Inspection on 11/07/07 for Beulah Road (55)

This inspection was carried out on 11th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beulah Road (55) 03/03/09

Beulah Road (55) 20/05/08

Beulah Road (55) 08/01/08

Beulah Road (55) 24/11/06

Beulah Road (55) 31/10/05

Beulah Road (55) 01/12/04

Beulah Road (55) 06/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beulah Road (55) 55 Beulah Road Thornton Heath Croydon Surrey CR7 8JH Lead Inspector Lee Willis Key Unannounced Inspection 11th & 17th July 2007 10:35 Beulah Road (55) DS0000028139.V345335.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 Beulah Road (55) DS0000028139.V345335.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. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beulah Road (55) Address 55 Beulah Road Thornton Heath Croydon Surrey CR7 8JH 020 8653 6377 T/F 020 8653 6377 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 Ltd (trading as CMG Homes Ltd) Iye Fornah Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 7 24th November 2006 Date of last inspection Brief Description of the Service: 55 Beulah Road is owned by CMG a specialist provider of care for adults with learning disabilities and challenging behaviour. The service provides accommodation and personal support for up to seven generally younger males. Iye Fornah has been in operational day-to-day control of the home since being appointed manager in July 2006. Located on a suburban street close to the centre of Thornton Heath the home is within easy walking distance of a wide variety of local shops, cafes, pubs, and banks. The home is also very close to numerous bus stops and a local mainline train station with excellent links to central Croydon and the surrounding areas. The main house comprises of six single occupancy bedrooms, a large open plan lounge/ dinning area, a designated smoking room, separate kitchen, office, and laundry room. There is also a one bedroom self-contained flat situated in the rear garden that has its own cooking and en-suite bathroom facilities. The garden at the rear of the property is well maintained and includes a new decking area. People who use the service have all been provided with copies of up dated versions of the homes Guide and a contract that sets out people’s terms and conditions of occupancy. Fees currently charged for facilities and services provided currently ranges from £1,418.93 to £1,850 per week. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process the Commission for Social Care Inspection (CSCI) has judged the service as having some strength’s, but also ‘significant’ weaknesses where important elements of certain key National Minimum Standards not are being met. Two site visits were carried out on this service in July, which both lasted a total of nine hours. Four people who live at 55 Beulah Road, the homes manager, three members of staff, and a visiting care manager were all spoken with at length during the course of these visits. A second care manager representing two of the people who use the service was also spoken with over the telephoned and it was these individuals whose care I chose to ‘track’ during my visits. The remainder of these site visits was spent examining the homes records and touring the premises. What the service does well: What has improved since the last inspection? Since the homes last inspection a new ‘health matters’ record has been introduced that contains detailed information about the medical history of each person who uses the service as well as the outcome of any health care appointments they attend. The new document enables anyone authorised to inspect it to determine whether or not all the health care needs of the people who use the service are being appropriately met. The record is also available in an easy to read format to ensure the people who use the service have access to its contents. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 6 Improvements have been made to the interior décor of the home in the past year with new soft furnishings bought for the lounge which along with several bedrooms has also been redecorated. The rear garden has a relatively new decking area and furniture for people who use the service to sit outside if they wish. The homes manager has recently achieved her National Vocation Qualification Level 4 in both management and care are is now suitably qualified to run a residential care home for people with learning disabilities. Finally, the relatively new quality assurance systems the providers have introduced, which are very thorough, ensures the views of the people who use the service underpin the homes develop and self monitoring practices. What they could do better: All the positive comments made above notwithstanding their remains a number of significant areas of weakness that require urgent action to be taken to ensure the people who use the service are kept safe: Each person who uses the service has a care plan that includes basic information necessary to deliver their care, but these documents do not contain enough detailed information about the actual support individuals require achieving their personal goals. Care plans need to be far more person centred and people who use the service need to be more actively encouraged to participate in their development and review. During the week people who use the service participate in a wide variety of prearranged social and educational activities in the wider community. However, these opportunities tend to be more limited in the evenings and at the weekends. The manager needs to review weekend staffing levels to ascertain whether or not they are sufficient to meet people’s social needs and preferences at this time. An unusually high number of poor medication handling practices were noted during the course of this inspection. A lack of refresher training for staff authorised to handle medication in the home was found to be a contributory factor. To ensure the people who use the service are not placed at risk the providers have been required to take urgent action to rectify these unsafe practices and remind staff about their medication handling responsibilities. The homes fire safety arrangements need to be tightened up and the manager has been required to undertake a fire risk assessment of the building and get the faulty sound activated release mechanism attached to a fire resistant door on the ground floor repaired as soon as reasonably practicable. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 7 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. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. People’s needs will be fully assessed prior to admission so the individual, their representatives, and the home can be sure the placement is appropriate. EVIDENCE: The manager told us each person who lives at 55 Beulah Road is supplied with a Guide that tells them what services and facilities are provided. During a tour of the premises it was noted that one of the individuals who care was being case tracked had been supplied with a new version of the homes guide, which they kept in their bedroom. The homes Guide was last reviewed in April 2007 and up dated accordingly to reflect any changes in provision. The manager told us the Guide is routinely revised on an annual basis. The Guide is illustrated with all manner of coloured photographs, pictures and symbols to enable people who use the service to access information about their accommodation, staffs qualifications, and how to make a complaint if they are dissatisfied. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 10 The manager told us that the homes Guide does not contain any comments made by the people who use the service about how they view the standard of care they receive. The home has received one new referral since it was last inspected, which was declined because of concerns about the prospective service user not being compatible with the existing group. The relatively new manager was very clear about her role and responsibilities regarding new admissions. The manager also confirmed that is was custom and practice for all new admissions to be asked about their religious beliefs and demonstrated a good understanding of why it was so important to ascertain this type of information prior to placing. The manager was able to produce two signed and dated contracts for the two service users whose care was being case tracked, which included fees charged for services and facilities provided, as well as what services were considered ‘extras’ that were not covered by the basic price of the placement (e.g. holidays, chiropody ect). A break down of all the fees the provider’s charge, which includes basic and additional costs, is also available on a separate document held in peoples care plans. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs and goals are not being met as well as they could be because care plans do not contain enough information about what each persons goals are and the support they would require to achieve them. However, staff did demonstrate they understood the importance of promoting peoples rights and choices. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are supported to take risks to enable them to become more independent. EVIDENCE: Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 12 The individual care plans for the two people selected for case tracking were both examined and it was noted that neither of these documents lacked any real detail about what these individuals wanted to achieve by living at 55 Beulah Road (i.e. what their personal goals and aspirations for the future were) or what support they required to achieve their personal goals and aspirations. Furthermore, the plans viewed were very cumbersome, and not available in formats that could be easily understood by the people for whom the service is intended. The manager told us the providers have developed a more person approach to planning care and that she had recently attended training in, but that none of her current staff team had received any training as yet. The manager conceded that the process of introducing the new care plan format could not begin until staff had received the relevant person centred training. One person who lives at the home told us they had been involved in developing their existing care plan, but were not aware it included any information about what their personal goals or aspirations for the future were. The manager told us that a central aim of the new care plan approach was to ensure people who use the service would be more involved in developing their care plans. It was positively noted that existing care plans for the two people being case tracked contained detailed information about each of their unique personal, social and health care needs, and what their leisure interests and food preferences were. These plans had both been reviewed in the past six months and up dated accordingly to reflect changes in provision. One of these reviews had been an informal in-house review involving the service users, their keyworker and the manager, who told us an annual review involving the individuals relatives and professional representatives (i.e. care manager) was scheduled to take place next month. The manager was able to accurately describe the plans for the two service users whose care was being case tracked. Two people who live at the home told us staff listened to them and consulted them about all aspects of life at Beulah Road. One resident told us they regularly attended meetings about the home, which records showed had been held every month since Christmas 2006. The minutes of these meetings revealed they had been well attended by the people who use the service and that a wide variety of topics are covered including menu planning, activity schedules, holiday destinations, changes to the homes environment and issues relating to respecting others privacy and dignity. It was also positively that people who use the service user had recently begun to have 1 to 1 sessions with their keyworkers at regular intervals, the outcomes of which were recorded. The manager also told us that service users were now given feedback about their involvement in running the home. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 13 A number of risk assessments were included in the two care plans being case tracked, which detailed any action to be taken to prevent and or minimise any identified risks/hazards. These assessments included specific guidance to help staff deal with incidents of verbal and physical aggressive behaviours, supervision in the wider community and using electrical equipment. The manager told us people who use the service are supported to take ‘responsible’ risks in order to enable them to develop their independent living skills. One person who uses the service told us they are supported to prepare a lot of their own meals, while another said they are actively encouraged to access the wider community and use public transport without any staff support. The manager also told us that a number of management strategies had been developed to enable a service user who has recently purchased a bicycle to take a positive risk and learn to ride it. The manager told us that the individual has also purchased safety helmet and has arranged to take cycle proficiency lessons in the local park under staff supervision. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 14 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, 14, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally people who use the service have the opportunity to participate in stimulating social, leisure, and recreational activities both at home and in the wider community. However, opportunities tend to be more limited in the evenings and at the weekends and the manager will need to review the homes arrangements for ensuring people who use the service engage in fulfilling social and leisure activities as and when they wish. People who use the service are provided with a wide variety of nutritionally well-balanced food and their diverse preferences and tastes are generally well catered for. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 15 EVIDENCE: Two people spoken with at length who live at the home told us they led active very social lives. The manager told us that new books for staff to record all the social and educational activities service users engage in each day had recently been introduced. The activity book’s for the two people being case tracked revealed the practice of filling them in each day was variable. Each service user has a daily diary notes and entries made in these records showed staff were far more consistent at keeping them up to date. The weekly activity schedules for the two individuals being case tracked generally matched the entries made in their daily diary notes regarding attendance of local day/youth centres and colleges. However, these records also revealed that these two individuals were not always being actively encouraged or supported to pursue other social interests specified in their care plans, especially in the evenings and at weekends. The vast majority of entries made in these individuals daily diary regarding their participation in social activities in the past two months repeatedly referred to going out for drives and watching DVD’s at home. There was no mention of these individuals being actively encouraged or supported to go out and play snooker or visit the cinema as indicated on their weekly activity schedules. The manager told us she was continually exploring new ways to encourage all the people who use the service to lead more fulfilling lifestyles, both at home and in the wider community, but conceded there was room for improvement in this area of practice. We feel the home should be far more proactive when it comes to keeping the people who use the service informed about what’s social events are happening in the local community and ensure staff actively encourage and support people to engage in a wider variety of community based activities in the evenings and at weekends. The home has a designated smoking room, which has been fitted with a mechanically closing door in line with new legislation. The manager is aware that if this space continues to be used as a smoking room the communal payphone, which is attached to the wall in this room, will need to be relocated. The manager told us she was going to ascertain the views of the one person who smoked in the home about the possibility of building a smoking shelter in the garden in order to convert the smoking room into a new sensory area. The manager told us that one service user attends church services every Sunday evening. This individual’s daily diary note revealed that they regularly attended these services and were always supported to do so by a member of staff. The manager also told that staff have been reminded about their responsibilities to always take into account the wishes of the people using the Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 16 service and now only leave before the end of a church service at the resident’s bequest. The home continues to maintain a visitors book which staff asked me to sign and date on entering the premises. Two people who use the service told us they see their families on a regular basis and staff actively encourage and support them to maintain good links