Inspection on 13/05/05 for Brickfield Road (39)

This inspection was carried out on 13th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brickfield Road (39) 21/08/06

Brickfield Road (39) 20/12/05

Brickfield Road (39) 12/11/04

Brickfield Road (39) 03/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Brickfield Road (39) 39 Brickfield Road Thornton Heath Croydon, Surrey CR7 8DS Lead Inspector Lee Willis Announced 13 May 2005 10:00 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 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 Stationary 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. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brickfield Road (39) Address 39 Brickfield Road, Thornton Heath, Croydon, Surrey, CR7 8DS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 764 9112 info@cmg-corporate.com Care Management Group Limited Ms Gertrude Mabaso Care home 6 Category(ies) of Learning Disability (6) registration, with number of places Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12/11/2004 Brief Description of the Service: 39 Brickfield Road is owned, managed and staffed by the Care Management Group (CMG), a specialist provider of services for adults with learning disabilities. The home is currently registered with the Commission for Social Care and Inspection (CSCI) to provide personal care and accommodation for up to six males aged 18 to 65 with mild to moderate learning disabilities and challenging behaviour. Gertrude Mabaso has been in operational day-to-day control of the home since September 2004 and has recenly completed a fit person inteview with the Commission to become the homes registered manager. Situated in a suburban street in the heart of Norbury the home is well placed for accessing local amenities, including shops, cafes, resturants and pubs. The home is within fifteen minutes walk of the centre of Norbury with its good bus and rail links to Croydon, central London and the surrounding areas. Since the homes previous inspection all the communal areas have been redecorated. This detached bungalow still comprises of six single occupancy bedrooms, a main lounge, dining room, smoking/visitors area, two bathrooms, a kitchen, office and laundry facilities. Since the last inspection the service users have voted to keep the smaller of the two lounges as the designated smoking room. There is an enclosed courtyard at the rear of the property which has a well maintained lawn and patio area with garden furniture for people to sit and relax on. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 10.00am. It took place over six and a half hours during the morning and afternoon of Friday 13th May 2005. People living at the home had all been made aware that the inspection was due and four service users were spoken to at length, including the homes most recent arrival. All the service users met were willing to share their experiences about life at the home and their help with this inspection is very much appreciated. A total of eight comment cards were returned to the Commission, half of which had been completed by the service users and the other half by their relatives. The comments made were generally very favourable about the overall standard of care provided, particularly those made by service users. Nevertheless, these comments notwithstanding, some adverse comments were received from service users relatives and Care managers about the overall standard of care provided, which will be discussed in greater depth in the section entitled ‘what the home could do better’. The homes Regional, newly registered, and newly appointed Deputy managers were all met at various times during the course of this inspection. The duration of the inspection was spent examining records, touring the premises, and as mentioned above, speaking to the majority of the service users and all the homes senior management team. In the last inspection year (i.e. April 2004 to April 2005) the home has had an additional visit to follow up concerns brought to the Commissions attention by relatives who felt the standard of care being received by their loved one had begun to deteriorate. Furthermore, the service providers have also been required to carry out there own internal investigation into other poor practice matters brought to their attention by a Care manager, who was concerned about the level of staff on duty at the time of their unannounced visit. Both these complaints were in the main upheld in favour of the complainants and further comments are made in the main body of this report regarding the action taken by the service providers to try and resolve these issues. What the service does well: As previously mentioned the service users met during the inspection were all very positive in their comments about the overall standard of care they received at the home. Staff were observed actively encouraging and supporting the service users to develop their independent living skills and be responsible for certain household chores. Staff met said they help the service users to buy and prepare their own meals. The three service users spoken to over lunch had all chosen something different to eat for their midday meal, which they all said they had helped prepare from ingredients they had bought Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 6 themselves. It was positively noted that the homes most recent admission had visited the home on two separate occasions before deciding whether or not to move in, during which time he had the chance to meet the other residents and staff, go on a tour of the premises, and have a meal with everyone. All the service users spoken to during the inspection were very clear which member of staff they would prefer to talk to if they had a problem or were worried about something. What has improved since the last inspection? What they could do better: The positive comments made overleaf notwithstanding, there are still some areas of the service that could be improved. There are three areas of major concern that need to be addressed as a matter of urgency. Firstly, the homes new management team both acknowledge that the service users should be given more opportunities to take part in social and leisure of their choosing, both at home and in the wider community. Secondly, the home must ensure that from now on all allegations of abuse are reported to all the relevant external agencies without delay, including the Local Authorities vulnerable adult protection team, Care managers and the CSCI. Finally, some less than favourable comments were received from relatives and care managers about low staff morale. As previously mentioned, the new management team believes the high turnover of managers the home has had in recent years has been a contributory factor. The managers acknowledge that staff morale/attitude and their working relationships with the service users Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 7 representatives and each other, is an area of practice, which needs to be improved. 