Inspection on 10/02/06 for 89-91 Bessborough Road

This inspection was carried out on 10th February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

89-91 Bessborough Road 22/05/07

89-91 Bessborough Road 19/04/06

89-91 Bessborough Road 06/06/05

89-91 Bessborough Road 13/01/05

89-91 Bessborough Road 10/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 89-91 Bessborough Road 89--91 Bessborough Road Harrow Middlesex HA1 3BD Lead Inspector Clive Heidrich Unannounced Inspection 10th February 2006 09:45 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 89-91 Bessborough Road Address 89--91 Bessborough Road Harrow Middlesex HA1 3BD 020 8423 1116 020 8864 4191 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) Harrow Consortium for Special Needs Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: 89 - 91 Bessborough Road is a care home for up to 12 adults who have enduring mental health problems and require medium to long term support. The home is run by Harrow Consortium for Special Needs (the registered providers), staffed by the Family Welfare Association, and with premises supplied by Paddington Churches Housing Association. At the time of inspection there were no service user vacancies. The home is situated on a busy link road to Harrow that includes bus access. It is fifteen minutes’ walk to Harrow town centre where there are shops, leisure facilities and further transport links. There is space for two cars to park on the forecourt, and there is unrestricted but regularly-used parking on the road. The home is made up to two interlinked semi-detached properties that span three floors. Access is by stairs only. Bedrooms are situated on the 1st and 2nd floors. Each service user has their own single room. The ground floor has communal living and dining rooms, a new conservatory, a laundry room, and office space. There is a well-kept garden at the rear of the property. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection initially took place across a cool day in February. It finished at 4:10p.m. Its focus was on compliance with previous requirements, and the assessment of core standards that were not considered at the previous inspection. The new manager was not present during this visit. Most of the service users were present at some stage during the inspection. The inspector met with five of them individually, to discuss the services provided in the home. The inspector also discussed aspects of the service with staff working during of the visit. Additionally, care practices were observed across the day, much of the environment was checked on, and a number of records were sampled. The inspector returned to the home for two hours, to meet with the new manager and gain access to certain records, on the 21st February. An urgent requirement was left with the manager at the end of this visit, in respect of sufficient staff recruitment checks, which was formally confirmed by letter the following day. The manager has reasonably co-operated with the requirement. Concurrent with the inspection, the manager was sent CSCI comment cards about the service to distribute to relevant people. An inspection questionnaire was also sent. At the time of drafting this report, 7 comment cards from service users have been received, five of which were anonymous, and most of which was positive. The inspector thanks all involved in the home for the patience and helpfulness during and after the inspection. What the service does well: What has improved since the last inspection? 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 6 A manager is now working full-time in the home. Discussions, and feedback from service users, show that he has good leadership qualities. The home has a permanent and suitably-qualified staff team. Progression has been made in terms of service users’ involvement in how the home operates, and independence with making decisions. Medication procedures are generally more robust and better managed, with just minor improvements now needed. The home’s Statement of Purpose has been developed, and the Service User Guide is almost completed. 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. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. The home has good procedures for enabling service users to visit the home, find out about how it operates, and move in for trial periods. Strong efforts are made to ensure that service users’ needs will be met. EVIDENCE: A copy of the completed Statement of Purpose, and the final draft of the Service User Guide, was provided to the CSCI at this inspection. Both documents provide suitable details about how the home aims to operate. One newer service user kindly showed the inspector the written information provided by the home to them at the time of moving in. The information included a brochure about the home, a statement of expectations, and a draft Service User Guide. This is reasonable information. Some other established service users said that they didn’t have much written information about the home. The manager later clarified that the draft Service User Guide has not yet been finalised. It will be further discussed with all service users, revised, and then distributed to all. When this appropriate consultation process is completed, standard one will then be met. There were suitable records of pre-admission assessments, both from senior staff in the home and from other professionals, for the newest service users. These assessments clearly stated the key needs and wishes of each service user, such as visiting arrangements of family, and where they wanted their 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 9 bedroom in the home. It was evident that a lot of planning work goes into assessing the service user’s needs and ensuring that they can be met. It was apparent, from feedback and records, that service users have the opportunity to visit the home, and stay overnight, before making a decision about whether to move in for a trial placement. It was also apparent that this process takes place at the service user’s pace. Review meetings then take place, with appropriate people present. 