Inspection on 06/09/06 for Blake Court

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Blake Court 27/08/09

Blake Court 05/09/08

Blake Court 03/01/06

Blake Court 22/09/05

Blake Court 07/02/05

Blake Court 03/12/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

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

CARE HOME ADULTS 18-65 Blake Court Flat 5 5a Barrow Road Waddon Croydon Surrey CR0 4EZ Lead Inspector Lee Willis Key Unannounced Inspection 6th September 2006 09:30 Blake Court DS0000025756.V310751.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 Blake Court DS0000025756.V310751.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. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blake Court Address 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) Flat 5 5a Barrow Road Waddon Croydon Surrey CR0 4EZ 020 8688 2682 020 8688 2682 SCOPE Mrs Carol Jones Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users aged over 65 to be accommodated. 3rd January 2006 Date of last inspection Brief Description of the Service: The five flats that make up Blake Court are owned by Croydon Churchs Housing Association, but are managed and staffed by the registered charity SCOPE. The scheme is registered to provide personal support for up to six younger adults with Cerebral Palsy and associated physical disabilities. Carol Jones, as the registered manager, has been in operational day-to-day control for the past three years. Situated on the ground floor of a residential apartment block these five purpose built flats are all self-contained and have there own separate entrances. All the flats comprise of a large lounge/kitchen area, separate bedroom, and en-suite toilet and bathing facilities and have been provided with suitable environmental adaptations and disability equipment to meet the individually assessed needs of the occupants. The open plan layout makes the flats wheelchair accessible. Within the apartment block there is also a separate staff office, sleep-in room, kitchen, and toilet/shower facilities. Situated in the heart of a residential estate in Waddon the scheme is well placed for accessing local shops and cafes. The service does not have its own transport, but is relatively close to a main line bus route and local train station, and has good links with local taxi and dial-a-ride companies. Prospective service users and their reprensentatives are given copies of the homes Statement of Purpose and Guide which contain the vast majority of information people need to know about the service, although it makes no reference to the fees charged, which stands between £39,000-£59,000 pa. Blake Court DS0000025756.V310751.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 the Commission for Social Care Inspection (CSCI) considers this residential care home to have substantially more strengths than weaknesses, although the schemes manager acknowledges that there is significant room for improvement in a number of key areas of practice. The Commission is confident the providers will acknowledge all the weaknesses identified in this report and will continue to manage them well. This unannounced site visit was carried out on a Wednesday between 10.00am and 2.00pm. During the course of this four hour inspection two occupants, the schemes registered manager, and two support workers were all spoken with. No comment cards were received from occupants or their representatives. The remainder of the site visit was spent examining the schemes records and touring the premises. What the service does well: The two occupants met both said they liked living at Blake Court and were on the whole very complimentary about the staff worker there. Both occupants met said one of the ‘best things’ about living at the scheme was having your own front door and the freedom to choose how much time you spent with others or alone in the privacy of your own flat. It was evident from staffs comments that the occupants have very diverse spiritual and religious beliefs which records revealed are well catered for with suitable arrangements in place for occupants to attend a variety of different places of worship as well as have a Catholic priest visit one occupants flat on a regular basis. Documentary evidence was made available on request to show SCOPE remain committed to staff training and the scheme itself also continues to experience a relatively low levels of staff turnover ensuring the occupants are supported by a suitably qualified staff team who are familiar with their unique needs and preferences. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The positive comments made above notwithstanding there remains a number new and outstanding areas of practice that it is essential the service rectifies as soon as reasonably practicable. The schemes manager acknowledged that despite recent improvements the service could do much better in a number of clearly identifiable ways: Firstly, care plans must be reviewed at more regular intervals (i.e. at least biannually) and up dated accordingly to reflect individual occupants changing needs and wishes. Secondly, a written record of all new staffs induction must be appropriate maintained as proof they have undergone this compulsory training and are fully aware of the schemes safe working practices, their role, and occupants individual needs. Furthermore, it was disappointing to note that staff were still not receiving regular one to one supervisions (i.e. at least once every two months) or annual appraisals of their job performance. These major shortfalls were identified at the schemes last inspection and the Commission is therefore ‘extremely concerned’ that very limited progress had been made to rectify these on going issues. SCOPE has subsequently been served with a ‘stern’ letter reminding them of their staff supervision responsibilities. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 7 Thirdly, the manager is still not suitably qualified to be in operational day to day control of a residential care service and SCOPE will need to provide the Commission with a time specific action plan setting out how they propose to enrol Carol Jones on a suitable NVQ course. Finally, although some progress has been made by the scheme to establish a quality assurance system the satisfaction questionnaires used to ascertain occupants and their representatives still need to be analysed and the results published. 