: Files for people using the service were examined / tracked and showed that the home’s admissions process was appropriately implemented - with information created and dated near, or on, the day of admission and risk assessments being in place within seven days of this date. An induction checklist / questionnaire had also been completed on the day of admission; ensuring adequate information was gathered to meet specific needs. CMG assessments stood alongside the care management information, and resultant action plans and personal profiles were quite substantial. All care plans inspected contained individualised procedures for staff to follow for service user assessed likely to have challenging behaviour, focusing on positive interventions (e.g. communication support and de-escalation techniques) in preference to physical intervention. The majority of staff members have had training in handling such issues - described by the company as the ‘dignified management of conflict’ training. Risk assessments are provided for each service user, specifically created to reflect the assessed situation for that individual. Risk assessment is clearly an important part of the ethos / thinking of the home, and was fully covered in the associated documentation examined. Assessments are in place for all, and cover the various aspects of needs, including personal hygiene, community presence, and behaviours likely to challenge the service. Each risk assessment identifies the risk, possible consequences, and any minimising actions to be implemented to handle the challenge. The registered provider’s finance officer is Appointee with regard to benefit issues for all six current service users. Services users’ monies held at the home are recorded and counter-checked regularly. The home has a corporate confidentiality policy. The parent company has recently renewed their Data Protection notification to the Data Commissioner; this being an important commitment for the home, keeping (as it does, appropriately), significant personal records on file on site. Storage of information was appropriate, with personal files being locked away in the medication cupboard, prior to the arrival of an additional filing cabinet. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can expect their lifestyles at the home to be individually focused and aimed at personal development, whilst providing a fulfilling programme of engagement with peers, friends, staff & families. Activities provided and pursued promote positive engagement within the home and the local community as far as is practicable, whilst acknowledging and respecting each individual’s needs and capacities. The needs of those of with a different cultural / religious background, however, should be more focused on. Service users can expect to receive a healthy and nutritious, culturally appropriate diet, provided within a pleasant and comfortable environment. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 13 EVIDENCE: People who use the service are encouraged to positively enjoy and engage with appropriate opportunities presenting themselves in the local community – both ‘main stream’ and within the local learning disability community. Service users regularly engage with leisure pursuits such as swimming, bowling, trampoline, and attending the cinema. Opportunities for exercise – be this walking in the park (Waddon Ponds is just a short walk away), or engaging in some shopping - or going for a bus ride (Freedom passes are held) and having lunch out contribute towards enjoyable focused activity. The home - being on the border of Croydon and Sutton, relates more to Croydon town centre (which is nearer) rather than the town centre of Sutton - to which the home is connected. Records showed that people are being provided with numerous opportunities to participate in a wide variety of stimulating social and recreational activities. Service users are supported to participate in a wide variety of individually appropriate and assessed activities - which may include regular attendance at a local day centre, educational centre and other activity clubs. The local Mencap activity / social clubs are being used positively. Individual assessments lead to the conclusion that it would be inappropriate for any of the current service users at the home to take up opportunities for paid / voluntary employment. Two of the six people at the home have no speech - though comprehension and hearing is present. Contact with local Churches is encouraged – Christianity is the expressed preference of all who use the service. One person at the home is Roman Catholic. The elements of service user’s challenging behaviour / concentration span can sometimes create a difficult dynamic in ‘formal’ settings - and some users will attend a Church Sunday Service for only a short period of time. Activities such as Christmas and Birthday and other celebratory parties, are evolving their own ‘house’ character. Other declared focuses at home include football, aromatherapy, board games, gardening and TV / Video / DVDs. The home is clear, in its Statement of Purpose, that visitors and especially family contacts are welcomed by the home - this on an unrestricted basis, whilst respecting the views of the people living at the home. The majority of service users have some active engagement with their loved ones, - if only phone contact from their residence in another country (a factor positively noted by a care manager). Some people at the home have regular ‘going home’ arrangements. Safe catering records were seen (refrigerator temperature checks, etc). A food was evidently appreciated. Meal times can be somewhat unpredictable, but the food is enjoyed and brings the community together with a common purpose. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident they will be supported in personal care according to their own preferences or assessed needs, and will receive physical and emotional health care support through the timely intervention of allied professionals (including any prescribed medication) in an appropriate way. The home manages the administration of medication (including ‘prn’ stocks) well, within the supportive context of policy, training and good record keeping. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each person using the service is clearly respected and supported by staff in a positive way to be ‘themself’ as much as possible, without offence or upset to others. Clothing, hairstyles and appearance reflected the individual’s gender identity and ethnic / cultural background. A health care professional visiting the home commented on the usually “respectful, kind and considerate” attitude of staff members - commenting on other care issues, they continued that care is taken to meet the individual diversity needs of individuals, and that referrals for health care issues are always made promptly, reflecting later that: “some carers work far beyond what is required of them”. There is little in the routine of the house that is not to a large extent flexible though of course, some service users need clear routine and order - relying on the domestic routine to enable them to in-build their own activities / response. Familiarity with staff, routines and everyday processes are acknowledged as all-important to certain service users. GP and other medical / health professional contact is arranged as needed; records of these appointments / visits are appropriately maintained. Five of the six people at the home have locally based health care services - one has their general arrangements at the residential school where they spend the majority of their time. Specialist practitioners monitor service user’s mental health on both ‘asrequired’ and a regular basis. Such specialist input is gained via Orchard Hill and optical & dental services are also either accessed from here, Geoffrey Harris House, or the local community. A local dental surgery is conveniently located next door at 74, Croydon Road. Feedback to the CSCI from the psychiatric consultants supporting people using the service was, in the main, very positive about the service provided commenting on the individually focused service and stating the rights of the individual are respected. Another commented on good liaison with medical services, and noted the home’s ability to implement guidelines / treatment plans. Comments for improvement (reiterated herein as a recommendation) of the service included having access to ‘in-reach’ psychology input to assist them with the management of challenging behaviour, and developed skills base in managing challenging behaviour. Service users have developing Health Action Plans - this assisting the personcentred planning of health care needs alongside the daily care plan. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 16 The records of medication administration were well maintained; all medicines are received, administered and disposed of [via the Chemist], and auditable. The home uses the ‘blister pack’ process for storage / administration. Medication profiles were also available, and clearly identified service user’s current medication regimes. Management, team leaders and seniors have been trained to, and do, administer the medication at the home. Management also audit the medication process on a regular basis. Eight of the ten care staff members have also been trained in First Aid - the staffing rota was audited - and found to provide the services of a First Aider on every shift across a week. Two other staff members are also booked to take their ‘Emergency aid’ training in the future. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service and their advocates can be assured that their comments or complaints will be taken notice of, investigated, and acted upon within the home’s stated procedural timescales. Feedback on investigations should, though, be provided to all involved in such circumstances. The home provides adequate support to service users to ensure that they are protected from harm, neglect and any form of abuse. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home’s Complaints Procedure is provided (in symbols format) and is included in the home’s Statement of Purpose / Information Handbook and contains information about how a complainant can also contact the Commission should they wish to do so. The procedure has clear timescales given, so that a complainant knows what to expect - and time frames for the resolution of such complaints. A record book for all concerns / complaints made about the service at the home is kept. An expression of concern from a relative of a service user that they had not received full feedback on concerns expressed both to the home and the care manager could, perhaps, have been avoided if the report back was made more universally available. The home now has a small safe for the safekeeping of monies, valuables, and service user’s possessions handed in for safekeeping. Day-to-day monetary items are kept safe locked in the office. The CMG organisation (through their Finance Department) acts as Appointee to all six service users, this being handled centrally by their Head Office located in Wimbledon. The CMG Policy and procedure for ‘Alleged Abuse’ refers directly to the primacy of the Local Authority’s Guidelines for dealing with any incidents of Adult Abuse. The home is currently in possession of the Croydon local authority protocol, and training has been accessed via the Borough. The manager was advised to access the LB Sutton document file - as, despite being closer to Croydon as a centre, the home administratively is situated within Sutton borough - and hence Sutton would be the ‘host’ borough for any necessary reports relating to adult protection. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service may expect their accommodation to be clean - and a generally pleasant & homely, comfortable environment to live in, meeting the needs of the individual, whilst providing privacy and the chance to express their own character / culture through furnishings and decoration. The home is generally well decorated and maintained with equipment being appropriately serviced, ensuring the safety of service users. ‘Snagging’ has left a small inheritance of works to be completed, but they are generally easily surmountable. The poor standard of the inherited kitchen units sadly lets the establishment down -and other issues arising from the actual use of the building require direct and speedy attention. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 20 EVIDENCE: The house is a pleasant well modernised building which is a substantial, detached family sized property with single, ensuite accommodation for up to six people who will use the service, and it has reasonably good communal space - and a substantial back garden with a garden shed. A kitchen and office complete the accommodation. The house is located conveniently close to a local park (Waddon Ponds), and also within a relatively short distance of the ‘Valley Park’ and major Purley Way shopping and leisure complexes. The location of the home is decidedly more Croydon [locally & centrally] focused than to Sutton town centre - which is significantly further away. Premises issues that have arisen at this visit related - to some extent - to smaller issues - many of which could be described as ’snagging’ (the inheritance from the home’s preparation works). Items ‘put right’ within a day or so of the inspection included: marking out the protruding overhang on the stairway for safety, the reaffixing of curtain poles, the venting of the gas central heating boiler, and the appropriate storage use being made of the cupboard under the stairs. A fire alarm break-glass in the quiet room was also restored to working order. The actual process of populating has revealed the actual practicality of certain measures put in place prior to the opening of the home; the more significant issues arising include: * The need to avoid using wedges to hold fire doors open - through the provision of electromagnetic door holders - which must be provided to the lounge door (and any others as appropriate) to ensure the safe passage of people through the house, whilst ensuring the best possible fire protection within the house. * The kitchen’s storage unit and work surface provision - which must be urgently reviewed with a view to replacement with working, functional and fitfor-purpose facilities provided - to assist both staff and those people living at the home to maximise the catering opportunities at the home. * The removal of the frosted glazing in the quiet room (the second downstairs communal area), which must be replaced with ordinary transparent glass. * The laundry facility - which must be improved to allow for better facilities for laundering within the home; the current cupboard being found in practice to be inadequate for the intended purpose. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 21 * The patio paving - which requires proper levelling before the summer to ensure the surface is as safe as possible to enable people to use this area unhindered and in safety. The office is small (there is no specific staff accommodation), and requires more appropriate storage space. This issue of bulk storage is now arising as being important for a number of purposes, including the storage of incontinence pads, and other items that do not merit being stored in the [potentially damp] garden shed. The location of the laundry - in a cramped cupboard opposite the office is a poor concept and the development of an alternative site is strongly supported to ensure that laundry is undertaken with appropriate attention to detail and care. Reports of allegedly shrunk and damaged clothing no doubt has stemmed from this inadequate facility. Bedrooms seen were pleasant, and as far as possible populated with the individual’s own items and furnishings. Some rooms have had to have more work due to the nature of some people’s behaviour in their own rooms. All bedrooms are ensuite and generally pleasant - as was the whole house, which was bright and odour-free during the visit. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can rely on the service providing adequate staff in sufficient numbers, being duly competent and well trained in most discipline areas, to provide a service that meets the service users’ individually identified needs. The home’s recruitment and staff support mechanisms - through supervision and staff meetings - are organised so as to ensure the safety, protection and wellbeing of service users. EVIDENCE: The inspector track-audited two new staff members’ personnel files and found the documentation to be complete and comprehensive. Evidence of Criminal Records Bureau checks, minimally two references, application form, interview schedule and proof of identity was all well catalogued - this evidencing the through recruitment process undertaken by the CMG company. Induction records were fully completed / signed off, and the 1:1 supervision process was clearly being provided for staff beyond this first phase of their 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 23 career at Croydon Road. All new members of staff are subject to a sixth month probationary period. The manager evidenced staff supervision records and supervision & training matrixes identifying areas of competence and deficit by each individual staff member. Staff meeting records showed a regular monthly meeting with most staff members. Staffing levels are provided at the home a minimum of three staff on duty for both the early and late shifts at the home and two staff members awake on site - with the manager’s hours generally being supernumerary. The manager or another senior is also on call when away from the building. No staff team member had left since the opening of the home, however parttime ‘bank’ cover, which had been ensuring full staffing at the home, has lead to an impression for some outsiders that there is a large staffing ‘turnover’. Now the home is ‘up to number’ the full staffing complement is being established and it is hoped that the greater stability that full time employees can bring will be fully evident. Examination of staff training records revealed that eight staff members are trained in First Aid, and many other ‘statutory’ qualifications - excepting Food Hygiene / Safety are well supported. The staff team is up to the minimum of 50 of care staff being trained to NVQ Level 2 in care or above - the target set by the Commission. Some other staff members are also undertaking the NVQ so the figure will, hopefully, rise. Other training input more recently provided either by CMG or the Local authority has included: Protection of Vulnerable Adults, First Aid, Autism & Asperger’s Syndrome, Medication Procedures (by Boots the Chemist), Fire Safety, Health & Safety and the Dignified Management of Challenging Behaviour. Future training planned includes: Makaton, Person-Centred Planning, Sexuality, Promoting Values, Food Hygiene, Infection & Communicable Disease Control. As pointed out as a requirement under standard 28, staff would benefit from having a space (a stack of smaller lockers would suffice) to specifically secure their valuables whilst at work in the building / whilst on duty. Other ‘informal’ provision is not acceptable. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives / friends can rely on the home being run well, providing a professional service with the best interests of the service user being central to the care provision. The registered providers can be relied upon to take seriously issues raised for their attention, through both the quality assurance & complaints mechanisms and embodied in the Company’s policies and procedures, contributing to both the wellbeing and safety of those residing at the home. The safety and welfare of service users is guaranteed by the home having a clear management and supervision structure - and providing suitable support with regard to such issues. 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager, Lydia Canrom, has a BA degree in Management and eight year’s experience in working with people with mental health, autism and challenging behaviour. She is currently undertaking her registered manager’s award (RMA). The deputy manager, Emmanuel Quartey-Papafio has NVQ Levels 2 & 3 and brings five year’s experience to the home. Senior support workers are both undertaking the NVQ at Level 3. Both staff and service users are encouraged to participate in the day-to-day operation of the home and to indicate their opinions at reviews, informal oneto-one meetings with Keyworkers, staff supervisions and through the home’s Quality Assurance and Complaints / Grievance procedures. Quality Assurance surveys are in place to be sent out to relatives, friends and representatives / advocates of service users to encourage feedback about the quality of the service provided. The responses are received back centrally and collated / assessed, prior to being sent on to the home itself. The home has a substantial ‘QA file’ - which requires focused work and attention to the broadest interpretation of ‘Quality assurance’. Residents’ meetings - an important aspect of ‘QA’ - have been held regularly, imaginatively when out of the building, as well as when actually on site. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes ‘Resident Times’ as well as the more global in-house Staff magazine. Unannounced visits by representatives of the registered provider are being carried out on a regular basis and the subsequently resulting reports are being forwarded to the Commission. Such visits involve checking documentation and the premises and interviewing both service users and staff. CMG has a comprehensive set of policy and procedures which cover the broad spectrum of needs identified for care homes; they have been very recently revised and the inspector is impressed by the clear focus and guidance provided by these documents. Regular maintenance / servicing records for equipment all appeared to be in place for the future and in date and commissioning of all areas had been fully undertaken. 72 Croydon Road DS0000067692.V331388.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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 5 Requirement The Service User Guide must be completed for all at the home and a copy submitted to the CSCI. Steps must be taken to ensure that the home has the full documentation relating to the London Borough of Sutton’s Adult Protection / Safeguarding procedures, as the home is within their administrative area. Electromagnetic door holders must be provided to the lounge door to ensure the best possible fire protection within the house. The frosted glazing in the quiet room must be replaced with ordinary transparent glass. Sufficient lockers must be provided for staff that they may secure their valuables whilst at work within the house / when on duty. The kitchen unit provision must be urgently reviewed with a view DS0000067692.V331388.R01.S.doc Timescale for action 30/05/07 2. YA23 13(6) 28/03/07 3. YA24 23(4) 31/03/07 4. YA28 23(2)(g) 30/06/07 5 YA28 23(3) 30/05/07 6. YA29 16(2)(g) 31/07/07 72 Croydon Road Version 5.2 Page 28 to replacement with working and fit-for-purpose facilities. 7. YA29 13(4) The patio paving requires proper levelling to ensure the surface is as safe as possible to enable people to use this area unhindered and in safety. 30/06/07 8. YA30 16(2)(f) The laundry facility must be 31/07/07 improved to allow for better facilities for laundering within the home. Qualifying Food Hygiene training must be undertaken by all staff to ensure the highest level of provision and understanding in food safety issues. 30/06/07 9. YA35 13(3) & 18 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 YA9 Good Practice Recommendations That risk assessments and care plans are located closer to the day-to-day records of each individual who uses the service; this will ensure the best ‘connection’ between the intention and reality of the day-to-day life at the home. That access to ‘in-reach’ psychology input to assist the staff with the management of challenging behaviour, and a further developed skills base in managing challenging behaviour should be pursued. 2. YA19 72 Croydon Road DS0000067692.V331388.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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