6 of the 7 comment cards received from service users stated that they like living in this home, with one stating sometimes. The majority stated that they feel well cared for here, and that they feel safe here, with none disagreeing. This is reasonable feedback. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service users are supported to make many decisions about their lives with appropriate assistance. Standards of documentation about service users’ support needs, and management of risks, was in many cases poor through being out-of-date and not reflecting practices. Improvements must be urgently made, so that service users and staff can be clear as to what the support needs of each service user is, and so that staff can provide support more effectively. EVIDENCE: Service users’ individual plans were seen to be very out-of-date in some cases, tending to be from between 2004 and 2002. Checks with staff found the old plans to have practices that are no longer used in the home. The practices now in use are judged as more respectful to the service users. The manager must ensure that the plans are reviewed with service users, updated, and distributed to each service user, so that there is clear guidance to the service user and staff members about the service user’ needs and the support expected. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 11 There were however suitable plans in place for the newest service users. The plans provided appropriate detail about the service users’ needs and how they should receive support. CPA meetings were seen to be up-to-date from those records seen. They included discussions around the most pertinent issues of the service user. The standard of recording about individual service users’ days was seen to be good. Pertinent details were noted, such as about visitors, community use, and concerning behaviours that might be indicators of mental ill-health. Some up-to-date individual service user risk assessments were in place. Some others were dated from 2004. Discussions with staff found that there are some ongoing issues with individual service users for which risk assessments have been discussed but for which there is no written record. The lack of current and formalised individual risk assessments put service users at risk of staff following old guidance, of staff miscommunication due a lack of written guidance, and of service users being unclear as to what staff support to expect in respect of hazards, all of which put service users at risk of poor care. The manager must ensure that key hazards to each service user are identified, risk reduction plans discussed and implemented, and that findings are recorded and reviewed. In terms of making decisions about their lives, staff noted that they do not look after service user’s money. Service users have security and support to manage this themselves. One service user is under the Court of Protection in this respect, and some others have family members who are actively involved in some aspects of financial support. Most of those service user spoken with noted that they are happy with the arrangements for money. Other feedback from service users about being enabled to make decisions in the home was mostly encouraging. For instance, one service user noted that they can prepare a different meal if they do not want to eat the main meal that is being prepared, and that a meal is left for them if they are late back to the house. Some other service users noted that the new hallway carpets, that were due to be laid shortly, were chosen by a consensus of service users. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 and 16. Service users are supported to have good lifestyle standards within this home, including in respect of independence, rights, communal responsibilities, and leisure activities. EVIDENCE: In terms of community presence, service users fedback about having day centre placements, going shopping, and about group activities such as going our for a meal. A couple of service users were planning to go food shopping for the home, with a staff member, at the start of the inspection. Where service users do not have clear weekly plans, those spoken with said that they have for instance house chores that occupy them, and that they are happy with their occupational arrangements. There was also positive service user feedback about going swimming. A staff member was overheard to suggest to some service users about going swimming during the visit. Staff spoke of when any service users need support to access the community. Most service users can go out independently, but there were exceptions for 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 13 when specific support issues apply to a few service users. Service users were seen to be able to go out freely by themselves, with the courtesy of informing staff of a likely return time generally respected. One service user noted that there is a meeting each Sunday morning in which service users decide what group activities they will do that day and what support from staff, if any, is needed. Feedback about activities has improved compared to last CSCI comment card audit, from the summer of 2004. All seven respondents on this occasion said that suitable activities are provided in the home. In terms of communal activity choices within the home, some service users spoke of there being a new TV in the main lounge. There is also a separate lounge available for smoking. Some staff and service users also pointed out the flowers and shrubs that they are cultivating in the