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. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 standard(s) 1,2 & 4 The home provides prospective service users and their representatives with all the information they need to make an informed choice about where to live. The homes admission procedures are very robust ensuring that there is a thorough assessment of prospective service users needs prior to them moving in. This information will guide staff on the action to be taken to ensure the new service users needs are planned for and met. EVIDENCE: A comprehensive Statement of purpose and guide is in place, which sets out in detail the homes aims and objectives, and the services and facilities provided. The document was last reviewed in March 2005 and includes information about recent staff changes. The manager acknowledged that the document was not dated. There has been one new admission and one discharge since the homes previous inspection. The one service user who has moved out to a more independent supported living project was relocated because it was felt that the home was no longer capable of meeting the individuals needs. It was also felt that this individuals increasingly challenging behaviour meant that they were no longer compatible with the existing service user group. Records indicate that the home undertook a thorough assessment of the new service users personal, social and health care needs and aspirations. A copy of the Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 10 assessment carried out by the individuals Care manager was also obtained by the home. During the new referrals trial period of residency the placement was reviewed twice before the decision was finally taken to make the move permanent. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 standard(s) 6,7, 8 & 9 Care plans accurately reflect service users assessed and changing personal, social and health care needs, ensuring staff can plan for and met these identified needs and aspirations. In the main service users are actively encouraged and supported by staff to exercise choice and control over their lives, although those service users who are willing and able to use a front door key should be given opportunity to have one. Service users are confident that their views are always sought about the homes operation and are actively encouraged to participate in its day-to-day running. EVIDENCE: Care plans sampled at random were all clearly based on individual needs assessments and covered every aspect of individual service users personal, social and health care needs. There have been no changes made to the service users care plan format in the last twelve months. The three Plans inspected referred to service users likes/dislikes and the action to be taken by staff to enable the service users to work towards there identified goals. These plans contained up to date information about each of the service users food preferences and social interests. One service user said he was aware that his care plan was kept in the office and although he had never asked to see it he felt confident he would be able too if he wanted too. He also said he was Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 12 always invited to his care plan reviews, along with his family. Two care plans sampled at random had been reviewed in the last six months and up dated accordingly to reflect any agreed changes in the package of care being provided. The minutes of service users meetings are appropriately maintained by the home and show that two have been held since Christmas 2004. These meetings are well attended by the service users and topics discussed at the last meeting were very wide ranging and included any concerns the service users had, holiday destinations and activities. Two service users said staff always give them feedback about the action to be taken in response to issues raised at these meetings, which is always recorded in the minutes. Risk assessments are included in service users care plans, which set out in detail what action is be taken by staff to ensure identified risks and/or hazards are, so far as ‘reasonably’ practicable, minimised. Two service users spoken with said staff encourage them to cook their own meals, clean their bedrooms and generally be more independent. One service user said he had been given a key to his bedroom, but not the front door. Having discussed this matter with the manager it was agreed that she would carry out risk assessments to establish which of the service users would be willing and able to have their own front door key. Specific behavioural guidelines also need to be draw up for service users who have been assessed as likely to be verbally and/or physically aggressive from time to time. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 standard(s) 12,13,15,16 & 17 Arrangements to ensure that the social, leisure and recreational interests of the service users are identified and met need to be improved to enable the service users to have far greater opportunities to engage in age appropriate activities, both at home and in the wider/local community. Dietary needs are well catered for and a well balanced diet is provided, to ensure a nutritious diet based on personal preferences is available. EVIDENCE: The local community is well used by the service users, particularly the convenience store, which is located next door. A number of people living in the home said they were generally satisfied with activities they take part in outside the home and said bowling on Tuesdays was very popular. These comments notwithstanding some of the feedback received from service users and their relatives, suggested that the variety of social, leisure and recreational opportunities on offer could be improved. One service user said before he came to