Inspection on 20/12/05 for Brickfield Road (39)

This inspection was carried out on 20th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brickfield Road (39) 21/08/06

Brickfield Road (39) 13/05/05

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 & David Halliwell Unannounced Inspection 20th December 2005 11:30 Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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 Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brickfield Road (39) Address 39 Brickfield Road Thornton Heath Croydon Surrey CR7 8DS 0208 764 9112 0208 764 9127 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) Care Management Group Limited Ms Getrude Mabaso Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th May 2005 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 younger male adults with mild to moderate learning disabilities and behaviours that challenge. Gertrude Mabaso has been in operational day-today control of the home for just over a year and was recently registered by the Commission as the homes manager. Gertrude has recently returned to Brickfield road having been seconded to another CMG care establishment for the past three months. During this period the Commission agreed to allow the homes suitably qualified deputy manager to be placed in temporary day-to-day conrol of the Brickfield Road in the registered managers absence. Situated on a quiet suburban street near the centre 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 Norbury train station and is also near some main line bus routes with good links to Croydon, central London and the surrounding areas. There have been no significant changes made to the physical environment of the home since it was last inspected in May’05. This detached bungalow still comprises of six single occupancy bedrooms, a main lounge, dining area, smoking/visitors room, two bathrooms, a kitchen, office and laundry facilities. There is an enclosed courtyard at the rear of the property which has a well maintained lawn and patio area with some garden furniture and a barbeque. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 11.30 on the morning of Tuesday 20th December 2005. It took four and a half hours to complete. Since the homes last inspection the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the homes registered manager, two service users in particular, although the vast majority were met at various stages during the course of this inspection, and several members of staff who were on duty at the time. The relatives of one service user, who had come to take there loved one out for a meal, were also met, albeit briefly. The rest of this inspection was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although several vulnerable adult protection meeting have been convened by the Local Authority in this time following the occurrence of two ‘significant’ incidents involving the same two service users. The outcome of these meetings and the action taken by the home is discussed in greater detail in the main body of this report. What the service does well: The home felt very lively throughout the course of this inspection with lots of service users, their relatives, and staff either getting ready to go out for lunch or returning to the home with Christmas decorations and food. All the service users and staff met said the range of opportunities the service users now had to engage in social, leisure and recreational activities of their choice was in the main ‘pretty’ good. Furthermore, despite the continual hustle and bustle the atmosphere in the home seemed to remain relatively relaxed and jovial throughout this visit. It was also evident from the staff practises observed during the course of this inspection that they continue to actively encourage the service users to maximise their independence and participate in the daily running of the home and household chores. All the service users spoken with said they could choose, within reason, when they went to bed, what they ate and what they did in their spare time. Finally, the home are commended for ensuring the Commission was notified without delay about the occurrence of all the ‘significant’ incidents that have taken took place at Brickfield Road in the past twelve months, and for their swift response to all these events. In particular the action taken to put in ‘extra’ staffing before the relevant placing authority had agreed to fund it, ensuring the potential risks to service users was minimised. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The positive comments made overleaf notwithstanding, there remains a number of core areas of practice the home still needs to improve upon. Firstly, records of all service user care plan review meetings must be appropriately maintained by staff and copies kept in the home at all times for inspection. Similarly, service users meetings, which take place on a monthly basis, must also be minuted. Secondly, the manager acknowledges that both the homes bathroom suites and kitchen units have all seen ‘better days’ and a time specific programme to have them replaced needs to be established by CMG. Damaged radiator covers that represent health and safety hazards also need to be repaired as a matter of urgency, especially the one that runs parallel with one service users bed. Finally, recruitment procedures need to be tightened up and communication between the home and CMG’s centralised Human Resources Department improved. Having inspected a number of staff files at random it was concerning to note that documentary evidence could not always be found to proof that CMG had obtained two written references and satisfactory Enhanced Criminal Records Bureau checks for all its new employees. The homes recruitment procedure need to be sufficiently robust to Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 7 ensure service users, so far as reasonable practicable, are not placed at risk of being harmed and/or abused by individuals who are ‘unfit’ to work with vulnerable adults. 