well-maintained garden. There were no concerns about appropriate relationships. One service user noted that they can phone family members when they want to, and that many service users have visitors. Another noted that they phone and visit family members. Service users’ records showed that many have strong family involvement, and that friends can come to the house to visit them. Progression has been made in terms of service users’ involvement and independence within the home. For instance, records showed that service users can return to the home late, although they are requested to inform staff if this is to be the case. Service users can stay up later if they wish. Service users’ feedback found that most will be in their rooms for the night at around the time that the sleep-over staff member retires for the night, and that this is fine for most people. Staff feedback noted that some service users do use the communal areas during the night. Service users confirmed that they have keys to their rooms, to the house, and that they have space in their rooms in which to store items securely. One service user said that their personal possessions are safe. Another noted that they trust people in the home, so do not need to lock their bedroom door. One service user stated that post is given to service users unopened, with service users being requested to leave relevant post in their keyworkers’ trays for information. Another service user stated that the house payphone is straightforward to use. Service users have weekly tasks, about the upkeep of the home, that they are excepted to fulfil. Those service users spoken with noted that these tasks are distributed fairly, and that they are regularly changed. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 14 Service users take minutes of their weekly meetings. These meetings were seen to include about such topics as how the house tasks are being distributed, about new staff, about house responsibilities, and about activities, which is appropriate and relevant. Comment cards from service users noted that most feel that their privacy is respected. There was an equal split of views in terms of whether they are provided with enough involvement in decision making in the home. Management should further discuss this with service users. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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. Service users receive good standards of personal and healthcare support. Improvements have been made to medication systems, including in respect of enabling service users to have appropriate levels of independence, but improvements are needed in terms of accurate recording of administrations by staff. EVIDENCE: Personal support needs are included within service users’ individual plans, at a level of detail relative to the support needed. There is an emphasis towards independence and prompting, and away from active staff support, which is appropriate for a home of this nature. One service user noted that staff had gone out with them recently to support them with having a haircut. There were no significant concerns with the general appearance of service users. Checks of service users’ files for health support found that they receive appropriate support to attend standard health check-ups such as with dentists and opticians. Specialist health support, such as with psychiatrists, dieticians, and for medication reviews, also takes place. Significant issues are discussed at CPA meetings. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 16 It was explained by staff that service users are supported to take weight measurements as per their individual needs. Some service users attend slimming clubs, for instance, and so they monitor their weight that way. One service user spoke enthusiastically about the weight they had lost. Service users’ medication is supplied in an MDS blister-pack system. Useful systems of monitoring service users who self-medicate are then used, and individual service users confirmed that they look after differing amounts of medication based on need and ability. Service users also confirmed that they receive medications as prescribed to them, and that staff remind them to take medications if the service user forgets or is asleep. Detailed checks were made of a sample of medications in terms correct quantities following administrations. Staff helped to work out that administrations across the last week, for complicated prescriptions of medications that were not within the MDS system, had been recorded about correctly. Staff noted that they have made good progress in reducing the amount of PRN (as-needed) medication that service users use. Checks of medications confirmed this. Greater consistency of accurately recording about administrations of medications to service users is needed. There was one case of a medication being recorded about four hours before it was due to have been given (it had not actually been given), and there were occasional gaps in the signing of medications across the previous week. This presents risks of service users being offered incorrect medications. Discussions with the manager also established that the home’s medication policy, although partially updated in 2005, lacks sufficient detail in terms of the self-medication processes that are used in the home. This could cause inappropriate staff approaches, and so must be addressed. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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): 22 and 23. Recent practices in response to complaints have been at a poor standard. Improvements must be made to ensure that investigations are timely, and that formal conclusions are recorded about. Improvements remain needed to ensure that the home’s adult protection policy suitably protects service users should an allegation be made. EVIDENCE: Since the last inspection, the CSCI has been copied into a complaint from a relative of a service user about the care provided. The complainant received a response around four months later, partially upholding the complaint. Despite the complexities of the issues involved, the response is viewed as taking too long, as this can leave complainants in limbo and can make accurate investigation harder. The manager must ensure that complaints are investigated and responded to within 28 days. Four of the seven comment card received from service users noted that they know who to speak to if they are unhappy with their care. This reflected verbal feedback from service users, who generally noted that staff listen to their views and support them if they have complaints. They also noted that there are weekly house meetings in which they air their views and any concerns. The complaints book was seen. There were records of two complaints from service users about other people’s behaviour in the home across the last year. The records included about initial responses but lacked reference to the conclusions drawn and consequent follow-up action. This allows complaints to become unaddressed, which renders the process ineffective. The manager 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 18 must ensure that complaints processes include the process of establishing formal conclusions and follow-up actions and that these are recorded about. It remains for a revision of the home’s adult protection policy to take place, to ensure that clear and effective procedures are available. There have been no adult protection referrals since the last inspection. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 and 30. The home provides a generally suitable and clean environment for communal living, including through reasonable décor, facilities and furnishings. Improvements are needed in a few areas, particularly for carpeting in hallways to be of a presentable quality. EVIDENCE: There have been no changes to the structure of the home since the last inspection. In terms of fabric, there was a new, small breakfast bar in the kitchen area. The other table there, as seen to be used by service users for breakfast, was very wobbly and so needs stabilizing or replacing. Service users fedback about the hallway carpets that are due to be changed within weeks, as has been required across previous inspection reports. The stair banisters in some areas were chipping significantly. The more recent banisters additionally did not match the established ones in terms of colour. Both of these issues must be addressed to uphold suitable standards of homeliness. The inspector viewed a maintenance request list during the second visit. It covered pertinent issues. One item, of redecoration of a service user’s ceiling 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 20 following a minor leak from a bathroom above, had at that stage been waiting for two months. It is reasonable for some time to be given to allow drying to occur, however the time elapsed is now seen as too long. The issue must be promptly addressed, so that the service user’s room décor is re-established as suitable. In terms of cleanliness, a cleaner was working effectively in the home at the time of the first visit. Service users are also involved in communal cleaning tasks with staff support where needed. Soap was available in communal areas of the home. One service user explained that everyone provides their own toiletries in the communal bathrooms upstairs. The laundry area was seen to have two washing machines and one tumbledrier. A service user explained that the two machines allow two people to undertake washing at the same time. The room was overall clean and with suitable facilities. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 and 35. Service users benefit from sufficient levels and qualifications of staffing. Staff show reasonable knowledge of the service users’ needs. Improvement are needed to documentation about staff training, so that gaps can be identified relative to service users’ needs. Significant improvements are needed to the home’s recruitment procedures, to show that reasonable checks of such things as CRBs and identification have been suitably undertaken. EVIDENCE: 6 of the 7 service users’ comment cards stated that staff treat them well, with the other stating sometimes. This reflected the verbal feedback receive from service users. One service user pointed out that some staff encourage people to join in with activities such as cooking, rather than telling people to join in, which they like. This appropriate behaviour was later observed by the inspector. Some service users spoke positively about the new staff in the home. It was encouraging that newer staff could speak knowledgably of service users’ needs. The newer staff also spoke positively of the induction that they have received. One was working through a shadowing period before being moved onto more responsible one-to-one work with service users. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 22 From a sample of the week’s roster, it was seen that minimum staffing levels, of two staff working between 9am and 9pm, and one sleeping-in, were being adhered to. Most weekdays have additional staff working during day and evening hours. Service users noted that there are enough staff working during the day and at night. Staff training profiles were in place for all established staff. They however almost always dated up to the end of 2004. They must be updated so that management can ensure that any relevant knowledge and competence gaps can be addressed. Additionally the home needs to have a training and development plan for staff, to help ensure that they continue to receive training relevant to service users’ needs. The agency induction folder was in need of updating. It contained older information about service users, for instance, and referred to keyworkers who had since left the service. Profiles of service users, whilst clearly useful as introductions, ought also to be dated. Checks of the recruitment records of two recently-appointed staff members were attempted. Some of the required documentation was available in the home (written references), some was supplied following the inspection (Criminal Record Bureau [CRB] disclosures and application forms), and some remains unsupplied (identification checks, start dates, and POVA-First checks). It was urgently and formally required for the manager to supply the CRB and some other information, and receipt of this found the CRB checks to be suitable. However, it was ultimately not established as to whether these were in place before each employee started work, which could have put service users at risk of working with unsuitable people, particularly as there was no evidence of the required POVA-First check being in place from their start date. The manager must ensure that this is addressed. It was additionally found that the recruitment policy does not stipulate the recruitment records that must be in place before someone starts working in the home. This must be addressed. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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, 40, 41 and 42. Service users and staff benefit from good standards of management. Service users’ views are starting to influence how the home operates, although this needs formalisation. Improvements are needed to some areas of health and safety, to protect service users and staff from risks. EVIDENCE: The manager has been working full-time in the home since the end of November 2005. He was previously involved in co-running the home for a number of months, whilst concurrently running another similar home. It is required that he now apply for registration with the CSCI as the home’s manager. The manager is working towards completion of the NVQ level 4, and has suitable management qualifications. He has many years’ experience of working in this field, including having run a similar local home for over ten years. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 24 There was plentiful written evidence of the manager discussing issues with service users. Feedback from service users confirmed this, noting for instance that the manager has set individual meetings with some service users in which to discuss issues that service users wish to raise. Service users also noted that the manager is approachable, with one person saying that he sees both sides of arguments. Staff spoke individually of receiving good support from the team and the manager. Staff were generally seen to interact comfortably together. Staff meetings were seen to be recorded about weekly. They included expected information about ongoing service user issues and staff team matters. The manager stated that a service review and plan is aimed for completion by April 2006. This is an outstanding requirement, based on the principle of all relevant people having a say in how the home should be developing. The manager noted positively that an away-day for service users and staff took place during the summer. This was useful for people to air their views about how the home operates. Further such days are planned, for instance to help finalise the Service User Guide. Monthly visits of the home on behalf of the registered provider are now both taking place regularly and being reported about to the CSCI, as previously required. It remains for key policies that have been drafted to be finalised and shared with service users, for service users’ information and comments about processes in the home. The manager noted that this process is ongoing. The home now has a visitors’ book in operation. It was not being used sufficiently. The inspector was not asked to sign in, and the book missed entries from other people whom other records showed had visited. The manager made the point that service users have been asked to let staff know if there is a visitor, and that the home has two entry points. Both these issues allow the visitor book recording to be missed. Systems must be designed to enable the book to kept up-to-date, for fire safety and transparency purposes. In terms of health and safety processes, some suitable systems are in place, but some improvements are needed. Suitable accident records are being kept separately within the home, in respect of both service users and staff. Internal and professional fire checks are suitably in place according to records. Discussions with the manager about fire evacuation procedures found that there may be risks around evacuation due to the size and shape of the building. It is recommended that a fire safety professional consider this as part of a fire safety risk assessment. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 25 Improvements are needed to ensure that portable electrical appliances receive an annual professional test against risks of electrical malfunction. The current test dates from 2004. Internal water temperature checks must result in actions where temperatures are too hot or cold. The recent test, and checks by the inspector during the visits, found some outlets to be both too hot and too cold, which presents risks to some service users. The meter cupboard in the alley also remains in need of being made secure. It was also found that a mop handle is sometimes being used to keep the laundry door open. Feedback from service users and staff found that this was a common occurrence for ventilation purposes, as the windows to the room are generally inaccessible without climbing over other items, and as that the extractor fan tends to be switched off by people. For reasons of general health and safety and of fire safety, a permanent and workable solution to this scenario must be found. 