with their families and friends. One person who lives at the home said they had been provided with a key for their bedroom door and that staff always give them their mail unopened. Planned menus are displayed on the kitchen, which indicate the meals the people who use the service can choose from each week. However, the menus displayed to not always accurately reflect the meals actually being consumed by the people who use the service. As staff do appropriately maintain a separate record of the food actually consumed by service users each day it is recommended the home may wish to consider replacing weekly planned menus with a wipe clean board that can be up dated on a daily basis to ensure people who use the service are kept informed about any changes in the meals being offered. One person who uses the service told us their favourite food was pizza, which they told us was always available at least once a week. Another person said they enjoyed having cooked breakfasts, which they had been offered that morning. According to the record of food consumed, it was positively noted that a wide variety of Afro-Caribbean style cuisine, including chicken curry, peas and rice, fried dumplings, had been recently eaten by a number of the people who told us they liked that style of food. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main suitably robust arrangements are in place to ensure the people who use the service receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are continually recognised and met. People who use the service are being place at risk by unsafe medication handling practices. Furthermore, a lack of refresher training regarding medication-handling procedures are limiting the homes prospects for improvement. EVIDENCE: Discussed with two people who use the service what choices they were given each day. Both stated they could choose what time they got up, had a bath, what they wore and when they had breakfast. Since the homes last inspection the providers have developed a new ‘health matters’ booklet which is a stand-alone record setting out the full medical Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 18 history of each person who uses the service and the outcome of all the appointments they attend with various health care professionals (e.g. GP’s, dentists, optician, community nurses, chiropodists ect). The new document is illustrated with all manner of pictures and is written in plain language to enable it to be better understood by both the people who use the service and anyone else ‘authorised’ to view it. A member of staff spoken with about the new ‘health matters’ booklet demonstrated a good understanding of how to maintain the record and what its purpose was. The booklets for the two individuals who care was being case tracked revealed they have attended appointments with their GP’s, dentists, opticians and various community based nurses in the past twelve months. Staff spoken with demonstrated a good understanding of these individuals’ specific health care needs. However, despite one care plan stating an individual had epilepsy their relatively new health matters booklet contained very little guidance to enable staff to help this person manage this health care risk. Staff maintain detailed records of all the accidents and incidents involving all the people who live at the home. Records revealed that none of the people who use the service had sustained any ‘serious’ injuries since the home was last inspected, although one individual was admitted to casualty with a bruised eye following an incident with a fellow service user. Evidence is available on the Commission database to show we were notified about this ‘significant’ event in line with the provider’s policies and procedures for reporting incidents to the CSCI. No recording errors were noted on Medication Administration Record (MAR) sheets sampled at random which all indicated that medicines are being given as prescribed. However, there was not a supply of every ‘as required’ (PRN) medicine listed on one MAR sheet. The manager told us that the PRN medication in question had passed its use by date that she was in the process of replacing it. This medication was later found stored in a zipped bag under the medication cabinet where the manager said it had been left for several weeks waiting to be returned to the dispensing pharmacist. Discussed with the manager whether this PRN medication had been administered since December 2006 when the label on the bottle states it expired. The manager conceded that it had been given in the past six months, which was confirmed on this individuals June 2007 MAR sheet. Two Immediate Requirement Notices were issued at the time of the first site visit for the manager to take urgent action to return or make secure the offending PRN medication and obtain an in date supply as soon as reasonably practicable. Followed up these two Immediate Requirements during a second site visit to the home on 17th July and was able to confirm all the required action had been taken in a timely fashion. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 19 Protocols for the use of as required medication are in place for all those people prescribed it and staff met were very clear when, and how to administer this type of medication. However, looked at the medication training delivered to staff and it was evident that well over 50 of the current staff team authorised to handle medication in the home would need to refresh their basic knowledge and skills in this area of practice in line with the providers own training policies. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people are unhappy with the care home, they or their relatives know how to complain and are confident their complaint will be looked into and action taken to put things right if necessary. People who use the service are also sure the care homes arrangements for dealing with suspected or actual abuse are sufficiently robust to protect them, so far as reasonably practicable, from harm or neglect. EVIDENCE: A copy of the homes complaints procedure is conspicuously displayed in the entrance hall which states how long a complainant can expect to wait for a response and who investigates it. The procedure was written in plain language and illustrated with all manner of easy to read pictures and symbols. The manager told us that no formal complaints about the homes operation have been raised in the past twelve months. Two people who use the service told us they could talk to their keyworker or the manager if they felt unhappy about anything at the home. The service has been subject to two safeguarding adults referral in the past year. The manager demonstrated a good understanding of her role and responsibilities regarding the Local Authorities vulnerable adult protection protocols. Following an internal investigation into the loss of large sum of money from the home the providers concluded that although the loss had been Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 21 accidental it could have been prevented if more suitably robust money transfer arrangements were in place. The manager told us all the money lost had been refunded and more robust financial monitoring systems established to prevent a similar incident reoccurring. The balances recorded on the financial sheets kept for the two service users being case tracked matched the amounts being held by the home on their behalves. Receipts are kept for all the items purchased on service users behalves. Staff number each receipt, which provides anyone authorised to inspect them with a clear audit trail. All the receipts sampled at random matched up with the information entered onto service users individual financial balance sheets in respect of the items purchased and amounts spent. Bank statements were made available on request for the two people being case tracked, which could be used to audit all incoming and outgoing payments made. The manager told us she had recently attended the providers new financial management training and was fully aware how much money she could release before she needed to seek the permission from her line manager and/or the relevant funding authority. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 22 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, 26, 27, 28 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in a relatively homely and comfortable environment that suits their needs and lifestyles. EVIDENCE: There have been no significant changes made to the physical design or layout of the home since it was last inspected. The manager told us the lounge and several of the bedrooms have been redecorated recently. The lounge also has some new soft furnishings by way of curtains and some seat cushions. A person who uses the service gave us a tour of their new look bedroom, which they said they were ‘very pleased with’. The individual told us they had been given ‘a new wardrobe and some blinds’. The bedroom also looked very personalised. Another individual told us during a guided tour of their selfcontained flat that they ‘had enough space to store all their belongings and liked the idea of having their own kitchen to cook in’. The manager told us Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 23 funds had now been secured to supply another service users bedroom with much needed sensory equipment. Progress on this matter will be assessed at the homes next inspection. During a tour of the premises it was noted that most of the homes radiators are uncovered and may present a risk to people that use the service. The potential risks to people who use the will need to be assessed. The home was clean throughout and no offensive odours were detected during a tour of the premises. The homes washing machine is capable of cleaning laundry at appropriate temperatures and has a sluice programme for dealing with foul laundry. The walls and floor of the laundry room are readily cleanable. Gloves and aprons were available in the laundry room and a member of staff was observed wearing appropriate protective clothing as they prepared to deal with a specific infection control issue. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have safe and appropriate support as there are enough competent and qualified staff are on duty during the week. However, weekend staffing levels need to be reviewed as a matter of urgency to ensure sufficient numbers of staff are also available at this time to meet people’s social needs. People who use the service and their representatives have confidence in the staff at the home because all the relevant recruitment checks have been done to make sure that they are suitable. EVIDENCE: Four support workers and the manager were all on duty on arrival at the time of the first unannounced site visit to the home. This ratio matched the staff duty roster for that morning and revealed that an additional fifth member of staff is regularly employed to ensure sufficient numbers of staff are always on duty to meet the needs of the people who use the service. It was therefore surprising to note the duty rosters revealed that a maximum of three members Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 25 of staff are only ever employed to cover weekends. The manager confirmed that none of the people who currently live at Beulah Road regularly stay with their families for any length of time or attend any prearranged community based activities at the weekends. The homes weekend staff levels need to be reviewed as a matter of urgency to ascertain whether or not sufficient numbers of staff are