Inspection on 15/01/08 for Birdhurst Rise, 7

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdhurst Rise, 7 03/07/08

Birdhurst Rise, 7 01/06/07

Birdhurst Rise, 7 04/08/06

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 Birdhurst Rise, 7 7 Birdhurst Rise South Croydon Surrey CR2 7EG Lead Inspector Lee Willis & Pharmacy Inspector Vashti Maharaj Key Unannounced Inspection 15th January 2008 09:15 Birdhurst Rise, 7 DS0000066789.V357630.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 Birdhurst Rise, 7 DS0000066789.V357630.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. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birdhurst Rise, 7 Address 7 Birdhurst Rise South Croydon Surrey CR2 7EG 020 8681 2216 020 8688 1723 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 vacant post Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Birdhurst Rise, 7 DS0000066789.V357630.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 (CRH - 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: 8 3rd December 2007 (Random) Date of last inspection Brief Description of the Service: 7 Birdhurst Rise 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 eight adults of either gender. Vivian Okeke (homes former deputy manager) replaced Sarah Brown, the former registered manager of Birdhurst Rise in October 2007. This detached Victorian property is situated in a quiet residential suburb to the South of Croydon. The service has its own transport and is within ten minutes of walk of several main line bus routes and a local train station. A variety of local shops, cafes, restaurants, and pubs are also within easy walking distance of the home. The property has eight single occupancy bedrooms all with en-suite toilet and bathing/shower facilities. Communal areas are largely located on the ground floor and comprise of a main lounge; separate dinning area/smoking room; a large open plan kitchen/dinner; spacious entrance hall, laundry room; and office. There is also a separate visitors room located on the top floor, a communal bath/shower facility on the first floor, and a second office in the basement. The garden at the front of the property is well maintained and there is a large lawn at the rear. The home has developed clear information to help people who use the service and their representatives to understand what specialist services the home provides. CMG currently charges £1,328.72 to £1,762.14 a week for placements. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence we gathered during this services second key (main) Inspection since 1st April 2007 the Commission for Social Care Inspection (CSCI) has judged the home as having a number of strengths as well as areas of particular weakness that will require urgent improvement through an action plan. The Commission will closely monitor this selfimprovement plan. The people who use the service have been placed at unnecessary risk of harm and/or abuse in the past six months largely because of the provider’s failure to take appropriate action to deal with one individuals increasingly challenging behaviour. We spent six hours in the home and spoke to five people who currently reside at the home, the new acting manager (former deputy), two support workers, and CMG’s new Director of Care – Michael Fullerton, who was providing inhouse staff training at the time of this visit. We also looked at records and documents, including the care plans for three people who live at the home and the Users Guide. The remainder of this site visit was spent touring the premises. One of the Commissions specialist pharmacy inspectors’ also accompanied us on this site visit to assess the homes medication handling arrangements and spent three hours speaking to CMG’s new Director of care and examining the homes medication records and practices. Their report is included in the main body of this report under the outcome group entitled ‘Personal and health care support’. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. What the service does well: Feedback received from a number of staff working at the home was very positive. Typical comments included “Birdhurst Rise provides a homely environment for people who live there”, and “the relatively new manager is very approachable and supportive”. CMG have clearly put a lot of thought into converting this detached Victorian building into a very comfortable and spacious home for a relatively small group of vulnerable adults to live in a non-institutional environment. This relatively new home remains decorated to a good standard and its furniture and fittings, which are domestic in style, continue to be well maintained. All the people who use the service met commented very favourably about the kind and caring approach of the staff team. Typical comments included “I like the staff”, and “I can talk to staff if I am unhappy”. Throughout the course of Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 6 this one day inspection staff were observed taking their time to calmly deal with a number of questions and concerns many of the people who used the service had at the time of this site visit. What has improved since the last inspection? The service has gone through a particularly difficult period of time in the past six months following the dismissal of the homes registered manager in October 2007 for gross misconduct and the rather protracted discharge of one person who used the service as a result of their placement ‘breaking’ down. CMG have acknowledged there is significant scope to improve they way this home is run and as part of that process have employed a new deputy manager who has a wealth of experience in that role working with vulnerable adults. We believe this is a positive move as the new deputy has the knowledge and skills to help the relatively new and inexperienced acting manager of Birdhurst Rise get the home back on track. The manager told us she believes the two of them will make a good team. Since the home was last inspected CMG have introduced a new admissions tool. The tool has been designed to ensure that the needs of all the people who already use the service are assessed and the affect any new admissions could have on existing group dynamics within the home is carried out prior to anyone moving in. The manager still needs to familiarise herself with the new tool and receive training in how best to apply it. Another new tool has been introduced for keyworkers to record the ‘success and achievements’ of the people they regularly support. The new tool will help keyworkers remain focused on peoples unique goals and what they hope to achieve from their placement, an area the providers acknowledge they could do better at. In addition to this, keyworkers have received half a days training in improving the way they communicate with the relatives and care managers of the people who use the service. Significant progress has been made by the new manager in a relatively short period of time to review all the risk management plans that were in place for the people using the service to ensure they reflect current needs. The manager conceded that this remains a work in progress. This area will be assessed in greater depth at the homes next inspection. Opportunities for people who use the service to engage in more meaningful and stimulating indoor activities has improved in recent months, although their remains considerable scope to improve the quality of community based activities. There are still far too many drives to non-specific destinations happening on a regular basis. Frequency of staff meeting has improved in recent months. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 7 What they could do better: All the positive comments made above notwithstanding their remains a number of significant areas of practice that the provider must take urgent action to rectify and improve the lives of the people who use the service, as well as keep them safe: CSCI specialist pharmacy inspector outlined a number of key areas where the home could improve its medication handling practices, including: maintaining clearer records to make auditing medication easier; establishing clearer protocols for the use of as required medication; ensure all staff ‘authorised’ to handle medication in the home up date their medication training; and ensure all medicines held in the home are correctly labelled and administered in accordance with their prescribed instructions. There is also scope for the home to improve the way its supports people who use the service to take greater control of their own medication as current arrangements limit choice and independence. All staff that work in the home must refresh their protection of vulnerable adults and managing challenging behaviour training. This will ensure the people who use the service are (s far as reasonably practicable) kept safe. The way in which the provider monitors and analyses incidents of challenging behaviour must be reviewed. The service was slow to take appropriate action to manage the increasing number of significant incidents involving the same person that placed this individual, the other people who used the service, and staff, all at risk of potential harm. Staff must be appropriately supervised at more frequent intervals and records of these sessions kept up to date. As the service has failed to address this on going shortfall at its last three inspections we issued a Warning letter reminding the provider that continued failure to meet this requirement would lead to the Commission taking enforcement action to ensure future compliance. Some progress has been made by the new manager to commence the process of addressing this issue. We are confident that with the support of the new deputy Vivian will be able to resolve this matter once and for all. It is essential staff are appropriately supervised at regular intervals to ensure they receive support from suitably competent staff. The new manager holds a mental health nursing qualification, but has yet to achieve the equivalent of an National Vocational Qualification Level 4 in management. Vivian assured us that she is enrolled on a suitable course and hopes to have achieved this award by June 2008. Homes fire safety arrangements need to be improved to ensure all staff who regular do nights participate in at least one fire drill every three months and Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 8 the building is assessed for the fire risk it presents the people who live and work at the home. 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. Birdhurst Rise, 7 DS0000066789.V357630.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 Birdhurst Rise, 7 DS0000066789.V357630.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 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 this service have good information about the home in order to make an informed decision about whether the service is right for them. People’s needs are fully assessed prior to admission so the individual, their representatives, and the home can be sure the placement is appropriate for them. However, the way in which the provider assesses and consults with other people who already use the service about the compatibility of new admissions needs to be significantly improved. EVIDENCE: The new manager told us the homes Statement of Purpose and Guide was in the process of being up dated at CMG’s central offices to reflect all the changes that had occurred at Birdhurst Rise in the past six months, including the gender typo that stated the home provided personal care and support for just female service users. Progress made on this matter will be assessed at the homes next inspection. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 11 Since the home was last inspected one person who used the service has moved out leaving a vacancy. Compatibility with others already living in the home has been an issue at Birdhurst Rise, and the new manager told us she was aware that her employer had introduced a new compatibility assessment tool that placed a greater emphasis on the unique needs of the people already residing within a home in order to minimise risk. The new manager is not familiar with the CMG’s new compatibility assessment tool and will need to be trained in its use. The new manager told us she would always expect to visit a prospective service user in their home and be fully involved in the assessment process, despite CMG having its own centralised admissions team. Furthermore, Vivian told us she would always invite a prospective new service user and their representatives to visit the home, meet the other service users, and staff before any decisions about moving in on a trial period of residency was made. Any new referrals accepted by the home to fill its one remaining place will be closely monitored by the CSCI. Birdhurst Rise, 7 DS0000066789.V357630.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&9 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. Care plans reflect what is important to the individual, their capabilities, and what support they need to achieve their personal aspirations. Significant progress has been made by the new manager to review all the risk management plans that were in place for the people using the service to ensure they reflect any changes in their needs and circumstances. Consequently, the people who use the service are much better protected by the recently updated risk management strategies that are now in place. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 13 EVIDENCE: We looked at the care plans for three people living at the home. The plans were person centred and tended to ‘celebrate’ an individuals life experiences, as well as setting out clearly how their current personal, social, and health care requirements and wishes were to be met through positive interventions. One care plan examined did not contain the individual’s photograph. The manager told us she would rectify this matter as soon as practicable. One member of staff met told us the relatively new approach to care planning that centred more on the individual was a much better working tool than the previous format that enabled them to deliver the support the people who used the service required. As previously mentioned in this report the new manager was fully aware of the importance of capturing good information about people before they move in. Care plans viewed were clearly generated from information obtained during the admissions process, and included detailed information about peoples backgrounds and life histories. Since the home last inspection another new tool has been introduced for designated keyworkers to record each month the ‘success and achievements’ of the people they regularly support. This new tool will help keyworkers remain focused on peoples unique goals and what they hope to achieve from their placement, an area the providers acknowledge they could do better at. No issues were identified at the homes last key inspection in relation to people who use the service making decisions about their lives (National Minimum Standard No7) and therefore we did not assess it on this occasion. In the past 6 months there have been real concerns that risk management strategies were not being up dated frequently enough to reflect the changing needs and increasingly challenging behaviour of all the people who used the service. Following the homes last random inspection undertaken in December 2007 the service was required to review the way in which risk assessment and management plans were updated to reflect the changing needs of people who use the service. Significant progress has been made by the new manager in a relatively short period of time to achieve this aim. Birdhurst Rise, 7 DS0000066789.V357630.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 & 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. People who use the service are actively encouraged to pursue a wide variety of stimulating social activities in their own home, although there remains considerable scope to improve the quality of the community based activities people who use the service can engage in on a regular basis. This will ensure they have far greater opportunities 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 and choice, although there is scope to improve the nutritional balance of the meals provided. This will ensure people who use the service have more opportunities for healthier eating. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 15 EVIDENCE: Care staff spoken to said they routinely supported people who used the service to participate in activities of their choice and were very clear this was an important part of their role. We saw a number of instances over the course of this five hour inspection where people who used the service were being actively encouraged by staff to pursue various social activities in the open plan kitchen, including colouring, doing puzzles, and playing a musical instrument. All the people engaged in these activities seemed to be having a great time and the atmosphere in the kitchen remained relaxed throughout the session. Staff supporting people to join in these activities also seemed to have time to talk and interact with everyone. The manager told us that one person who used the service was out attending classes at a local day centre. We over heard one person ask staff if they could go out for a walk, which was promptly arranged by the senior in charge of the shift that morning. Also, records maintained by staff of all the activities people who use the service engage in each day showed some progress had been made to ensure people had far greater opportunities to participate in more stimulating in-house activities. However, these records also revealed there remained considerable room for improvement with regards the number and type of opportunities the people who used the service had to engage in more meaningful activities in the wider community. Too many of the entries made in daily diary notes referred to people going out for drives to unspecified destinations. The new manager told us she is very keen to improve the community active people who use the service engage in at present, and wants to introduce trampolining and aromatherapy sessions - for example. The requirement made at the homes last inspection regarding community-based activities is considered partially met and progress made to comply with it in full will be assessed at the homes next inspection. No issues relating to the opportunities people who use the service to maintain links with family members or develop independent living skills were identified at the homes last key inspection and consequently NMS No’ 15 & 16 were not assessed on this occasion. Main meals displayed on weekly menus were varied and nutritionally well balanced. One service user spoke with told us “meals were nice”. The lunchtime meal served on the day of this site visit matched the one displayed on the published menu for the week. This meal of salad and hot dogs looked and smelt very appetising. The new manager told us she planned to look at new ways of actively providing the people who used the service with healthier meal options. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 16 The recommendation that the new manager seeks the advice of a dietician and considers arranging for her staff team to receive nutrition/healthier-eating training will be reaped in this report. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Suitably robust arrangements are in place to ensure the people who use the service receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are continually recognised and met. People who use the service are being placed at risk by unsafe medication practises. Furthermore, there is also scope for the home to improve the way its supports people who use the service to take greater control of their own medication as current arrangements limit choice and independent. EVIDENCE: All the people who use the service were suitably dressed in well-maintained clothes that were appropriate for the season. One individual told us they like to go clothes shopping with staff and always chose what they wore each day. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 18 Detailed care planning in the form of health action plans were in place to meet people’s unique health needs. Three action plans sampled at random contained detailed infiramtion regarding the support these individuals required to ensure their health care needs were met and the outcomes of appointments they had attended with various health care professionals, including GP’s, community based nurses, dentists, opticians, and chiropodists. It was positively noted during this visit that a number of the people who used the service were being encouraged to get the flu jab as a preventive healthcare measure and that staff were observed taking their time to reassure and explain its benefits to people using the service. The manager told us no significant incidents or accidents involving the people who use the service had occurred since the homes was last inspected in December 2007. At the beginning of the year (2008) we wrote to CMG to formally warning the organisation we would take enforcement action if this home continued to fail in its duty of care to notify the Commission without delay about the occurrence of any ‘significant’ incidents involving people who used the service. The relatively new acting manager demonstrated a good understanding of what constituted a ‘significant’ incident and was able to name all the external agencies, including the CSCI and the relevant placing authorities, which needed to be notified about the occurrence of such events without delay. The manager told us lessons had now been learnt from mistakes made by her predecessor regarding incident reporting. We will continue to closely monitor progress made by the home to meet its incident reporting responsibilities. 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. We recommend the views of these people about the possibility of having greater control over their medication is ascertained and based on the outcome of these discussions the risks involved are thoroughly assessed and suitable risk management strategies developed as needed. Listed below is the full report compiled by the Commissions specialist pharmacy inspector, Vashti Maharaj, who accompanied us on this site visit: The Director of Care was at the home on the day of the inspection to carry out a training session and check on medication records. There are plans to improve medication handling through training by the Pharmacy and by the organisation, an updated competency assessment for staff who give medicines, updating the medication policies, and by inspecting medication handling during Regulation 26 visits as well as audits carried out by the homes manager. These improvements are needed as current arrangements leave the people who use the service at risk. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 19 Medication Administration Record (MAR) Charts for all the people who use the service, including records of receipts and returns of medicines, storage areas, and staff training in medication were inspected. Several areas require improvement, including: -Recording of medicines received into the home -More information needed on the use of sedating medicines -Recording when medicines are not given as prescribed -Assessment and training in medication handling Quantities of medicines received into the home were missing for eight prescribed medicines and quantities of medicines brought forward from the last month were missing for three prescribed medicines. If receipt quantities are missing, the home cannot account for the use of medicines. The quantity in stock of one sedating medicine, diazepam, was incorrect on the MAR chart. There were 95 in stock, however the MAR chart indicated 55. There was a separate log for medicines used on a PRN “as required” basis, this did have the quantity stated as 95, however these quantities had been crossed through and amended several times, and so it was not clear what the total in stock should be. The actual quantity in stock must be recorded to provide an accurate audit trail of medicines received, used by, and returned to the pharmacy, and also to enable a stock check to be carried out. This is particularly important for sedating medicines (See Requirement 4) One prescribed item, with instructions to apply 2-3 times a day was being used once a day, with no explanation for change. One prescribed medicine, with instructions to use at night had been given in the morning during June/July 2007, with no explanation why. All prescribed medicines must be given according to the prescribers’ instructions, and the reason for any changes must be recorded. (Requirement 5) Two sedating medicines were being used for one person who used the service without clear guidelines for use e.g. when they should be used and whether they should be used at the same time. This is potentially dangerous, as these medicines should only be used if the prescriber has provided clear instructions for use. Also these medicines had been given to one resident every morning for a week in December, which is an unusual pattern. Any unusual need for these medicines should be investigated e.g. why the resident has been agitated more than usual, the daily notes should indicate why these medicines were needed and what other strategies were tried before deciding to give sedating medicines. The Director of Care was investigating this on the day of the inspection (Requirement 6) A training plan showed that some staff administering medicines has not had medication training for several years. Medication training must be assessed for all staff and only staff who have been assessed as competent should administer medicines. All staff, even those who do not administer medicines, needs medication training on induction (Requirement 7) Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 20 A bottle of prescribed eye drops did not have the date of opening; this is needed to ensure the drops are not used past the expiry date once opened. The box was labelled; the bottle needs to be labelled also (Requirement 8) There was also no tablet counter, which is needed to carry out stock checks of medicines hygienically without touching tablets (Recommendation 2) Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 21 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 poor 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 complaints are sufficiently robust and understood by staff to ensure people who use the service feel listened and safe. People who use the service and staff were all placed at risk of harm because of ineffectual management of one individual very complex and changing healthcare needs. Unclear risk management planning and lack of any evaluation of the increasingly challenging behaviour of this individual limited prospects for improvement until their rather ‘messy’ discharge at the end of 2007. EVIDENCE: Records are kept of any concerns or complaints received and we saw that these were well maintained. The manager confirmed there has been no issues raised both verbally or in writing by people living there or their representatives since the home was last inspected in December 2007. As requirement was made after that visit for all complaints made about the home and the action taken in response to be recorded. The new acting manager told us she would always take any concerns or formally complaints made about the homes operation seriously and was fully aware of the importance of recording what action (if any) the organisation took in response. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 22 Comments from people who live at the home included “I can talk to staff if I’m unhappy”, and “staff listen to me”. Throughout the course of this inspection several members of staff were observed taking their time to calmly deal with one individuals queries, who were clearly very anxious about having to visit the surgery that day. The complaints policy and procedure is displayed in the home and is part of the guide for the people living there. The provider has clearly put a lot of time and effort into making sure the complaints procedure is available in different formats, including pictorial and plain English versions, to ensure the people who use the service can understand it. Since the home was last inspected in June 2007 it has gone through a particularly difficult time with three separate allegations of abuse all resulting in the Local Authority convening case conferences to investigate these matters. The first allegation concerned financial abuse was up held following a police investigation and the homes former registered manager being dismissed for gross misconduct in October 2007. The individual was referred to POVA for possible inclusion on their register as being ‘unfit’ to work with vulnerable adults. Further allegations that there was a ‘culture’ of abuse of the people who used the service by staff was brought to the attention of the Commission at the end of 2007 by a whistle blower. This information was immediately passed onto to the Local Authorities safeguarding adult’s team. In accordance with recommended good practice all the members of staff accused of verbally, physically, and psychologically abusing the vast majority of people who use the service over the past 12-months were suspended from their duties while the Local Authority and CMG jointly investigated these allegations. No evidence was found to substantiate any of the allegations of abuse made and all the suspended members of staff, including the acting manager, returned to work in January 2008. The third incident of abuse occurred in December 2008 when another person who lived at the home made inappropriate sexual advances towards another service user. The allegation was upheld following an internal investigation undertaken by CMG. The perpetrator, who had already been served notice to leave the home several weeks before, was eventually transferred out over the Christmas period. The process of discharging this individual became unnecessarily protracted as a consequence of a disagreement between the various placing agencies about who was ultimately responsible for funding this individual. A discreet door alarm that alerts staff when anyone enters this service users bedroom was working when it was tested at the time of this site visit. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 23 With the homes former registered manager dismissed and so many permanent members of staff suspended CMG is commended for ensuring suitably experienced and competent temporary staff, including a registered manager from another CMG home in the vicinity, were seconded over to minimise (so far as reasonably practicable) the adverse affect this staffing ‘crisis’ inevitably had on the people who used the service. The manager demonstrated a good understanding of the Local Authorities reporting abuse protocols and was able to produce a copy on request. The home has copies of the Department of Health ‘no secrets’ and CMG’s own whistle blowing policy for staff to follow if they witness or suspect abuse. However, the recent crisis at the home highlighted a shortfall in some staffs knowledge about when, how and to whom, they should report abuse if they suspected or witnessed it. The homes records also revealed gaps in a number of staffs abuse and approved physical intervention techniques training. A training matrix showed that some staff had not attended refresher courses in the appropriate use of dignified management of conflict (DIGMA) contrary to CMG’s own policy. All staff authorised to use DIGMA should up this at least once a year. As previously mentioned in this report the new manager has taken significant steps in a relatively short period of time to review risk assessments and up date them accordingly to reflect any changes in need, which included specific guidance to help staff deal with incidents of challenging behaviour. Since the home was last inspected we have received an unusually large number of reports of aggressive incidents involving the same individual whose behaviour had clearly become increasingly challenging in the later half of 2007. The sheer volume and increasingly violent nature of the Regulation 37 reports we were receiving prompted us to contact the home to discuss the suitability of the placement. The homes former manager assured us that appropriate risk management strategies were in place to enable staff to meet these individuals rapidly changing needs. However, incident records showed that staff at the home, especially those on duty at night, had become increasingly reliant on the support of the local constabulary to help them deal with this persons increasingly challenging behaviour. The staff were evidently not suitably experienced or qualified to deal with this individuals complex mental health issues and swifter action should have been taken by CMG to review this persons placement and the risks their deteriorating mental ill health posed to the other people using the service, as well as staff. This failure to act or indeed monitor the situation eventually lead to a third safeguarding adult referrals being made to the local safeguarding adults team in as many months. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 24 The balances recorded on the financial sheets sampled at random for two people using the service matched the amounts being held by the home on their behalves. Receipts are also kept of all purchases made on service users behalves and money is individually stored in a secure place. In response to the theft of large sums of both the providers and service users monies in 2007 a whole range of new financial checks and balances have been introduced to minimise the risk of similar abuses reoccurring in the future. Measures included financial audits being carried out by two staff at each shift handover and during monthly Regulation 26 visits carried out by CMG’s Regional managers. The manager demonstrated a good understanding of these new financial monitoring arrangements and had booked a date to attend CMG’s own financial management training. Progress made on this matter will be assessed at the homes next inspection. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 25 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, 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. The excellent condition of the décor, fixtures, and fittings in this relatively new care home means the people who use the service live in a very 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. EVIDENCE: People spoken to were happy with the environment. Typical comments included “I like my bedroom”, and “I got enough space to keep my things”. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 26 We saw that the home generally provides a very pleasant, comfortable, and well-maintained place for people to live. All the furnishings and fittings are relatively new, are of excellent quality, and domestic in appearance. The large open plan kitchen with work surface in the centre of the room and large wooden table appeared to be a very popular place for people who use the service eat their meals or engage in various indoor activities. The garden at the rear of the property contains a number of broken items of garden furniture which should been replaced as soon as reasonable practicable. The new manager told us she had plans to landscape the lawn at the rear of the garden and encourage the people who use the service to make better use of it in the summer months. Progress made on this matter will be assessed at the homes next inspection. The home was very clean and tidy. The manager told us the home has a contract for dealing with clinical waste, which is collected on a weekly basis. Staff met demonstrated a good understanding of the homes arrangements for disposing of clinical waste and how to appropriately control infection in general. In line with environmental health guidelines the homes laundry room is located in an area where food is prepared, eaten, or stored. The laundry room contains a wash hand basin, plentiful stocks of latex gloves and plastic aprons, and the floor is readily cleanable. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 27 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. Sufficient numbers of staff are employed on a daily basis to support the people who use the service. However, inadequate supervision of staff with infrequent individual sessions and gaps in their training means the people who use the service are not always supported by suitably qualified and/or competent staff. The homes recruitment procedures are sufficiently robust to minimise the risk of service users being harmed by people who are ‘unfit’ to work with vulnerable adults. EVIDENCE: As previously mentioned throughout this report we saw that staff were caring and spoke to individuals in a polite and respectful manner. Care staff we spoke to had a good understanding of what person centred care is. It was clear from the comments made by staff that they see supporting people who live at the home to meet their social and emotional care needs as an important part of their carers role. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 28 Having arrived in the morning we noted that three support workers and the new acting manager were all on duty. The manager told us this ratio of staff was sufficient to meet the needs of the people who used the service. Staffing levels matched those identified on the duty roster for the day. Also present during the visit was CMG’s new Director of care who as previously mentioned in this report had come to refresh a number of staffs medication handling knowledge and skills. Mandatory training is provided in a number of areas including fire safety, manual handling, first aid, food hygiene, and health and safety. The manager told us the current training matrix that should identify all the staffs training needs, as well as their current qualifications and skills, has not been kept up to date. In light of all the recent problems the home has experienced the new manager and Director of care have agreed to work together to identify what the current teams areas of particular weakness are and what additional workshops they would benefit from attending. The Director of care told us arrangements had already been made for staff at Birdhurst Rise to up date their knowledge and skills with regard their keyworker roles and responsibilities, improving communication with the relatives of people who used the service and care managers, care planning, and supporting people with a past or present experience of mental ill health. Progress made by CMG to resolve gaps in training will be assessed in more depth at the homes next inspection. Having recently employed a new deputy manager who already holds a National Vocational Qualification in care the home has now achieved a ratio of 50 trained care staff in line with National Minimum Standards. However, in order to continue to drive improvement new staff should go on an NVQ course as the 50 target is not merely a minimum, which homes only have to meet – hence we recommended the home establishes a time specific action plan setting out how it proposes to achieve the aim of having 100 of its workforce NVQ trained. The manager told us that new members of staff have been employed from outside CMG since the summer. The home now has three support worker vacancies. The manager demonstrated a good understanding of the checks that needed to be carried out on new staff and the importance of asking appropriate questions at face-to-face interviews. Infrequent one to one supervision of staff and failure to maintain appropriate records has been identified as a major shortfall at the homes last three inspections. We issued a warning letter on 25th January reminding the providers that we would take enforcement action to ensure future compliance if the home continued to fail to address this outstanding requirement. Staff records inspected showed the new manager had undertaken one to one Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 29 supervision sessions with 20 of her current staff team since returning to work less than two weeks before. The new manager is evidently committed to ensuring her staff team is appropriately supervised and this task will be made easier to achieve with the appointment of a new deputy manager. Both the homes acting and deputy managers are both suitably qualified to supervise their colleagues. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A relatively new management team has been put in place and they are working to put in place the necessary improvements to ensure the home is better run in the future and thus ensure the safety of the people who use the service. People know that their opinions are central to how the home develops and reviews their practice because there are good quality assurance systems in place. People using the service and staff are being put at risk of harm because the homes fire safety arrangements are at present not sufficiently robust to safeguard them. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 31 EVIDENCE: The acting manager, Vivian Okeke, has worked for CMG for over six years and just about meets NMS 37 that recommends registered managers have at least two years experience in a senior capacity. The manager told us she has worked as a senior support worker in other CMG homes for well over a year, and was the deputy manager at Birdhurst Rise for seven months before being appointed the manager in October 2007. Vivian demonstrated she had considerable knowledge of helping others run a residential care service for adults with learning disabilities and challenging behaviour and said she feels ready to take on the responsibility of being the sole person in operational day-to-day control of this service. Vivian is a qualified mental health nurse (RNM) and is on course to have completed her NVQ level 4 (Registered Manages Award) training in management by June 2008. The manager is aware that her appointment is subject to a fit person interview with the Commission, which she must pass to be registered. Vivian needs to submit an application to the Regional Registration Team within a month to comply with CMG’s new service development plan for Birdhurst Rise. Progress made on both these matters will be assessed at the homes next inspection. With the recent appointment of a new deputy manager, Jamil, who has a lot of experience in a senior capacity supporting vulnerable adults with similar needs, the manager told us she is confident together they will be able to get the home back on track. The manager also told us that she was receiving a lot of additional support from the homes Regional manager and the new Director of care who were both visiting the home on a more regular basis as a consequence of all the problems experienced by the service in the second half of last year. Minutes were produced on request to show that the frequency of staff meetings has improved in the last quarter of 2007 with the appointment of the new manager. These meetings were well attended by staff and the manager is evidently committed to ensuring they are held more frequently than they have in the past. Topics covered included the needs of the people who use the service and worker roles and responsibilities. In response to concerns raised by the relatives of some of the people who use the service it was positively noted that CMG have developed new strategies to improve communication with various stakeholders. The new Director of care told us he would be arranging half-day training sessions to familiarise keyworkers with the new tool. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 32 The quality assurance systems CMG have introduced in recent years cover every aspects of life in the home and use the views of major stakeholders to monitor how successful or not the home has been regards achieving its stated goals. An annual quality assurance report for 2007 was produced on request, which contained a lot of feedback from the people who used the service about the standard of care they received at the home. Documentary evidence in the form of Regulation 26 reports showed monthly inspections continue to be carried out by CMG’s regional managers. In addition to these reports 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, although the providers could do better at following up issues identified as a result of their quality monitoring visits. The manager told us she believed a fire risk assessment for the building had been carried out, but was unable to locate at the time of this visit. The manager agreed that the plan was more than likely overdue its annual review and would undertake the assessment in line with the local fire authorities fivestep plan. This matter had also been identified during a Regulation 26 carried out at the end of last year (2007). Fire records revealed that the homes fire alarm system continues to be tested on a weekly basis and that fire drills are carried out on a monthly basis in line with the London Fire and Emergency Planning Authorities good fire safety guidance. However, it was noted that none of the records kept of the six fire drills undertaken since June 2007 contained the names of staff who regularly worked nights. Staff who regularly work nights should participate in at least one fire drill every quarter or alternatively have their fire safety awareness up dated through one to one supervisions or group meetings every three months or so. During a tour of the first floor a fire resistant door was found wedged open. The managers told us the individual who occupied this bedroom liked to keep their bedroom door a jar and would frequently wedge it open themselves. This door needs to be fitted with a suitable mechanism that would ensure it closed automatically into its frame in the event of the fire alarm being sounded. An up to date Certificate of worthiness was made available on request to show that a suitably qualified engineer had checked the homes fire alarm system in the past twelve months. During a tour of the kitchen it was noted that all items of food were correctly stored in line with basic food hygiene standards. A set of multi-coloured chopping boards was also found for the safe preparation of food. The home monitors and records the temperatures of fridges and freezers. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 33 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 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 1 3 3 X X 1 X Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 34 Yes 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 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 trained in its use. This will ensure all the people who use the service are kept safe. Timescale for action 01/03/08 2. YA9 14(2) 15/02/08 Risk management plans in place for all the people who use the service must be reviewed on a regular basis and up dated accordingly to recent any changes in need and/or circumstances. This will ensure staff have all the information they require to keep the people who use the service safe. Previous timescale for action of 1st January 2008 partially met. 01/04/08 3. YA14 16(2)(m) (n) People who use the service must have far greater opportunities to participate in community-based activities that are more meaningful and stimulating. This will ensure DS0000066789.V357630.R01.S.doc Birdhurst Rise, 7 Version 5.2 Page 35 the people who use the service have their social, leisure, and recreational needs met. Previous timescale for action of 1st January 2008 partially met. 4. YA20 13(2) The actual quantity of medication held in stock on behalf of people who use the service must be recorded to provide an accurate audit trail of medicines received, used by, and returned to the pharmacy. This will also enable a stock check to be carried out. 15/02/08 5. YA20 13(2) All prescribed medicines must 15/02/08 be given according to the prescribers’ instructions, and the reason for any changes must be recorded. This will ensure the people who use the service receive the correct levels of medication they are prescribed. All staff who handle 15/02/08 medication in the home must have access to up to date protocols regarding the safe use of ‘as required’ medication which makes it clear when and how this type of medication is administered, and who authorise its use. This will ensure all the people who use the service receive the correct levels of medication. All staff who handle medication in the home must be suitably trained to perform this task and continually up date their existing knowledge and skills as and when DS0000066789.V357630.R01.S.doc 6. YA20 13(2) 7. YA20 13(2) 15/02/08 Birdhurst Rise, 7 Version 5.2 Page 36 required. This will ensure staff have the necessary expertise to meet the needs of the people who use the service. 8. YA20 13(2) The home must ensure all bottles of prescribed medicines are correctly labelled indicating the date it was opened to minimise the risk of the contents being used after its expiry date. This will ensure the safety of the people who use the service. All staff that work in the home must be appropriately trained to recognise, prevent and report abuse. All staff that work in the home must be appropriately trained to use British Institute of Learning Disability approved physical intervention techniques as a ‘last resort’, and this training must also be refreshed on an annual basis in line with CMG’s staff training policy. The way in which the provider monitors and analyses incidents of challenging behaviour must be reviewed. This will ensure the people who use the service are kept safe and the suitability of placements where individuals need have significantly altered are reviewed in a more timely fashion. Records of all the formal supervision sessions a person working at the home has with a suitably qualified member of staff must be made available DS0000066789.V357630.R01.S.doc 15/02/08 9. YA23 13(6) & 18(1) 01/04/08 10. YA23 13(6) & 18(1) 01/04/08 11. YA23 12(1) & 15(2)(c) 15/02/08 12. YA36 17(2), Sch 4.6(f) & 18(2) 01/06/08 Birdhurst Rise, 7 Version 5.2 Page 37 for inspection on request. Previous timescales for action of 1st February 2007, 1st July 2007, and 1st January 2008 all not met. Warning letter issued on 25th January 2008 reminding the provider that continued failure to meet this outstanding requirement will lead to enforcement action being taken by the Commission to ensure future compliance. 13. YA37 9(2)(b)(i) The individual responsible for the day-to-day operation of the home must be suitably qualified and hold the equivalent of an NVQ Level 4 in both Management and Care. Previous timescales for action of 1st March 2007 and 1st September 2007 partially met. 01/06/08 14. YA42 23(4)(a) The building must be assessed 15/02/08 for the fire risk it presents to the people that use and work at the service and action taken to minimise any identified hazards or risks. All staff who regularly work nights in the home must be involved in at least one fire drill every three months or receive fire safety instructions in that time. This will ensure the safety of the people using the service. The practice of wedging home fire resistant doors must cease immediately and the providers should consider alternative ways of helping DS0000066789.V357630.R01.S.doc 15. YA42 23(4)(e) 22/01/08 16. YA42 23(4)(c)(i) 01/03/08 Birdhurst Rise, 7 Version 5.2 Page 38 people who use the service keep their bedrooms a jar if they choose that complies with fire safety regulations. 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 YA17 Good Practice Recommendations The home should be more proactive when it comes to encouraging service users to eat healthier meals by seeking the seeking the advice of dietician and training staff in preparing more nutritionally balanced meals. This recommendation was made at the homes last key inspection, but has not been implemented. The unhygienic practice of touching tablets to count them needs to cease and we recommend the home obtain a tablet counter to facilitate this. This will enable staff to count tablets without touching them. 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. Broken furniture should not be left abandoned in the rear garden for any length of time and new garden furniture should be purchased to replace these damaged items. This will enable the people who use the service to make better use of the homes extensive grounds. The service should consider establishing a time specific action plan setting out how it intends to ensure 100 of its staff team hold an NVQ in care. This will ensure the home continues to drive improvement and the people who use the service are supported by suitably qualified staff. The homes training matrix used to identify the staffs teams knowledge and skills strengths and weaknesses should be kept up to date to reflect any changes. In DS0000066789.V357630.R01.S.doc Version 5.2 Page 39 2. YA20 3. YA20 4. YA28 5. YA32 6. YA35 Birdhurst Rise, 7 addition, all staff should receive an annual appraisal of their work performance that includes a thorough assessment of gaps in their knowledge and skills. This will help the manager plan staff development programmes and ensure her staff team are suitably qualified and competent to meet the needs of the people who use the service. 7. YA39 Issues identified through the provider’s relatively new quality monitoring systems should always be followed up and a suitable action plan developed to resolve shortfalls. Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 40 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 Birdhurst Rise, 7 DS0000066789.V357630.R01.S.doc Version 5.2 Page 41 - 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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