Inspection on 20/05/08 for Beulah Road (55)

This inspection was carried out on 20th May 2008.

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 6 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) 08/01/08

Beulah Road (55) 11/07/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Beulah Road (55) 55 Beulah Road Thornton Heath Croydon Surrey CR7 8JH Lead Inspector Lee Willis Key Unannounced Inspection 20th May 2008 10:30 Beulah Road (55) DS0000028139.V362853.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.V362853.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.V362853.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) Manager post vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beulah Road (55) DS0000028139.V362853.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 8th January 2008 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 recently resigned as the homes registered manager and the day-today running of the service has been overseen since February 2008 by the registered manager of another CMG care home until 19th May 2008 when Pat McGarry was appointed the homes new acting manager. 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 at the rear of the property that has its own cooking and en-suite bathroom facilities. The garden at the rear of the property is well maintained and includes a 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.V362853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The new quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes This is an improvement on its zero star rating given at its last Key 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 strengths, but also areas of particular weakness that the service still needs to take urgent action to improve. In total we spent five hours at the home. During this unannounced visit we spoke to two people who currently use the service, the new and former acting managers, and three support workers. We also looked at a variety of records and documents. The remainder of this site visit was spent touring the premises. We received comment cards from one person who uses the service, the relative of another, and a member of staff. The former acting manager also provided us with a completed Annual Quality Assurance Assessment (AQAA) that tells us about the service, how it makes sure of good outcomes for the people using it, and any future developments that are being planned. What the service does well: What has improved since the last inspection? The department of the homes registered and long-standing deputy manager has been the single most significant change that has occurred in the home since it was last inspected. The former acting manager who took over the running of the home for three months at the beginning of February 2008 has made a number of significant improvements to the service in a relatively short Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 6 period of time. The homes new acting manager, who had only been in post for less than a week at the time of the site visit, told us they are very keen to take over where the former acting manager had left off. The new manager has recently been registered by the Commission as a ‘fit person’ to run a residential care service for adults with learning disabilities and has a clear vision about the direction she wants to take the home. All the care plans in place for the people who use the service have been up dated recently to make them far more person centred. The new manager told us she is aware that this an on going process and will continue improving care plans with the involvement of the people who use the service. All the risk management plans that enable people who use the service to take ‘responsible’ risks have been reviewed in the past three months and up dated accordingly to reflect any changes in need. There has been some improvement with regard the number and variety of opportunities the people who use the service have to engage in more meaningful social and leisure activities in the local community, although the new manager acknowledges there is still considerable room for further improvement in this area. The people who use the service have far greater opportunities to eat healthier meals while their right to continue choosing the food they prefer to eat has not been totally compromised. Information about what activities and meals are offered each day are also available in far more easy to read formats that are illustrated with all manner of coloured pictures and photographs. The restrictive practise of locking peoples bedroom doors at certain times of the day to prevent them sleeping when they like has ceased. The home is much better at keeping us informed about the occurrence of significant events in the home that adversely affect the welfare of the people who live there. Changes to the homes environment include new curtains in the lounge, new table, and chairs in the dinning room, and a new water feature in the garden. The self-contained flat at the rear of the garden has been redecorated. A new delegation book has been introduced to ensure staff have a better understanding of their roles and responsibilities and the supervision of staff has improved. Finally, all the homes night staff are participating in fire drills at regular intervals and the unsafe practice of wedging open fire resistant doors, which prevents their automatic closure in the event of the fire alarm being sounded, has ceased. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 7 What they could do better: All the positive comments made above notwithstanding there remains a lot for the new manager to do in order to improve the lives of the people who use the service, as well as keep them safe: Staff should be more proactive when it comes to encouraging and supporting the people who use the service to maintain and develop their independent living skills. We agree with the former acting managers’ comment, “that staff tended to pay far too much ‘lip service’ to this concept during his short tenure of the home.” Arrangements for up dating medication administration sheets in order for them to accurately reflect what medicines have been discontinued must be improved. This will ensure the people who use the service are kept safe. We agree with the statement made by the former acting manager in the homes AQAA that staff training is an area where the service could significantly improve. The home has been required to ensure all staff who work there, including the new manager, up date or receive further training in a number of key areas of practice including, safeguarding vulnerable adults, basic food hygiene, and using the providers new compatibility assessment tool for new admissions. The new manager has also been asked to carry out a thorough assessment of her staff teams training strengths and weaknesses and establish a time specific action plan to address any identified gaps in her teams knowledge and skills. The service needs to review its fire risk assessment for the building as a matter of urgency to ensure (so far as reasonably practical) the people who use the service are kept safe. Failure to address this outstanding fire safety issue in a timely manner will result in the Commission considering taking enforcement to ensure future compliance. We recommend the new manager should actively encourage anyone who is willing and capable of managing their own medication to do so providing suitable arrangements are in place to manage any identified risks. The providers should give serious consideration to establishing a time specific rolling programme that makes it clear what changes they are proposing to make to the interior design and layout of the home. Finally, the new manager needs a suitably competent and experienced deputy manager to help her run the home and achieve her vision for it. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 8 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.V362853.R01.S.doc Version 5.2 Page 9 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.V362853.R01.S.doc Version 5.2 Page 10 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 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. In the main people who use this service are provided with relatively good information about the home that enables them to make an informed decision about whether the service is right for them, although the Guide could still be improved to reflect all the recent changes at the home. People’s needs are fully assessed prior to admission so the individual, their representatives, and the home can be sure the placement is appropriate for them. EVIDENCE: The homes newly appointed manager told us the services Statement of Purpose and Guide were still in the process of being up dated to reflect all the changes that had occurred at Beulah Road in the past 4 months. The new manager was confident that the up dated version would include details about her qualifications and experience, and the views of the people who use the service. This was a good practice recommendation made at the homes last two inspections, but we have agreed to give the new manager more time to this aim as we accept that she has only been in post for less than a week. The recommendation is repeated for the third and final time in this report. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 11 The home currently has one vacancy following the recent departure of one individual whose changing needs the providers concluded they were no longer capable of meeting safely having recently reassessed the needs of all the people living at 55 Beulah Road. The new manager told us she was very conscious about the high number of significant incidents that had recently occurred at the home involving the same individual and issues surrounding their compatibility with the other service users. The new manager has a lot of experience assessing the suitability of new referrals as the registered manager of another CMG home for adults with learning disabilities. Pat McGarry was able to demonstrate a good understanding of what constituted ‘best practice’ with regards accepting new referrals and how important it was to ensure they would be (so far as reasonably practical) be compatible with the other people already living in the home. The manager told us she has copies of CMG’s new compatibility assessment tool, but was not familiar with its use having not received any training in its application. The outstanding requirement that anyone authorised to use the new assessment tool is trained in its use is repeated for a second and final time in this report. The previous timescale for appropriate action to be taken to meet this requirement has been extended because we accept the new manager has only been in post for less than a week. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 12 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. Care plans reflect what is important to the individual, their capabilities, and what support they need to achieve their personal aspirations. In the main people who use the service are protected by the homes arrangements for assessing and managing identified risk, although there remains significant scope to improve the way the service supports people who live there gain a greater degree of independence. EVIDENCE: It was evident from the two care plans selected for case tracking that they are person centred and look at all areas of an individual’s life. One individual told us their keyworker had helped them “write stuff in their care plan”. This individual also knew were their care plan was kept and that they could access it when ever they liked. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 13 As required in the homes last inspection Onyi (former acting manager) had up dated a number of care plans to ensure they were all person centred and reflected each service users unique strengths and needs. Two care plans selected at random contained reviews undertaken by the individual’s keyworkers on a weekly basis and recently up dated risk management strategies. The former acting manager also introduced a co-keyworker system to ensure everyone who lived at the home had an additional member of staff specifically allocated to them. The new manager told us she has a positive approach to managing risk and is very keen to enable the people who use the service to take ‘responsible’ risks as part of a structured programme to help them maintain and develop their independent living skills. In line with this ethos one individual was recently offered the chance to move into the self-contained flat at the rear of the property in order to support them gain a greater degree of independence. Both the homes new and former acting managers conceded there was still significant scope to improve the way the home supports people who use the service to become more independent. Beulah Road (55) DS0000028139.V362853.