employed to effectively meet the personal, social and health care needs of all the people who currently reside there. The home continues to experience relatively low rates of staff turnover and consequently the manager has only needed to recruit one new member of staff in the past six months. The new employees personal file was examined in some depth and found to contain all the relevant information the service is legally obliged to carry out before allowing any person to commence working at the care home. This included two written references, of which one had been supplied by the individuals most recent employer; up to date Criminal Records Bureau and Protection of Vulnerable Adult checks, proof of their identify; a completed job application, Home Office approved work permit, and their induction record. The homes induction programme ensures all new staff are given the right information to be able to do their jobs well. Individualised training plans are in place for each member of staff that not only identifies what skills people have, but also what their training needs are. This new member of staff was met during the first site visit, was very clear about their responsibilities as a support worker, and showed a good understanding of the actions they needed to take in the event of the fire alarm being activated. Documentary evidence was made available on request to show this individual had received two formal supervision sessions with the manager in their first six months of their probationary period of employment, in line with the providers own staff supervision policy. Records in the form of certificates of attendance were made available on request to show that sufficient numbers of the homes current staff team had received training in fire safety, food hygiene, first aid, and dignified management of conflict (i.e. Managing challenging behaviour). The manager told us that half her staff team had attended a recognising, preventing and reporting abuse course and that arrangements had already been made for the rest to receive this training by the end of August 2007. Progress on this matter will be assessed at the homes next inspection. The manager confirmed that less that a quarter of her current staff team have achieved a National Vocational qualification in care, but is confident five more staff would have commenced this training by September 2007. Progress on this matter will be assessed at the homes next inspection. The manager also told us that very limited numbers of her current staff team had received any specialist training in supporting people who have autism and/or epilepsy. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 26 Furthermore, none of the staff team have received any training in how to implement the providers new person centred care plans. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the care home because a suitably qualified manager runs it. People know that their opinions are central to how the home develops and reviews their practice because there are good quality assurance systems in place. People using the service are being put at risk of injury because the homes fire safety and water temperature control arrangements are not sufficiently robust to safeguard them. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 28 EVIDENCE: The homes registered manager successfully completed her National Vocational Qualification Level 4 in both management and care in June 2007. The manager also told us that in the last six months her employer has provided additional training in person centred care planning, managing finances in a residential care setting, dignified management of conflict, staff recruitment, and equal opportunities. Minutes of the homes last three staff meetings revealed they continue to be held on a monthly basis and are well attended by staff. Topics covered at the last staff meeting included specific changes in the needs of people using the service, the new smoking ban, outstanding maintenance issues, and staff training needs. The providers have developed quality assurance and monitoring systems that cover every aspects of life in the home. In addition to the unannounced monthly visits that are still undertaken by the homes Regional Operations Manager a member of the providers own quality assurance team also carries out quarterly inspections. A copy of the homes last quarterly quality assurance report was made available on request that set out in detail what the service needed to do to improve and develop. The report was extremely thorough and the frequency of these new internal audits exceeds the Commissions expectations. Furthermore, the results of all the satisfaction surveys all the people who use the service had been actively encouraged and supported by their keyworkers to complete this year had recently been published in an easy to read format which was illustrated with all manner of colorful pictures and symbols. However, it was noted that these results represented the views of all the people residing in CMG homes around the country and not just Beulah Road. It is therefore recommended the manager undertake a localized analysis of just the feedback received from the people living at 55 Beulah Road and publishes the results in the homes Guide. The manager told us she has not yet carried out a fire risk assessment for the building in line with the local fire authorities five step plan, but was fully aware this matter needed to be resolved as a matter of urgency. The homes fire records revealed that the fire alarm system continues to be tested on a weekly basis and fire drills are carried out at least once a quarter. The damaged wooden flooring in the office represents a tripping hazard and the manager told us the faulty sound activated release mechanism fitted to the fire resistant door in this room could not be repaired until the floor was fixed. These major breaches of health and fire safety regulations need to be rectified as a matter of urgency. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 29 Daily records are appropriately maintained by staff of hot water temperatures emanating from all the homes water outlets. The manager told us that all the homes baths had been fitted with suitable thermostatic mixer valves that prevented water temperatures exceeding 43 degrees Celsius, but was unsure about the first floor shower unit. The temperature of the hot water emanating from this shower unit was found to be an unsafe 59 degrees Celsius when tested at 11.10am. Up to date Certificates of worthiness were made available on request to show that suitably qualified engineers had checked the homes gas (Landlords) installations, portable electrical appliances, and fire extinguishers in the past year. Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 3 4 X X 1 X Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 31 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Timescale for action 01/11/07 2. YA14 3. YA16 4. YA19 All the people using the service must have more person centred care plans. This will ensure that they receive person centred support that meets their unique personal needs and goals. 16(2)(m) (n) People who use the service 01/08/07 must be supported (as far as reasonably practicable) to attend a wide variety of social, leisure, and recreational activities of their choice at the weekends and in the evenings. 23(2)(a) The communal payphone must 01/08/07 be relocated to a smoke free area of the home and the designated smoking room be clearly marked as a place where smoking is permitted. 12(1)(a) & People using the service must 01/08/07 17(1)(a), Sch have up to date care plans 3.3(m) that set out in detail all their 13(4)(c) 23 health care needs. This will ensure that they receive all the support they require to effectively manage their DS0000028139.V345335.R01.S.doc Version 5.2 Beulah Road (55) Page 32 epilepsy. 5. YA20 13(2) There must be an up to date supply of every medicine listed on medication administration records to ensure people who use the service are able to receive the correct levels of medication they are prescribed. An Immediate Requirement Notice was issued at the time of the 1st site visit. All medicine stored in the home must be kept secure and be accessible only to people ‘authorised’ to handle it. This will ensure the safety of people using the service. An Immediate Requirement Notice was issued at the time of the 1st site visit. All ‘as required’ (PRN) medication that has passed its use by date must be returned to the dispensing pharmacist in a timely fashion and under no circumstances be administered. ‘Stern’ warning letter sent to providers reminding them of their responsibilities regarding the handling and monitoring of PRN medication. All staff ‘authorised’ to handle medication in the home must be appropriately trained to perform this role and ensure their basic knowledge and skills in this area of practice are kept up to date. This will ensure the safety of people using the service. Radiators within the home must be assessed for the risk they present to the people that use the service and DS0000028139.V345335.R01.S.doc 13/07/07 6. YA20 13(2) 13/07/07 7. YA20 13(2) 11/07/07 8. YA20 18(1) 01/10/07 9. YA24 13(4)(a) 15/08/07 Beulah Road (55) Version 5.2 Page 33 10. YA33 18(1)(a) 11. YA42 23(4)(a) 12. YA42 13(4) 13. YA42 23(4)(c)(iv) action taken to minimise any identified risk. Staffing levels at weekends must be reassessed to determine whether or not numbers are sufficient to meet the personal, social, and health care needs and wishes of the people who use the service. The building must be assessed for the fire risk it presents to the people that use and work at the service and action taken to minimise any identified hazards or risks. All shower facilities within the home must be fitted with thermostatic mixer valves that prevent hot water temperatures exceeding 43 degrees Celsius to ensure the safety of people using the service. The damaged wooden flooring and the faulty sound activated release mechanism in the office must be repaired to ensure the safety of the people using the service, their guests, and staff. 15/08/07 01/08/07 01/08/07 01/08/07 Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 34 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. 2. 3. Refer to Standard YA1 YA14 YA17 Good Practice Recommendations The homes Statement of purpose/Guide should be revised to include stakeholder’s views about the quality of the care provided. More information about what social, leisure and recreational events people who use the service can engage in locally should be made more widely available the home. The way in which the service keeps people who use it informed about the choice of meals on offer each day should be reviewed to make the process more open and transparent. More of the homes staff team should receive training with regard implementing the providers new person centred care plans and supporting people diagnosed with epilepsy and autism to ensure the needs of all the people who use the service are met. All the feedback received from the people who live at the home about the service they receive should be analysed at a local level as will as national one and the results published. 4. YA35 5. YA39 Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 35 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. Extracts may not be used or reproduced without the express permission of CSCI Beulah Road (55) DS0000028139.V345335.R01.S.doc Version 5.2 Page 36 - 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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