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. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using all the available evidence. Prospective occupants and their representatives have access to the vast majority of the information they need to know about facilities and services provided at Blake Court, although more detailed information about the level of fees people can expect to be charged for there use needs to be included in the Guide in order to make the process far more open and transparent. EVIDENCE: The manager was able to produce copies of the schemes Statement of Purpose and Occupants Guide on request, which had recently been reviewed in March 2006 and up dated accordingly to reflect changes in provision. The new version of the schemes Statement of Purpose/Guide contained the vast majority of information prospective service users and their representatives would need to know about the services and facilities provided, although the document did not contain any specific details about the range of fees people could expect to be charged for there use or information about periodic fee increases. One occupant spoken with at length said they had been provided with an up dated version of the schemes Guide. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 10 The manager confirmed that despite having vacancies following the recent departure of two of the schemes former occupants no one new had moved in during that period. The manager, who has never been involved in the process of admitting an occupant, also demonstrated a good understanding of the providers admissions’ procedures and was very clear that a thorough assessment of any prospective new occupants needs would need to be undertaken before a decision about allowing them to move in could be taken. Furthermore, Carol Jones showed a good understanding of the schemes criteria for admission and was very clear that no prospective occupant would be offered a permanent place unless the scheme was capable of meeting their individual needs and they were compatible with others already living at Blake Court. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. The homes arrangements for developing care plans are sufficiently robust to ensure occupants unique needs and personal goals are identified, but they do not describe in any great detail how the service will meet these individuals current and changing needs. Overall, suitable arrangements are in place to ensure occupants have opportunities to participate in all aspects of life in the home and to take responsible risks as part of an independent lifestyle. EVIDENCE: Three care plans sampled at random each contained detailed information about each individual occupants personal, social and health care needs. These plans had all been formally reviewed in the past twelve months and up dated accordingly to reflect any changes in need. These reviews had all been well attended by the individual occupant whose care plan was being discussed, their keyworker, the homes manager, and where applicable next of kin, care Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 12 manager and independent advocate. However, the manager conceded that contrary to National minimum standards and SCOPES own policies no care plans had received a more informal in-house review in the past six months with just the occupant and their keyworker and updated to reflect changing needs. This was particularly concerning as one occupants needs had significantly altered in this time. Minutes of occupants meetings revealed that two had been held since January 2006, which were both well attended by all the occupants. A wide variety of topics were discussed at these meetings, including the ‘brunch club’, day trips destinations, and aromatherapy sessions. The two occupants spoken with at length they found these meetings useful forums for expressing their views about the schemes operation. A comprehensive list of assessments that set out in detail all the action to be taken by staff to minimise identified risks were available from two care plans sampled at random. A support worker who was informally interviewed about one occupants changing needs was very clear about the new guidance since that had been established to minimise the risk of this individual falling and when and how to use their new portable hoist. Records of these new risk management procedures were included on the individuals care plan. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence. The scheme has sufficiently robust arrangements in place to ensure the opportunities occupants have to engage in age, peer and culturally appropriate activities of their choice, both at home and in the wider community, provide them with daily variety and stimulation. Dietary needs are well catered for and meals served nutritionally well balanced, providing daily variety and interest for the occupants. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 14 EVIDENCE: One occupant spoken with at length said staff always offer to take them to attend services at the church next door if they choose to go and if a member of the congregation is unavailable to escort them. The individual said they are very happy with these arrangements and their spiritual need was noted in their care plan. The manager confirmed that occupants spiritual needs are always ascertained during the admission process and included in their care plan, including what support they will require to have those needs met. It was positively noted that all four occupants currently living at Blake Court have different spiritual needs which the scheme is able to meet. As previously mentioned, staff support one occupant to attend services at a local church as and when they require; help two others make their own travel arrangements to attend places of worship that specifically cater for their religious beliefs; and ensure a local Priest continues to visit another occupant in their flat on a regular basis. On arrival one occupant was out attending vocational sessions at a local day centre. One occupant spoken with at length said they were able to participate in various social activities of their choice, both in their own flat and in the wider community. It was evident from the minutes of occupants meetings