Inspection on 24/11/06 for Beulah Road (55)

This inspection was carried out on 24th November 2006.

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 8 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) 11/07/07

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 24th November 2006 10:30 Beulah Road (55) DS0000028139.V317257.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.V317257.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.V317257.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 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) Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: 55 Beulah Road is owned by Care Management Group and is currently registered with the CSCI to provide personal support and accommodation for up to seven young men with learning disabilities and challenging behaviour. Iye Fornah was appointed the homes new acting manager in July 2006 following the recent resignation of Venise Browne, the homes long-standing registered 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 within yards of several bus routes and a local mainline train station with good links to central London and Croydon. The main house comprises of six single occupancy bedrooms, a large open plan lounge/ dinning area, a small visitors/smoking room, separate kitchen, office, and laundry room. There is also a one bed roomed self-contained flat situated in the rear garden that has its own cooking and en-suite bathroom facilities. Within the past few months there have been a number of significant changes made to the homes physical environment with a new shower unit and bathroom suite installed in the main house and two decking areas laid out in the rear garden. Service users have all been provided with copies of the homes Statement Of Purpose, Guide, and their terms and conditions of occupancy. These documents contain all the information service users and their representatives need to know about the home, including the range of fees currently charged for facilities and services provided, which currently stands at £1,500 - £2,000 pw. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This service has substantially more strengths than weaknesses and is safe for service users. The new acting manager acknowledged there was nevertheless room for improvement and the Commission is confident the service will rise to this challenge. This unannounced site visit was carried out on a Friday between 10.30am and 3.00pm. During the course of this four and a half hour inspection four service users were met, along with the homes new acting manager, and three support workers. Ten comment cards were returned to the Commission, 50 of which had been completed by service users, and the rest service users relatives and care managers. The remainder of the site visit was spent examining the homes records and touring the premises. What the service does well: What has improved since the last inspection? Where weaknesses have emerged in the past the home has always managed them well and it was positively noted that all the requirements identified in the homes previous report have been met in full. The Commission accepts the new manager’s comments that as she has only been in post for a few months she will need more time to make all the changes she wants to improve the service. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 6 It was noted during this visit that all the staff authorised to use physical intervention techniques when dealing with incidents of challenging behaviour had either recently updated their Dignified Management of conflict training or were booked to attend a suitable refresher course. During a tour of the premises it was positively noted that none of the homes fire resistant doors were being inappropriately propped open and that they had all recently been fitted with effective smoke seals. Other significant changes made to the homes physical environment included the installation of a new bathroom suite and shower unit in the main house and two areas decked out in the rear garden. New leather sofas and dinning room chairs have also been purchased for the main lounge. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to ensure prospective service users and their representatives are provided with all the information they require to make an informed choice about whether or not to move in. All service users have written contracts that set out in detail their individuals terms and conditions of occupancy ensuring any interested party has access to up to date information about the range of fees they can expect to be charged for facilities and services provided. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 9 EVIDENCE: The homes Statement of purpose was recently reviewed by the new acting manager and up dated accordingly to reflect any changes in provision that have taken place in the past twelve months. The document contained all the information prospective service users and their representatives would need to know about the facilities and services provided by the home, although it did not have a review date. One service user spoken with at length said they had been provided with a copy of the homes Statement of purpose sometime ago and felt confident they could obtain an updated version from the office if they wished. The acting manager confirmed that the home had not accepted any new referrals in the past twelve months as it continues to operate at full capacity. The new manager demonstrated a good understanding of CMG‘s admissions procedures and said she would not hesitate to refuse any new referral if it was clearly not in the existing service users groups ‘best interests’ (i.e. not compatible). The new manager was also able to produce written contracts that set out in detail the individual terms and conditions of two service users files sampled at random. These documents accurately reflected the range of fees these service users were being charged for facilities and services provided, including the cost of ‘extras’ not covered by the basic price of each placement. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are reviewed at regular intervals, although arrangements for ensuring these plans are up dated to reflect service users changing needs must be improved. Suitable arrangements are in place to ensure service users have every opportunity to participate in all aspects of life in the home and are able to take ‘responsible’ risks as part of a structured programme to promote their independent living skills. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 11 EVIDENCE: The care plan for the homes most recent admission was examined in depth. The document contained all the information the home is legally obliged to keep in respect of anyone residing there, including their needs assessments undertaken by the individuals Care manager and CMG, and care plan. The care plan was very detailed and identified the individuals unique life history, their induction to the home, personal, social and health care needs, strengths, as well as likes and dislikes. The document also contained details regarding this individuals communication needs, although the plan needed to be updated to include more detailed information about the actual support they would require to ensure their language needs were properly met (e.g. Communication book used and English language course attended at college). Both plans sampled had been reviewed in the past six months. Service users had been invited to the meeting along with various representatives, including their relatives, care managers, and in one case their advocate. The new manager acknowledged that there had been some delays in implementing all the action agreed at one service users last care plan review meeting, but was adamant this issue had now been resolved. The new manager is aware that this individuals care plan still needs to be updated to accurately reflect all the changes agreed at their last care plan review (See Requirement No#1). The minutes kept of service users meetings revealed that they continued to be held at regular intervals (four since the turn of the year), which had all been well attended by service users. It was positively noted that the date of the next service user meeting was conspicuously displayed on a notice board in the lobby, which also invited service users to help set the agenda for the next one. One service user spoken with at length said he liked to attend residents meetings and thought they were useful forums for sharing your views about the home and the way it was run. The homes most recent admission has an independent advocate that records revealed the staff are keen for them to continue playing a very active role in the service users life. The advocate is always invited to attend the individual they represents annual care plan review. Care plans sampled all contained risk assessments and associated management strategies that were relevant to the individual. It was positively noted that while most risk assessments carried out in respect of he homes latest admission had been undertaken prior to their arrival, new ones had been drawn up in response to a number of incidents regarding unplanned absences. All the information about service users is securely stored in locked filling cabinets in the office and the new manager was aware when and with whom to share confidential with others. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social, leisure and recreational opportunities service users have to engage in, both at home and in the wider community, are well managed and provide people who use the service with daily variety and stimulation. Suitable arrangements are in place to enable service users to maintain appropriate relationships with their family and friends, whilst daily routines and house rules promotes freedom of choice and independent living. In the main dietary needs are well catered providing daily variation, choice, and interest for the people who use the service, although more consideration must be given to service users different cultural backgrounds to ensure the meals provided match individual preferences. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 13 EVIDENCE: During a tour of the premises it was noted that large prints of Makaton signs used by one service user as their preferred method of communication were conspicuously displayed on notice boards in the dinning room and office. Staff spoken with about communication in Makaton said they found the print useful reminders and would regularly refer to them. The new manager said staff regular accompany a service user who chooses to attend services at a local church each week. Daily diary notes confirmed that staff had accompanied a service user to church for the past two consecutive Sundays. This spiritual need is clearly noted in the individuals care plan. On arrival most of the service users were at home engaged in various activities either in their bedrooms or in the dinning room. One service user spoken with at length said they were planning to go out to the local job centre later that day to try and find some paid work. The manager said that in accordance with each service users daily activity schedule, one service user was out attending sessions at a day centre and another was staying over at their parents place. It was positively noted that one service users musical likes and dislikes were clearly noted in their care plan. Daily diary notes revealed that staff regular accompany this individual to a local record shop that specialises in African music, which their care plan states is their preferred style of music. The home continues to operate an open visitors policy and all the service users spoken with about visiting times said they were not aware of any restrictions. The visitors book is conspicuously displayed in the entrance hall and is a working document that staff were observed politely asking people to sign on their arrival. The daily diary notes for one service user revealed that in accordance with their care plan the home has made suitable arrangements for them to spend weekends away with their parents. The new manager demonstrated a good understanding of how importance it was to support service users to maintain good links with their families, providing it was in their ‘best interests’. During the site visit one service user said they had just finished cleaning their bedroom, which they had agreed to do once a week. Another service user was observed helping themselves to a hot drink in the kitchen during a tour of the premises. This expectation that service users are responsible for undertaking certain household chores on designated days was clearly noted in care plans sampled at random. The weekly menu was displayed in the kitchen and the manager said service users are invited to plan them. One service user spoken with at length said his food preferences are usually taken into account by staff when they plan the weekly menus, although he felt more Caribbean style cuisine could be included on them. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 14 Similarly, despite the fact that one-service users care plan clearly stated that staff should be supporting them to prepare a Congolese style dish each week, this was not reflected on the menus or the individual daily diary notes. The new manager said staff had recently received some instruction in coking Congolese style cuisine, but confessed the practice had now ceased because it was felt this specific need was being well catered for at the weekends when this particular service user went home to his parent’s home. These arrangements will need to be reviewed as a matter of urgency and the all the relevant documentation amended to reflect the service users wishes (e.g. care plan and published menus). Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to ensure service users physical and emotional health care needs are recognised and met. Sufficiently robust systems are in place to ensure medication records are appropriately maintained and monitored to safe guard and protect the service users ‘best interests’. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 16 EVIDENCE: Two service users spoken with at length said they are able to choose when they got up and went to bed. A record of all the health care appointments service users keep is appropriately maintained in their care plans. The homes accident book revealed that four accidents involving service users had occurred in the home in the past year. None of these accidents had resulted in a service user being admitted to accident and emergency or sustaining any serious injuries. All the other significant events involving service users, which varied considerably in their severity, were all reported to the CSCI without delay and appropriate action taken at the time to minimise the likelihood of similar incidents reoccurring in the future. All the relevant care plans were up dated accordingly to include detailed risk management guidance for staff to follow. Two service users medication administration sheets sampled at random had both been appropriately maintained by staff authorised to handle medication in the home with no recording errors noted. Both these records accurately reflected the current medication stocks held by the home on these two particular service users behalves. All medicines held by the home on service users behalves are securely stored in a locked metal cabinet located in the office. Protocols for the use of all ‘as required’ (PRN) medication were made available on request, which set out in detail when and how staff should administer this type of medication. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficiently robust arrangements are in place to ensure any complaints or concerns service users and their representatives raise about the homes operation will be taken seriously and responded to in a timely fashion. Suitable arrangements are also in place to ensure service users are not placed at unnecessary risk of harm, neglect, and/or abuse. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 18 EVIDENCE: All the service users spoken with said staff were on the whole very approachable and would always listen to any concerns they may have. The homes complaints log revealed that service users and their representatives had raised nine complaints/more informal concerns about the home in the past twelve months. The record contained detailed information about the nature of all the complaints/concerns made and whether or not the providers substantiated them following an internal investigation. Although nine is an exceptional high number of complaints to receive in one year it nevertheless demonstrated that CMG takes all complaints and concerns seriously and would always follow them up. The two complaints the Commission received about practices in the home in the past six months, which were both up held following an internal investigation by CMG, were discussed with the new manager. The new manager acknowledged that recent mistakes had been made regarding the homes recruitment and care plan reviewing practices, and said she had learnt from the experience. Documentary evidence was made available to show all the complaints/concerns received by CMG either directly or via the CSCI about the homes operation have all been dealt with in a timely fashion (i.e. within 28 days). Information about complaints is displayed on a notice board in the lobby, which is available in an easy to understand format, setting out exactly how your complaint will be dealt with. The new manager confirmed that there had not been any allegations of abuse made within the home in the past twelve months and demonstrated a good understanding of her responsibilities regarding both CMG’s and the Local Authorities vulnerable adult protection protocols. The home keeps up to date records and receipts of all the financial transactions taken on service users behalves by staff. The balance recorded on one service users individual financial sheet for the past month matched the sum kept in the individual’s cash box. Receipts sampled at random also tallied with entries made on this record. It was positively noted that in response to a number of incidents involving misappropriation of service users monies in recent years the providers have introduced tighter financial monitoring controls and additional safe guards to try and minimise the risk of similar incidents reoccurring in the future. The new manager said she had recently attended a training course on the new procedures for handling service users monies and demonstrated a good understanding of the new checks and balances she was responsible for. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users continue to live in a reasonable comfortable and safe environment, which has recently been improved to make it more homely. One bedroom needs to be refurbished to ensure it meets the occupant’s needs and suitable locking devices fitted to toilet doors to ensure service users privacy and safety is protected. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 20 EVIDENCE: Significant changes have been made to the interior of the home in the past twelve months with a new bathroom suite and shower unit installed in the main house. Two large areas have also been decked out in the rear garden and new leather sofas and dinning room chairs bought for the lounge. The new manager said she had been in contact with CMG‘s maintenance department to dispose of all the building debris left over from the refit currently being stored in the front garden. The manager also said she was aware that the plastic garden furniture currently being used for seating in the smoking room was inappropriate and that arrangements for it to be replaced had already been made. Progress on these matters will be closely monitored over the next few months. Two service users gave their permission to allow the inspector to view their bedrooms. Both the rooms were decorated to a reasonable standard and contained a lot of the service users personal belongings, including a wide variety of electrical home entertainment equipment, pictures, and photographs. Both the occupant of one of these bedrooms and the new manager acknowledged that as a result of this service users lifestyle all the items of furniture in their room had seen better days and needed to be replaced. The homes new bathroom suite although installed still needs to be plumbed in and therefore the temperature of the water emanating from the hot tap could not be tested on this occasion. The new manager said the hot water temperature of the new bath would be tested on a regular basis when it is fully operational. None of the toilet doors on the ground floor have been fitted with fully functioning locks that can be overridden by staff in an emergency. Suitable locks must be fitted as standard in order to protect the privacy, dignity, and safety of service users. The homes washing machine is capable of cleaning clothes at appropriate temperatures in accordance with good infection control standards. The machine is situated in the laundry room with hand washing facilities prominently sited. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main sufficient numbers of suitably competent and well supervised staff are employed on a daily basis to ensure the collective needs of the service users are met, although more staff will need to achieve an NVQ in care to ensure they have the necessary knowledge and skills to remain an effective staff team. Sufficiently robust staff recruitment arrangements are in place to ensure service users are not placed at risk of being abused by individuals who are ‘unfit’ to work with vulnerable adults. However, the homes initial inductions programme for new staff employed on a temporary basis needs to be improved to ensure that have a better understanding of the homes safe working practices and the individual needs of service users. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 22 EVIDENCE: All the service users met said they got on well with staff and knew who their keyworkers were. On arrival four members of staff, which included the new acting manager, two other seniors, and a bank worker were all on duty. It was positively noted that the manager had acquired the services of an experienced bank worker to cover staff sickness at very short notice thus ensuring the home had its full compliment of staff for the morning shift. Staff turnover remains low and the new manager confirmed that she had only recruited one new member of staff since the homes last inspection. The new staff members file contained all the information the home is legally required to obtain in respect of anyone working there, which included two written references, photographic proof of their identity, and the individuals most recent Criminal Records Bureau (CRB’s) and Protection of Vulnerable Adults (PoVA) checks. The new manager was very conscious that despite the vast majority of the current staff team being enrolled on suitable National Vocational Qualification in care courses, very few had successfully completed this training. Consequently the home continues to fall well short of the 50 required by the National Minimum standards. The manager was able to produce evidence by way of certificates of attendance and prearranged training days to show that sufficient numbers of her current staff team had either achieved or were already booked on courses to up date their knowledge and skills base. However, the new manager conceded that she was not know all her new staffs teams strengths and weaknesses and would need to carry out a thorough assessment of their needs. The manager assured the inspector that all the staff who had not up dated their managing aggression training were booked to attend a course in December 2006. Progress regarding staff training issues will be closely monitored over the next year. Having spoken to the Bank worker on shift at length it was clear from the comments made that they had a wealth of experience working with adults with learning disabilities. The support worker went onto so that their overall impression of the home was that is was a good service with a strong emphasis on promoting independent living and choice, although conceded that his initial induction to Beulah Road had not been particularly good, despite this being his first ever shift there. The ethnic diversity of the homes staff team is reasonably reflective of the area and the cultural backgrounds of many of the service users currently residing there. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 23 The one member of staff spoken with at length said they continue to be supervised at regular intervals by senior members of staff. Record of all the formal supervisions sessions received by one member of staff revealed that they had attended four in the past ten months in accordance with CMG’s own procedures. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from living in a reasonably well run home which a suitably experienced and competent individual manages. Suitable arrangements are in place to ensure service users and their representative’s views about the quality of the care being provided are ascertained at regular intervals to enabling them to affect the way the service is run. In the main sufficiently robust health and safety arrangements are in place to ensure service users, their guests and staff are protected from avoidable harm, although the homes basic food hygiene standards will need to be improved. EVIDENCE: Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 25 The new acting manager, Iye Fornah, has been in operational day-to-day control of the home since her appointment in July 2006. Iye has a wealth of experience working with adults with learning disabilities managing another CMG home and hopes to have achieved her National Vocational Qualification Level 4 in management and care by April 2007. Iye says she has completed three quarters of her NVQ course. As previously mentioned the new manager has recently attended the provider’s new managing service users monies course and feels she receives all the support she needs from her new line manager, Matt Betts. It is recommended the new manager should familiarise herself with CMG’s staff recruitment and equal opportunities, following recent failings, and possibly attend refreshers course in the aforementioned areas of practice. The new manager was aware that CMG have developed a new quality assurance system, which seeks to ascertain the views of service users, their relatives, and professional representatives at regular intervals. The new manager was aware these surveys have to be distributed each year and a annual report compiled. Progress on this matter will be assessed at the homes next inspection. As part of the providers quality assurance systems unannounced inspections continue to be carried out be senior representatives of CMG each month and copies of their findings forwarded to the Commission at regular intervals. Fire records revealed that the homes fire alarms continue to be tested on a weekly basis and that two fire drills involving all the homes current staff team have been carried out in the past six months (i.e. quarterly) in accordance with recommended good fire safety practice. During a tour of the premises it was noted that none of the homes fire resistant doors were being inappropriately wedged open to prevent there automatic closure in the event of the fire alarm being tested. Up to date Certificates of worthiness were in place to show that suitably qualified engineers had checked all the homes electrical wiring, fire extinguishers, and portable electrical appliances in the past twelve months. Documentary evidence was available on request to show that the homes gas installations; water heating, and emergency lighting had also been tested recently in accordance with good health and safety guidance. During a tour of the kitchen it was noted that a tin of condensed milk was being stored in the fridge contrary to basic food hygiene standards. Under no circumstances must food stored in fridges be left in opened tins as this places service users, their guests, and staff at risk of aluminium poisoning. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 27 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(2)(c) & 17(2), Sch 3.3(l) Requirement Detailed information about the nature of the support and methods of communication a service user requires to ensure their identified communication needs are met must be included in their care plan. Care plans must also be updated at regular intervals to reflect any agreed changes in need. Timescale for action 01/01/07 2. YA17 12(3) (4)(b) So far a practicable service & 15(c) users wishes about the food they eat must be taken into account when planning the menus, as well as due regard given to their racial origin and cultural background. 16(2)(c) All the damaged furniture in one service users bedroom, which includes a chest of drawers and wardrobe, must be replaced with more suitable items that will suit the occupant’s needs and lifestyle. 01/01/07 3. YA26 01/02/07 Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 28 4. YA27 12(4)(a) & 13(4) All toilet doors must be fitted with suitable locking devices that can be overridden in an emergency. A time specific action plan setting out how the providers intend to ensure at least 50 of the homes support workers achieve an NVQ Level 2 in care by the end of 2007 must be established. 08/12/06 5. YA32 18(1) 01/04/07 6. YA35 18(1)(c)(i) All new members of staff, 08/12/06 including bank workers, must receive an initial induction before they commence working at the home, which covers safe working practices and the needs of service users. Records of the induction must be kept at the home and made available for inspection on request. The new manager must achieve an NVQ level 4 in management and care. Under no circumstances must any opened tins of food be left in there original container in the fridge. 01/04/07 7. YA37 9(2)(b)(i) 8. YA42 13(4) & 16(2)(i) 01/12/06 Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 29 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 YA35 YA37 Good Practice Recommendations The homes Statement of Purpose and Guide should include a review date. The new manager should carry out a thorough assessment of her current staff teams training needs and strengths. The new manager should familiarise herself with the providers staff recruitment and equal opportunities policies and procedures. Beulah Road (55) DS0000028139.V317257.R01.S.doc Version 5.2 Page 30 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.V317257.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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