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 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 2 2 3 3 3 4 3 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 2 2 2 X 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes 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. Standard Regulation Requirement A copy of the (revised) Service User Guide must be given to each service user. Previous timescales of 1/12/04 and 1/4/05 partially met. The manager must ensure that service users’ individual plans are reviewed and updated, where plans are more than six months old. Service users individual plans must capture both the planned and actual methods in which each service users needs will be addressed and with respect to any updated CPA meeting decisions. Previous timescales of 1/5/05 not met. Service users must be given a copy of their individual plan, unless there are clear and recorded reasons against this for individual service users. Previous timescales of 1/12/04 not met. Timescale for action 1 YA1 5(2) 01/04/05 2 YA6 15(2) 01/06/06 3 YA6 15(2) 01/06/06 4 YA6 15(2)(a) 01/07/06 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 28 5 YA9 13(4), 15 6 YA20 13(2) 7 YA20 13(2) 8 YA22 22 9 YA22 22 10 YA23 13(6) 11 YA24 23(2) 12 YA24 23(2)(b) The manager must ensure that key hazards to each service user are identified, risk reduction plans discussed and implemented, and that findings are recorded and reviewed. The manager must ensure that staff accurately sign for medications administered to service users. The home’s medication policy must accurately describe the processes and safeguards used in respect of enabling service users to self-medicate. The manager must ensure that complaints processes include the process of establishing formal conclusions and follow-up actions and that these are recorded about. The manager must ensure that complaints are investigated and responded to within 28 days. The adult protection policy needs expanding to include response times. The reporting procedure needs to be accurate. Previous timescale of 1/1/05 and 1/4/05 not met. The carpets in the corridors leading to the bathroom and in the hallways need to be replaced. Previous timescales of 9/10/03 not met. The gap between the hallway and the smoking lounge, which is a tripping hazard, needs to be addressed. Previous timescales of 15/12/04 and 15/4/05 not met. One table in the kitchen was very wobbly and so needs stabilizing or replacing. DS0000017519.V283262.R01.S.doc 01/06/06 01/05/06 01/07/06 01/05/06 01/05/06 01/04/05 09/10/03 15/04/05 13 YA24 23(2)(c) 01/05/06 89-91 Bessborough Road Version 5.1 Page 29 14 YA24 23(2)(b, d) 15 YA24 23(2)(b, d) 16 YA34 17(2) s4 pt6f, 19 s2 17 YA34 Misc Amend Regs 2(9) The stair banisters in some areas were chipping significantly. The more recent banisters additionally did not match the established ones in terms of colour. Both of these issues must be addressed. The necessary redecoration of one service user’s ceiling following a minor leak from a bathroom above must be promptly addressed. Copies of application forms, CVs, start dates, and identification checks including recent photographs, must be in place within recruitment records before any staff member commences employment. POVA-First checks through the employer must be in place for any new staff before they commence supervised employment in the home. CRB checks through the employer must be in place for staff to start work unsupervised. A training and development plan for the staff group needs to be implemented. Previous timescales of 30/9/03 not met. Staff training profiles must be kept up-to-date and accurate. 01/07/06 15/04/06 21/02/06 21/02/06 18 YA35 19 30/09/03 19 YA35 19 s4 pt6(g) 01/05/06 20 YA35 18(1)(c) The agency induction folder must be updated to contain appropriate and accurate 01/05/06 information about service users and the home. It is required that the manager applies for registration with the CSCI as the home’s manager. 21 YA37 10(1) 01/05/06 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 30 22 YA39 21, 24 23 YA40 12 24 25 YA41 YA42 17(2) s4 pt17 23(2)(c) 26 YA42 13(4) 27 YA42 13(4) 28 YA42 23(2)(b) A further service review is required. It must consider how the goals from the previous review have been progressed. Previous timescale of 1/2/05 not met. Key policies that have been drafted must be finalised and shared with service users. Previous timescale of 1/2/05 not met. Systems must be designed to enable the visitors book to kept up-to-date. The manager must ensure that the home’s portable appliance test is kept up-to-date. Internal water temperature checks must result in actions being taken where temperatures are too hot or cold. A permanent and workable solution to the laundry room ventilation issues must be found. Mop handles must not be used to prop the laundry room door open. The meter cupboard in the alleyway at the side of the home needs to be covered and made secure. Previous timescale of 1/8/05 not met. 01/07/06 01/08/06 01/06/06 01/06/06 01/05/06 01/05/06 01/07/06 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 31 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 YA16 Good Practice Recommendations There was an equal split of comment card views in terms of whether service users are provided with enough involvement in decision making in the home. Management should further discuss this with service users. It is recommended that a fire safety professional consider evacuation processes as part of a fire safety risk assessment. 2 YA42 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 89-91 Bessborough Road DS0000017519.V283262.R01.S.doc Version 5.1 Page 33 - 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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