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): 12, 13, 15, 16, & 17 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. The service treats all the people who use it as individuals and is relatively responsive to people’s diverse cultural and religious needs and wishes. The number and variety of social, leisure and recreational activities the people who use the service have the opportunity to participate in has improved since the homes last site visit, although there remains scope to continue improving links with the local community. This will enable the people who use the service to live more meaningful and fulfilling social lives. Dietary needs and preferences are well catered ensuring the people who use the service are provided with daily variation, choice, and far more nutritionally well-balanced meals. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 15 EVIDENCE: On arrival two people who use the service were out attending educational and leisure activities at local day centres. Two daily diary notes sampled at random showed that in the past three months these individuals had participated in a wide variety of stimulating activities both at home and in the wider community. The former acting manager and two support workers met during this site visit all told us the range and number of activities people who use the service now have the opportunity to participate in on a regular basis has significantly improved in recent months. One person who uses the service told us they “can go out when ever I like”; while another said “they had been to church recently”. The new manager told us she was very keen to continue improving the opportunities people who used the service to engage in more meaningful community based activities, especially in the evenings and at weekends. It was evident from comments made by one person who uses the service and several members of staff that the home continues to operate an open visitors policy without restrictions. There is a visitor’s book in the porch, which all visitors to the home are expected to sign and date on their arrival. Since the homes last site visit the former acting manager introduced new weekly activity and menu schedules in ‘easy to read’ formats that were illustrate with all manner of colourful pictures and symbols to enable everyone who used the service to understand them. These schedules also sent out in detail all the domestic chores these individuals had agreed to be responsible for each week as part of a structured programme to enable people to maximise their independent living skills. As previously mentioned in this report one individual is being actively encouraged to live semi-independently in the selfcontained flat at the rear of the property. This individual told us they are looking forward to living in their own flat and are keen to develop their cooking skills. It was evident from comments made by the new manager that she is committed to ensuring her new staff team are far more proactive when it comes to encouraging service users to develop their independent living skills than they have in the past. During a tour of the premises it was noted that none of the bedrooms were locked. One member of staff spoken with told us the practice of locking one individuals bedroom door at certain times of the day to limit their access to this area had ceased. Both the new and former managers agreed that this restriction, which had ceased before they had arrived, had been an unnecessary infringement on this individual right to privacy and freedom to make informed choices. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 16 Since the homes last inspection a new menu has been introduced that provides the people who use the service with greater opportunities to eat healthier meals. The former acting manager told us the new menus were developed with the help of a nutritionalist who advised the home about healthier eating options. As previously mentioned in this report the new menus are available in ‘easy to read formats that are illustrated with colourful pictures and conspicuously displayed in the kitchen. One member of staff spoken with demonstrated a good understanding of the dietary wishes of a number of people who used the service with diverse cultural backgrounds. Staff continue to maintain a record of all the food served each day that showed Caribbean style cuisine still features regularly on the menus, which also matched the food preferences identified in a number of peoples care plans. One person who uses the service told us they “enjoyed eating Caribbean style food such as rice and peas and Ackee …. and was looking forward to learning how to cook more dishes for himself.” During the site visit a member of staff was observed preparing lunch that consisted of either pasta or assorted sandwiches. The lunchtime pasta dish looked and smelt quite appetising. Beulah Road (55) DS0000028139.V362853.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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. Policies and procedures for handling medication are in the main sufficiently robust to keep the people who use the service safe, although the way the services up dates its records to reflect changes in medication will need to be reviewed. EVIDENCE: All the people who use the service met during this site visit were suitably dressed in clothing that seemed to match their own personal style. One individual was wearing a hat they told us they had bought for themselves during a recent shopping trip. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 18 Health care action plans were made available on request that outlined what peoples unique health needs were, and the input they received from various health care professionals, such as GP’s, nurses, dentists, opticians, and chiropodists. The homes accident books revealed that none had occurred involving the people who used the service since it was last inspected. As previously mentioned in this report the vast majority of significant incidents that have occurred in the home in the past six months involved the same individual who recently moved out as a direct consequence of their increasingly challenging behaviour. Staff on duty appropriately dealt with these incidents, along with two others involving another service user who still resides at the home, at the time, reported to all the relevant professionals, and risk management strategies up dated accordingly. No recording errors were noted on medication administration records (MAR) sheets sampled at random. These records reflected current medication stocks held by the home on service users behalves, which were securely stored in a locked metal cabinet in the office. The new manager told us that with the right support she believed a number of the people who use the service could self medicate if they wished. The recommendation made in the homes previous report that the views of the people who use the service about the possibility of them having greater control over their medication be ascertained and their capacity to do so risk assessed. Protocols for the use of ‘as required’ medication held in the home on behalf of the people who use the service were made available on request. It was noted that there had been a significant reduction in the use of ‘as required’ medication and staff spoken with were all clear when and how to give it. The new manager also demonstrated a good understanding that ‘as required’ psychotropic medication must only ever be administered as a ‘last resort’ when all other methods have failed. The former acting manager confirmed during the site visit that as required medication prescribed one individual had recently been discontinued by their GP and replaced as a short term measure with another type of as required medication. Medication records showed that staff who had administered this new as required medication had done so correctly, but it was unclear on the individuals medication administration sheet that this temporary change in their prescribed medication had occurred. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes arrangements for dealing with concerns and complaints are sufficiently robust and understood by staff to ensure people who use the service feel listened too and safe. In the main the homes safeguarding arrangements are sufficiently robust to protect the people who use the service, although they are still being placed at unnecessary risk of harm and/or abuse because a third of the people working there have still not received or up dated their safeguarding vulnerable adults training. EVIDENCE: Homes complaints log showed that none had been made since it was last inspected. One person who uses the service told us “staff usually listen to what they have to say and would take it seriously”. This same individual also told us they “would talk to the manager if they were unhappy with anything at the home”. The new manager demonstrated a good understanding of what the term safeguarding meant and was able to produce the local authorities safeguarding protocols on request. One allegation of abuse has been disclosed within the home since it was last inspected. This matter was referred to the local authorities safeguarding team by an external source and investigations are Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 20 currently on going. CMG are cooperating fully with the local authority to conclude this matter. The lasted assessment of the training needs and strengths of the homes current staff team indicates that a third still need to receive and/or up date there safeguarding vulnerable adults training. A requirement was made about this training shortfall at the homes last inspection. Nonetheless we are satisfied that the new manager has not been in post long enough to put things right and therefore we will be repeating it in this report with a new timescale for appropriate action to be taken. Failure to do so will result in the Commission considering taking enforcement action to ensure future compliance. Reports compiled by senior representatives of the providers showed that monies held by the home on behalf of the people who use the service are being audited at regular intervals. The new manager told us she was familiar with CMG’s new financial checks and balances procedures and had recently received training in how to manage a care homes budget and look after services users monies safely. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 21 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. Some improvements have been made to the décor and soft furnishings within the home although there remains significant scope to change some of its layout and redecorate other areas to ensure the people who use the service live in a more homely and comfortable environment. The homes arrangements for controlling infection are sufficiently robust to ensure the people who use the service also live in a very clean and safe environment. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 22 EVIDENCE: People spoken with about the physical environment of their home were in the main quite positive about it. Typical comments included, “I am very happy with my new flat”, “I’m going to learn to cook in my new kitchen”, and “I chose the colour my bedroom was painted”. Since the homes last inspection some improvements initiated by the new manager have been made to the homes soft furnishings and fittings. This has included, new curtains and table and chairs in the dinning room, and a new water feature in the garden. The self-contained flat has also been redecorated. The new manager told us she is very keen to improve the physical layout and interior design of the home to improve the lives of the people who live there. We recommended the providers establish a time specific rolling programme to implement the new managers environmental proposals which include, redecorating most of the homes interior, fitting new wooden flooring in the office and main lounge areas, reducing the number of doors in the office and lounge to make this areas more homely, replacing all the damaged leather sofas in the lounge, replacing the old bathroom suites with new ones, and retiling these areas. As recommended in the homes last report the new manager also told us she is very keen to convert the former smoking room into a sensory area as none of the people who live in the main part of the home currently smoke. Progress made to improve the homes environment will be assessed at its next inspection. During a tour of the premises it was noted that all the communal areas were spotlessly clean. Records are appropriately maintained of regular checks carried out by staff on hot water emanating from the homes baths. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 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. Not all persons working at the home have been suitably trained. The homes approach to the training of staff must be reviewed to ensure the people who use the service benefit from being supported by a suitably competent staff team who can meet their needs and wishes. The homes recruitment procedures are sufficiently robust to minimise the risk of service users being harmed and/or abused by people who are ‘unfit’ to work with vulnerable adults. EVIDENCE: Two support workers on duty at the time of this site visit were observed interacting with a number of the people who currently use the service in a very caring and respectful manner. Typical comments made by one person who uses the service included, “I like most of the staff who work here”, “I know who my keyworker is and I can speak to them if I’m unhappy”, and “the new manager seems nice”. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 24 Since the homes last inspection the former acting manager has introduced staff delegation records that he feels has helped staff have a better understanding of their roles and responsibilities. Staff duty rosters sampled at random and the numbers found to be working on the afternoon of this unannounced inspection were more than adequate to meet the assessed needs of the people using the service. It was also noted that the ethnic, age, and gender mix of many of the staff currently employed by the home was relatively reflective of the service user group. One person who uses the service told us they were pleased the home employed a number of men with the same cultural heritage as themselves. The new and former acting managers confirmed that no new support staff had been employed since the home was last inspected. The new manager told us she believed the recruitment of good quality carers was the cornerstone of delivering good outcomes for the people who use the service and was very keen to ensure the right people for the job are employed. As previously mentioned in this report the new manager told us she is aware that the staff training needs and strengths assessment undertaken by the former registered manager was now out of date and therefore did not accurately reflect what her teams current training shortfalls were. The new manager has agreed to reassess her staff teams training needs and establish a time specific programme to address any identified gaps in it. The requirement that sufficient numbers of staff are suitably trained in basic food hygiene was identified in the homes last report. We except the new managers explanation that she has not been in post long enough to address this training shortfall. The timescale for appropriate action to be taken to address this shortfall has been extended for the final time and failure to meet it will result in the Commission considering taking enforcement action to ensure future compliance. The recommendation that the homes staff team also receive additional training with regard person centred care planning, epilepsy and autism is repeated in this report. We will monitor closely progress made by the home to address all the training shortfalls highlighted above. The former acting manager of the home told us he had begun the process of supervising the staff team, but conceded the service had a long way to go to ensure this continued to occur at regular intervals. The new manager told us she is very keen to employ a new deputy manager as soon as reasonably practicable to recommence the process of ensuring her staff receive formal supervision sessions with suitably competent senior staff at regular intervals. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 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. People who use the service have confidence in the care home because a suitably qualified manager now runs it. Sufficiently robust quality assurance and monitoring systems are in place that allow the views of the people who use the service to influence homes operation and development. The people who use the service are being placed at unnecessary risk of harm because not all the homes fire safety measures are sufficiently robust to promote and protect their health and welfare. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 26 EVIDENCE: The new manager – Pat McGarry was able to describe a clear vision for the home and has a reputation of being a strong leader of staff. The manager was also recently registered by the Commission as a ‘fit’ person who was capable of running residential care homes for adults with learning disabilities. Pat is also aware that she will need to get in contact with our Regional Registration Team to ensure Beulah Roads certificate of registration is up dated to reflect the change of manager. Pat told us she is continues to be enrolled on a suitable NVQ level 4 course in management and care which she intends to have completed by the end of the year. Since the home was last inspected both the registered and long-standing deputy managers have resigned. As mentioned throughout this report the former acting manager has done his best to stabilise the home and make a number of significant improvements in a very short period of time. The new manager told us she is very keen to continue the process of moving this service forward and will be actively seeking to employ a suitably experienced and competent deputy manager to help her achieve this aim. We agree with the manager that she will need the support of a competent deputy if the process of improving the standard of care received by the people who use this service is to continue. Records revealed the former acting