the home he liked to play table tennis, watch football and go to the cinema, but since his arrival he had not been given the opportunity to pursue Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 14 these interests. These comments were feedback to the homes Regional, registered and deputy managers who all conceded that this was an area where the home could and must do better, especially now the home has a service user group who seem more compatible with one another. Individual daily diary notes kept for each service user did show that the majority attend a number of different day centres and colleges during the week. Several of the comment cards completed by service users relatives and the subsequent telephone conservations with these family members felt staff did not always keep them informed about their loved ones care. Once again the homes management team acknowledge that communication between staff and service users families must be improved. The registered manager stated that she was in the process of making arranging for a service user to visit his family on a more regular basis. All the service users met said they were not aware of any restrictions on ‘reasonable’ visiting times. Two service users and the manager said that all six of the service users had recently taken a vote at a residents meeting to allow the second lounge to be used as a smoking room for service users, their guests and staff, providing guests and staff asked the service users permission to smoke there. The manager said the service providers were still drawing up a policy regarding smoking, which needs to clearly set out the homes rules on this matter, particular those regarding where staff and visitors may smoke. A number of service users were asked about the meals and everyone who commented said they were tasty, hot and plentiful. Two service users said staff help them to shop for their own food and advice them about healthy eating options and budgeting. Service users have their own designated cupboards in the kitchen, where they store their own food and drink. Having been invited to join three service users at the dining room table while they had ate their lunches it was noted that everyone had chosen something different to eat. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. The homes policies and procedures for handling medicines in the home are very robust, although none of the service users have been asked if they would be willing and able to self-administer their own medication. This shortfall is unnecessarily restrictive as it impinges upon the rights of those service users who based on an assessment of risk may be willing and able to take greater control of their lives. EVIDENCE: Several of the service users spoken to said they could all choose what time they got up, went to bed, go out, and have a bath. The homes accident book contained only one new entry since the last inspection, which contained details regarding a fall a service user recently had. No major injuries were sustained and none of the service users have been admitted to hospital in the past twelve months. Detailed records are kept of all the service users health care appointments with community-based professionals, including GP’s, psychiatric nurses, dentists, opticians and chiropodists. Medication administration records sampled at random accurately reflected medication stocks currently held by the home at the time of this visit. The manager said none of the service users are currently prescribed any Controlled Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 16 Drugs or ‘as required’ (PRN) medication. The manager said that none of the service users have been asked if they would be willing to self-administer their own medication. If service users wish to retain control of their own medication they should be given the opportunity to do so where appropriate, providing ‘suitable’ arrangements are put in place to minimise risks associated with this practice. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Complaints are handled objectively and the service users are confident that any concerns they may have are listened to and acted upon. There are adequate procedures in place regarding the protection of vulnerable adults, although these are not always followed. To ensure the service users are protected the service providers must ensure a proper response to any suspicion or allegations of abuse. EVIDENCE: The home has produced a detailed complaints procedure that is available in an appropriate format, e.g. Written in plain English, and includes symbols and photographs, which the service users can understand. Two service users spoken to said they had both been given a copy of the procedure and felt confident that staff would always listen to any concerns they may have. Entries in the complaints log revealed that seven complaints had been made and acted upon in the past twelve months. The service users and their relatives made the majority of the complaints, while a visiting Care manager made one. In addition, a formal complaint was also received by CSCI from a service users relative about the falling standards of care at the home. All the complaints recorded in the past year were either partially or fully substantiated. Of particular concern was the inadequate numbers of staff found to be on duty at the time of an unannounced visit carried out by a service users Care manager in March 2005. The homes Regional and Registered managers both conceded that the service had received an alarmingly high number of substantiated complaints about its operation in the past year, which they hoped to reduce now the new management team had been appointed. The home has a comprehensive collection of procedures for responding to allegations or suspicion of abuse. However, an incident sheet revealed that an Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 18 allegation of physical abuse made by a service user in February 2005 had not been reported to their Care manager, the CSCI or the host Local Authority, directly contravening the service providers own, as well as the Local Authorities, Vulnerable Adult Protection procedures, and the Care homes Regulations (2001). A member of staff was immediately suspended by CMG pending an internal investigation by the service providers into the matter, which was still on going at the time of this inspection. The registered manager was required to notify Croydon’s Councils vulnerable adult protection team and the service users Care manager about the incident during the latter part of this inspection. The Local Authorities Vulnerable Adult Protection team has now set a date for all the relevant parties to get together and discuss this matter. There has been one other vulnerable adult protection meeting held in response to an incident involving two service users, which was dealt with promptly at the time in accordance with the service providers and Local adult protection protocols. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 standard(s) 26, 27, 28, 29 & 30 The size and layout of the home, which is furnished and decorated to a reasonable standard, ensures the service users live in a homely, safe and clean environment that maximises their independence and privacy. EVIDENCE: There have been no significant environmental changes made to the home since the last inspection, although all the communal areas, including the main lounge, dining room, smoking room, kitchen and laundry have recently been redecorated. Four bedrooms were viewed with the service users permission and all were found to be very personalised and decorated to a reasonable standard. Two service users met said they had all the bedroom furniture and equipment they needed. As recommended in the homes last report a table has been purchased to go with the garden chairs. The faulty call bell system in the bedroom nearest the Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 20 office has been risk assessed and as a consequence the decision has been taken to remove the alarm, which is considered to be surplus to requirements. The leaky pipe work and the water-damaged cupboards in the laundry room have now been repaired as required in the homes last report. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 34 Staff are employed in sufficient numbers and on the whole ‘suitably’ trained to meet the health and welfare needs of the service users. Sufficient numbers of staff, including night staff, still need to attend vulnerable adult protection and basic food hygiene training to ensure they have the necessary knowledge and skills to carry out all their duties competently, whilst ensuring the service users are protected. The homes procedures for the recruitment of staff do not provide all the safeguards to offer protection to the service users. EVIDENCE: The manager and staff members on duty at the time of this visit were observed interacting with the service users in a very caring and respectful manner throughout the course of the day. Several of the service users spoken to said they generally got on well with the staff and that they were very approachable. However, in the past twelve months the Commission has received a significant number of adverse comments from service users relatives and a Care manager alleging that certain members of staff seem unmotivated and lack initiative at times. This matter was raised with the homes Regional, Registered and new appointed deputy manager who all conceded that staff morale and their working relationships with the service users, their representatives, especially relatives, and each other, was an area of practice that needed to be improved. The senior management team suggest that because of the high turnover of managers the home had experienced in Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 22 the past two years the staff team have lacked continuity and consistent leadership, which has had an adverse effect on staff morale. The manager was mindful that the cultural and ethnic mix of the staff team did not accurately reflect that of the service users and as previously mentioned a new deputy manager has been employed to begin addressing this issue. The manager says that only one member of her current staff team have achieved a National Vocational Qualification in care Level 2 or above, although eight others have now started the course, which they plan to have achieved by the end of 2005. The home is on course to ensure that 50 of its staff team have been trained to NVQ level 2 or above by the end of the year to meet the standards. There have been no changes to staffing levels since the last inspection, which remain adequate to meet the assessed needs of the service users. Turnover of staff also remains low and a core team of five bank workers who are familiar with the service users and the daily routines of the home cover staffing shortfalls. As previously mentioned a complaint was raised by a visiting Care manager about the insufficient numbers of staff on duty at the time, which the manager and senior representatives of the service providers who investigated the matter say was a ‘one off’ incident which was the result of a member of staff going off sick without notifying the person in charge of the shift. This matter was dealt with after an internal investigation by CMG and the manager is confident that all shifts will be suitably covered in the event of staff sickness. Since the last inspection the home has employed two members of staff, including a new deputy manager who transferred from another CMG home. All new member of staffs files were examined in some depth and found to contain the majority of information required by the Care Homes regulations (2001), including a completed job application, the terms and conditions of their employment, a reference number to show that an Enhanced criminal records check (CRB) had been carried out before the individual was allowed to commence their employment, and proof of their identify. However, the manager was unable to locate copies of the new deputy’s references contrary to the homes recruitment procedures and the Care Homes Regulations (2001). Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 23 Training records revealed that both new members of staff had started their induction-training package on their first day of employment. The majority of staff have attended a number of compulsory training courses that are relevant to their work, including fire safety and prevention, moving and handling, first aid, basic food hygiene, and the service providers own dignified management of conflict training, which covers managing aggression/challenging behaviour and using physical intervention techniques as a ‘last resort’. The manager acknowledges that more staff need to attend an accredited recognising, preventing and reporting vulnerable adult abuse training. One member of the night staff team has still not attended a basic food hygiene course, despite this being identified as a shortfall in the homes previous report. The manager said the individual and been on sick leave and unable to attend the training which had been arranged on two separate occasions. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 & 42 There are clear lines of accountability within the home and the management style is open and transparent. Records held at the home provide evidence that maintenance is regularly carried out to ensure the well being of the service users. EVIDENCE: Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 25 The manager has been in operational day-to-day control of the home since September 2004 and has recently successfully undergone a ‘fit’ person interview with the Commsion to become the homes registered manager. The manager states she is on course to have completed her NVQ level 4 in management and care by August 2005 to meet the National Minimum Standards. In the past year the manager has undertaken a number of training course to up date her knowledge and skills, including managing change, budgets, quality assurance and recruitment. There is clear lines of accountability within CMG and the manager says her line manager is always on hand to offer advice and support as and when requested. In addition, as previously mentioned, the home also has a new deputy manager who has a wealth of experience working with adults with learning disabilities. Records indicate that staff meetings are held approximately once every two months and cover a variety of subjects. Topics discussed at the last staff meeting, include personal care, social activities, record keeping, care plan reviews and staff communication. The home is well maintained and ‘suitable’ arrangements are in place to promote and protect the health and safety of the service users and staff. Inspection of the homes fire records indicate that the manager has carried out a recent fire risk assessment for the entire building, the fire alarm system is tested weekly basis, and fire drills carried out every quarter. The manager was unsure when a fire officer from the London Fire and Emergency Planning Authority last visited the home and has agreed to liaise with them on this matter and either supply the Commission with the existing fire report or request another visit. Up to date Certificates of worthiness were in place as evidence that a ‘suitably’ qualified professional had recently checked the homes gas (Landlords) installations, water heating check for compliance with Legionella, fire alarms and extinguishers, emergency lighting and portable electrical appliances. The temperature of water running from hot taps attached to the homes two baths were found to be a safe 40 Degrees Celsius at 3pm. COSHH products were observed to be securely stored in a locked cupboard in the laundry room. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 2 x 3 3 3 Standard No 11 12 13 14 15 16 17 x 2 2 x 2 2 3 Standard No 31 32 33 34 35 36 Score 3 x 3 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brickfield Road (39) Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 27 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 9 Regulation 13(4), 17(1)(a), Sch 3.3(q) 12(3) & 16(2)(m) (n) Requirement Risk assessments must be carried out in respect of all those service users who wish to have a front door key and who have a history of aggressive behaviour. Service users must be consulted about their social, leisure and recreational interests and suitable arrangements must put in place to enable them to engage in activities both at home and in the wider community. Suitable arrangements must be put in place to ensure good commnication exists between the home and service users families. A copy of the homes amended smoking policy must be avialable for inspection on request and set out clearly the homes rules regarding where staff and visitors may smoke. Previous timescale for action of 1st September 2004 not met. Based on individual assessments of risk service users who are willing and able must be gvien the opportunity to manage their own medication. All external agencies, including the local authorities vulnerable Timescale for action 1st September 2005 1st August 2005 2. 12 & 13 3. 15 16(2)(m) 1st August 2005 1st August 2005 4. 16 12(1) (3) & 13(4) 5. 19 12(3) & 13(2) 1st September 2005 1st August 2005 Page 28 6. 23 13(4) (6) & Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 37(1)(g) 7. 8. 26 34 16(2)(c) 19, Sch 2.5 9. 35 13(6) &18(1)(a) , Sch 2.4 10. 42 23(4) adult protection team, the Commission, and the relevant placing authority must all be notified without delay about any allegations of abuse. Stained carpet in the bedoom nearest the office must be thoroughly cleaned or replaced. Two written references, including one from a persons last employer, must be obtained in respect of each person working at the home and be made available for inspection on request. The one member of staff who has not attended a basic food hygiene course must do so. Documentary evidence of this training must be forwarded to the Commission on completion. Prevous timescale for action of 1st January 2005 not met. The homes most recent inspection report undertaken by the local fire authority must be forwareded to the Commission. If a fire officer has not visited the home recently the London Fire and Emergency Planning Authority must be consulted about the possibility of arranging another inspection of the premises. 1st September 2005 1st August 2005 1st October 2005 1st September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 1 32 Good Practice Recommendations The homes Statement of purpose and guide should contain a review date. 50 of care staff to have achieved an NVQ level 2 in Care by the end of 2005. G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 29 Brickfield Road (39) 3. 37 The manager should have achieved an NVQ level 4 in management and care by the end of 2005. Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 Page 30 Commission for Social Care Inspection Croydon, Kingston & Sutton 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 Brickfield Road (39) G53-G53 S28229 Brickfield Road (39) V211336 130505 Stage 0.doc Version 1.30 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. 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