and entries made in the recently established activities record book that occupants still actively encouraged to pursue recreational activities of their choosing. Comments made by several occupants and staff indicated that the recently renamed ‘Brunch club’, where an occupant flat is chosen each week as the venue for everyone to get together to have a meal, was still proofing for very popular. The new activities record revealed that in the last six months occupants have been on various day trips to central London, the south coast and continently Europe; regularly have meals out at various restaurants and pubs; continue to go shopping with staff; visit garden centres; go swimming; have barbeques on the office patio; and have thrown all manner of parties to celebrate various Birthdays and other special occasions. The manager confirmed that relations with one of the schemes immediate neighbours had been relatively stable throughout 2006, although the schemes incident book did reveal that the occasional ‘minor’ incident was still occurring despite risk management strategies to resolve the on going issues being in place. The schemes visitors book was conspicuously displayed in the office lobby and staff are duty at the time were observed politely requesting all visitors to sign the book on their arrival. Two occupants spoken with at length said they were not aware of any restrictions on visiting times. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 15 During the course of this visit the manager and the two staff on duty at the time were observed on numerous occasions knocking on occupants doors to ask their permission to enter their flats before doing so. Throughout the course of this inspection staff were also observed interacting with the two occupants met in a very caring and courteous manner. The two occupants met said staff always prepared the meals they wanted to eat at the time they wanted to eat them. As a consequence, there are no planned menus, but staff kept a record of all the food consumed by the occupants in their daily diary notes. A bowl of fresh fruit was noted in one occupant flat, which they said they could help themselves too. One occupant’s kitchen cupboards and fridge/freezer was noted to be well stocked with a wide variety of nutritious and correctly stored items of food during a tour of their flat. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to ensure occupants receive personal support in the way they prefer and require, and their unique physical and emotional health care needs also recognised and met. Furthermore, occupants retain control of their own medication where appropriate and are protected, so far a reasonably practicable, from unnecessary harm or abuse by the schemes policies and procedures for handling medication. EVIDENCE: The care plan in respect of the occupant whose physical needs had significantly altered in the past twelve months had recently up dated to include new guidance for staff to enable them to meet this particular individuals changing health care needs. The guidance was clearly based on and a professional assessment carried out in March 2006 by an occupational therapist. The recommendations that a mobile hoist and shower seat should be purchased for this person were adhered by the scheme. This particular individual said they were satisfied with the new arrangements and their revised manual handling Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 17 assessment. Staff informally interviewed were fully aware that the new ‘Oxford Midi’ hoist should only be used as a ‘last resort’ when the occupant was clearly unable to transfer without it to ensure they continued to maximise their independent living skills. Two occupants’ daily diary notes revealed that staff appropriately maintain a record of occupants health care appointments with GP’s, OT’s, dentists, opticians and nurses. The homes accident book revealed that there had been no accidents involving occupants since the scheme was last inspected and the new hoist was purchased. In this same period eleven incidents have occurred, although on further inspection of the schemes incident book it was evident that many of the entries made were not about the occurrence of significant incidents involving occupants, but staffs’ personal views about particular issues affecting the scheme. The manager has agreed to remind her staff team about their reporting responsibilities during supervision and the schemes next team meeting. No recording errors were noted on two medication administration sheets sampled at random. Stocks of medication viewed in two occupants’ flats were securely stored away in locked cupboards, which matched medication records being kept. It was positively noted that based on a thorough assessment of one occupants wishes the scheme continues actively supports this individual to self administer their own medication. A record is kept of the individual’s current medication and discrete staff checks in place to minimise the risks associated with this task. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to enable occupants and their representatives to feel any concerns they may have about the schemes operation are taken seriously and acted upon. Suitable arrangements are also in place to ensure the occupants are not placed at unnecessary risk of harm or abuse. EVIDENCE: One occupant spoken with at length said staff were generally good listeners and always took on board any concerns they may have. The schemes complaints log revealed that one formal complaint had been made since the schemes last inspection, which was currently being dealt with. The manager conceded that although formal complaints about the schemes operation are always recorded more informal concerns raised, especially by occupants, are not. The idea of establishing a concerns book that could be used inn addition to the SCOPE’s formal complaints log should be considered. One occupant met said they had been provided with a copy of SCOPE’s complaints procedures, which included the name and contact details of the CSCI. One member of staff informally interviewed said they had attended a whistle blowing training in June 2006 and where very clear what constituted abuse and to whom it should be reported. Records revealed that there have been no allegations of abuse made within the schemes in the past twelve months. Blake Court DS0000025756.V310751.