manager reinstated monthly staff meetings, which the minutes of the last three held in the home showed covered a number of vital areas of practice, which it needed to improve. This included actively supporting and encouraging the people who use the service to develop their independent living skills, engage in a wider variety of community based activities, and recording and reporting incidents Regulation 26 reports continue to be compiled by senior representatives of CMG who following monthly quality assurance visits to the home. In addition to these visits members of CMG’s relatively new quality assurance team also undertake quarterly quality monitoring assessments. All the reports referred to above were found to be extremely thorough covering every aspect of life in the home, and involved all the homes major stakeholders including, services users and staff. We accept the new managers explanation that as she has not had enough time to up date the fire risk assessment for the building. This outstanding requirement will be repeated for a final time in this report. Failure to meet it within the new extended timescale for action will result in the Commission considering taking enforcement action to ensure future compliance. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 27 Fire records revealed that the homes fire alarm system continues to be tested on a weekly basis and that three fire drills had been carried out in the past five months in line with the London Fire and Emergency Planning Authority guidance. During a tour of the premises none of the homes fire resistant doors were found to be inappropriately wedged open preventing there automatic closure in the event of the fire alarm being activated. An up to date Certificate of worthiness was made available on request to show that suitably qualified engineers had checked the homes water heating systems for traces of legionella, gas installations, and fire fighting and warning equipment in the past twelve months. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 28 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 1 X Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 29 Yes Are there any outstanding requirements and recommendations 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 YA2 Regulation 9(2)(b)(i) & 18(1) Requirement All staff, including the manager, who will be expected to use CMG’s new compatibility assessment tool must be suitably trained in its use. This will ensure all the people who use the service are kept safe. Previous timescale for action of 1st March 2008 not met. When there is a change (temporary or permanent) in medication prescribed the people who use the service part-way through its use medication administration sheets must be up dated to clearly reflect this discontinuation. This will minimise the risk of medication errors occurring and keep the people who use the service safe. All staff that work in the home must be appropriately trained to recognise, prevent and report abuse. This will ensure the people who use the service are kept safe. Previous timescale for action of 1st April 2008 not met. DS0000028139.V362853.R01.S.doc Timescale for action 01/07/08 2. YA20 13(2) 21/05/08 3. YA23 13(6) & 18(1) 20/08/08 Beulah Road (55) Version 5.2 Page 30 4. YA35 18(1) The assessment tool used by the home to identify staffs training achievements and needs must be up dated as a matter of urgency to accurately reflect any gaps. This will enable the new manager to plan future training programmes for her staff team to ensure all persons working at the home are suitably competent to meet the needs and wishes of the people who use the service. This was a good practice recommendation made at the homes last inspection, but has not been implemented. All staff that prepare meals in the home must receive basic food hygiene training. This will ensure the safety of the people using the service. Previous timescale for action of 1st May 2008 not met. 01/07/08 5. YA35 18(1) 20/08/08 6. YA42 23(4)(a) 04/06/08 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. This will ensure the safety of the people who use the service. Previous timescale for action of 1st August 2007 & 1st March 2008 not met. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 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 YA1 Good Practice Recommendations The homes Statement of purpose/Guide should be revised to include stakeholder’s views about the quality of the care provided and reflect all the recent changes in the homes management. This recommendation was made at the homes previous two inspections, but has still not been carried out. People using the service should be able to manage their own medication if they wish in order to promote their choice and independence providing all the risks associated with the activity are thoroughly assessed and managed. This recommendation was made at the homes last inspection, but has not been implemented. The providers should give serious consideration to establishing a time specific rolling programme that makes it clear what changes they are proposing to make to the interior design and layout of the home. This will ensure the people who use the service live in a more homely and comfortable environment. People who use the service should be able to access a sensory room. This will ensure that they receive person centred support that meets their social needs. This recommendation was made at the homes last inspection, but has not been implemented. 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. This recommendation was made at the homes previous two inspections, but has not been implemented. 2. YA20 3. YA24 4. YA28 5. YA35 Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 32 6. YA37 To enable the new manager to run the home effectively and continue the process of improving the standard of care received by the people who live there a suitably competent deputy manager should be recruited. This will ensure the people who use the service live in a well managed home. Beulah Road (55) DS0000028139.V362853.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V362853.R01.S.doc Version 5.2 Page 34 - 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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