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using all the available evidence, including a site visit to the scheme. The new interior designs of occupants self contained flats ensures they live in a safe and comfortable environment that suits their individual lifestyles and so far as reasonably practicable maximises independent living. EVIDENCE: During a tour of the premises it was noted that building work to up grade the interior design of all the flats was well underway. It was positively noted that a comprehensive assessment of the risk associated with the on going building, which included the interim arrangements put in place to minimise these hazards had been established and was made available on request. A occupant who was temporarily living in a flat recently made vacant by the previous tenant said they were happy with the interim arrangements and had been made fully aware of the situation and had been part of the decision making process. The manager confirmed that all the flats would eventually been fitted with new kitchen units, shower facilities, flooring and intercom systems. Two occupants spoken with at length said they had been invited to help design the layout of their new kitchens and choose the colour they wanted. One Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 20 completed kitchen looked domestic in scale and was suitably adapted to be wheelchair accessible with lowered work surfaces and all manner of adjustable storage systems attached. The temperature of hot water emanating from the bath in flat #9 was noted to be a safe 40 degrees Celsius at 11.30am. The manager said all the new showers will be fitted with preset, fail-safe and tamper proof thermostatic mixer valves that will ensure the hot water emanating from these outlets never exceeds a safe 43 degrees Celsius. The manager said SCOPE plan to replace the rotten wooden door and window frames in the office as recommended in the schemes last report. Progress on this matter will be assessed at the schemes next inspection and in the interim the outstanding recommendation will merely be repeated in this report for SCOPE to consider implementing. Each flat has its own washing machine that is capable of washing clothes at appropriate temperatures. Blake Court DS0000025756.V310751.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. Sufficient numbers of suitably competent and trained staff are employed on a daily basis to meet the collective needs of the occupants. The schemes arrangements for recruiting new staff are in the main sufficiently robust to ensure occupants are, so far as reasonably practicable, not placed at risk of harm from people who are ‘unfit’ to work with vulnerable adults. However, records of all new staffs induction training needs to be kept as proof they are suitably competent to work unsupervised with the occupants. Arrangements for ensuring the schemes staff team are supervised at regular intervals remain inadequate, consequently, the occupants do not benefit from well-supported staff. EVIDENCE: The manager said that out of a total of four full, two part time and two bank workers three had already achieved a National Vocational Qualification in care (Level 2 or above) and two others are enrolled on suitable courses which they planned to complete by the end of the year (2006). A sixth member hopes to commence their NVQ training next year. As a result the scheme is well on Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 22 course to ensure that in line with National Minimum training targets for support workers at least 50 of its current workforce are NVQ trained. At the time of arrival two support workers and the manager were all on duty. The number of staff on duty at the time matched the duty roster for that morning and the manager said current staffing levels were adequate to meet all the occupants assessed needs both during the day and at night. The manager said the scheme still employs two sleep-in staff at night. Records revealed that only one new member of staff had been recruited since the schemes last inspection. The individual was already a SCOPE employee having transferred within SCOPE from another project. There personal staff file kept on the premises was examined in depth and found to contain all the relevant recruitment information, including two written references and Criminal Records (CRB) and Protection Of Vulnerable Adult register (POVA) checks. It was positively noted that as a good practice measure new CRB and POVA checks had been carried out on this individual before they were allowed to commence working at Blake Court to ensure they were still suitable to support vulnerable adults. The manager confirmed that all new staff, including members who transfer within SCOPE receive a structured induction within the first 6 weeks of their employment. However, no record that the homes most recent recruit had undergone such an induction could be located at the time of this visit. Nevertheless, documentary evidence was available on request to show that sufficient numbers of the schemes current staff team had received up to date training in a number of core areas of practice, including; fire safety, moving and handling; first aid; basic food hygiene; vulnerable adult protection, medication, equal opportunities, and infection control. Due to the changing cognitive needs of one occupant it is recommended that scheme consider arranging for the individuals keyworker and/or seniors members of staff to attend working with older adults with short-term memory loss and mild dementia. The two staff spoken with at length during this visit said they were both satisfied with the number of the training opportunities they were offered improve their core support worker knowledge and skills. A member of staff informally interviewed said they had only received one formal supervision with their line manager since the turn of the year. The schemes manager conceded that none of her current staff team had been received at least one recorded supervision with her every two months or so since the schemes last inspection, despite this being identified as a major shortfall in practice at the time. This outstanding requirement has been repeated for a second and final time with the timescale for action extended to 1st January 2007 for the schemes entire staff team to receive at least two formal supervision sessions with their line manager. It was agreed that this target would be far easier to achieve if a suitably qualified ‘senior’ member of staff who was also capable of supervising colleagues supported the manager. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 23 Records revealed that one member of staffs performance in the past year had recently been appraised by the manager. The manager was confident that her entire staff teams work performance over the past twelve months would be individually assessed by the end of the year. The timescale for this outstanding requirement to be met will therefore be extended for a second and final time. Blake Court DS0000025756.V310751.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made using all the available evidence. Occupants and staff continue to benefit from the managers open and inclusive approach to running the scheme. The schemes self-monitoring arrangements for assuring quality, which are currently based on seeking the views of occupants, need to be improved and the results of any satisfaction questionnaires undertaken by the scheme published. The scheme has sufficiently robust health and fire safety arrangements in place to ensure, so far as reasonable practicable, occupants, their guests and staff are not harmed. Blake Court DS0000025756.V310751.R01.S.doc Version 5.2 Page 25 EVIDENCE: The schemes registered manager is still experiencing problems enrolling on a suitable NVQ Level 4 course and a time specific action plan setting out how the providers intend to resolve this on going matter needs to be resolved. All the staff spoken during the visit said they liked the very hands on and open approach of the manager, which they felt created an inclusive atmosphere at Blake Court. Records revealed that four staff meetings had been held since the beginning of the year and the manager demonstrated a good understanding of the importance of these forums for initiating debate and empowering staff to have their say about how the scheme should be run. The scheme has adopted a quality assurance system and has used satisfaction questionnaires to ascertain the views of occupants about the service they receive. The manager is aware that the results of these surveys still need to be analysed and the published for all to view. The manager is aware that many of the schemes policies have not been reviewed since the late nineties and many will need to be up dated to reflect current good practice. The homes fire records indicated that the fire alarm system continues to be tested on a weekly basis and fire drills undertaken on a quarterly basis, in line with the local fire authorities recommended good practice guidance. Up to date Certificates of worthiness were available on request as proof that suitably qualified engineers had carried out periodic tests of the schemes gas installations, electrical systems, potable electrical appliances, and new mobile hoist in the past twelve months. Blake Court DS0000025756.V310751.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 2 2 3 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 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 3 28 3 29 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 2 X 3 X Blake Court DS0000025756.V310751.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 YA1 Regulation Requirement Timescale for action 01/11/06 2. YA6 3. YA35 4. YA36 5(1)(b) (c) Occupants Guide to the scheme & 5(A) must contain more detailed information about the level of fees currently charged for facilities and services provided, payment arrangements, and periods of notice regarding fee changes, including reasons for any increases. 15(2)(b) Care plans must be reviewed at least every six months with the service user and updated accordingly to reflect changes in need. 17(2), Sch All staff, including support 4.6(f) & workers members who have 18(1) transferred from other SCOPE projects, must receive a structured induction and up to date records of this training kept in the home. 18(2) All staff must receive at least one recorded supervision session with a suitably qualified senior every two months. Previous timescale for action of 1st January 2006 not met and Warning letter served as a consequence. DS0000025756.V310751.R01.S.doc 01/10/06 01/10/06 01/01/07 Blake Court Version 5.2 Page 28 5. YA36 18(2) 6. YA37 9(2)(b)(i) 7. YA39 24 8. YA40 12 The schemes manager must appraise all staffs’ job performance each year. Previous timescale of 1st April 2006 only partially met. A time specific action plan setting out how the providers propose to ensure the schemes registered has either achieved the management component of her NVQ Level or at least be enrolled on a suitable course must be established as a matter of urgency. The results of any quality assurance surveys undertaken by the scheme must be analysed and the findings published on an annual basis. All the schemes policies and procedures that have not been reviewed for at least three years must be up dated accordingly to reflect current good practice and legislation. 01/01/07 01/01/07 01/01/07 01/04/07 Blake Court DS0000025756.V310751.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. Refer to Standard YA19 Good Practice Recommendations Staff should be reminded what constitutes an incident and where such occurrences should be recorded, which should include any action taken by the scheme to deal with the event. The Scheme should consider establishing an informal concerns book that is separate from SCOPE’s formal complaints log. The rotten wooden window and door fames in the office/staff sleep-in room should be replaced. This recommendation was made in the schemes previous inspection report. Sufficient numbers of staff should receive training to improve their knowledge of skills regarding working with people with short-term memory loss and mild dementia. Sufficient numbers of suitably competent ‘senior’ staff should receive training in supervising their colleagues to support the manager carry out this task more effectively. 2. 3. YA22 YA28 4. 5. YA35 YA36 Blake Court DS0000025756.V310751.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Blake Court DS0000025756.V310751.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!