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) DS0000028229.V258156.R01.S.doc Version 5.0 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 Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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 & 3 The home ensures prospective new service users and their representatives are supplied with all the up to date information they need to know about the home in order to make an informed decision about whether or not to move in. EVIDENCE: The homes Statement of purpose/service users guide was last reviewed in March 2005 and updated accordingly to reflect all the changes that had occurred in the previous past twelve months. The manager said a lot of changes have occurred in the preceding eight months since the homes last inspection and intends to up date the homes Statement of purpose in January 2006. The layout of this document makes it very accessible and the clever use of photographs, symbols, pictures and plain English make it easier to read and ultimately understand. At the time of this inspection the home was fully occupied, although following the occurrence of two ‘significant’ incidents involving the same two service users in the past twelve months it was agreed at the subsequent strategy meetings, convened by Croydon’s vulnerable adult protection team, that it would be in everyone’s ‘best interests’ if one service user moved out. The service user in question, their placing authority (Sutton Social Services Learning Disabilities team), the service providers (CMG), Croydon Social Services (Vulnerable Adult Protection team – LD), and the CSCI, were all involved in the decision making process and arrangements have now been Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 10 made for this particular individual to transfer to one of CMG’s supported living units on 2nd January 2006. The homes recently registered manager was acutely aware of CMG’s admissions procedures and the criteria to be used when considering a new referral. The manager said all the existing service users would be consulted about all new referrals and any compatibility issues raised would be taken into account when deciding whether or not to make a ‘trial’ placement permanent. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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&9 Care plans are being reviewed at least every six months, although the minutes of these meetings were not always available on request, making it difficult to determine who was present at the review and what actions were agreed. Suitable arrangements are in place to ensure service users continue to have every opportunity to take ‘responsible’ risks as part of a structured programme to promote their independence and choice. EVIDENCE: It was evident from entries made in the homes appointments diary and the managers comments that care plans are being reviewed on a sixth monthly basis, and in some cases more often, depending on the need. However, having inspected three care plans at random it was evident that they had not been up date accordingly to reflect agreed changes. The manager explained that it was usually the responsibility of the placing authority to record the minutes of these reviews and consequently the home was dependent on care managers to provide them with this information in a timely fashion. It was evident from one care plan that the home had been waiting for over four months for the relevant placing authority to supply them with the minutes of their clients last care plan review meeting. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 12 The manager conceded that four months was far to long a period to be waiting on minutes in order to update a service users care plan. Furthermore, without the availability of any minutes it is extremely difficult for anyone ‘authorised’ to inspect them to determine whether or not these meetings actually took place and who attended. The manager must device a system whereby minutes of all service user care plan review meetings are available for inspection at all times. The home has a comprehensive set of risk assessments in place, which set out in detail the action to be taken by staff to minimise the occurrence of any identified risk and/or hazard. It was positively noted that as required in the homes previous report both service user who travel independently in the wider community without the need for staff support have been offered keys to the front door, based on an assessment of risk. Overall, a comprehensive set of risk assessments had been drawn up, which covered strategies employed by staff to appropriately deal with aggression and violence, including possible ‘triggers’ of such behaviour. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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): 12, 15, 16 & 17 Social, leisure and employment opportunities for service users to engage in both inside the home and in the wider community are well managed, age appropriate, and provide the service users with daily variety and stimulation. EVIDENCE: On arrival several of the service users were out with staff shopping for a Christmas tree, while another was getting ready to have lunch out with two members of his family. It was evident from comments made by service users and staff met, as well as entries made in the homes activities book, that the service users are actively encouraged to participate in a wide variety of different community based activities. A couple of service user spoken to at length said they had recently been to the cinema to watch the new King Kong movie and had also been to their local pub on numerous occasion in the past few weeks. One service use said he still went Go-karting on a regular basis with staff, which he enjoyed. The homes new activities book is a useful tool and makes finding about the number and range of activities the service users engage in a lot easier. It is therefore recommended the manager should Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 14 consider including information about all the in-house activities the service users engage in, and not just the community based ones. During the course of this inspection the relatives of one service user, who were visiting their loved one to take them out for a meal, were spoken with, albeit briefly. They both said that overall they were satisfied with the standard of care being provided by the home and the attitude of most of the staff team, although they were concerned about the homes repeated failure to ensure their loved one came to visit them at their home on the south coast. This matter was raised with the homes manager who explained that the service user in question would often change their mind at the last minute and refuse to go, despite previously agreeing to the arrangement. This behaviour needs be included in the individuals care plan, including what action should be taken by the staff to minimise its occurrence. The manager said the family were always kept informed about their loved ones decisions and last minute changes of plan, which as already mentioned, is a regular occurrence. As required in the homes two previous reports it was positively noted that a copy of the homes revised rules regarding smoking were conspicuously displayed on a notice board near the front door. The policy made it clear that as agreed at a service users meeting the second lounge was to remain the homes designated smoking area, and visitors and staff would need to seek service users permission to smoke in this room. One service user was observed smoking in this room during the course of this inspection. One service user spoken with at length said he needed to stock up on food, as his designated kitchen cupboard was almost bare. During the course of this inspection a couple of service users went out with staff to buy food and eat out afterwards. As previously mentioned, one service users relatives had come to take their loved one out for a pre-Christmas meal and the manager said that as only a few service users would be at home for Christmas a table at a local restaurant had been booked for Christmas Day. It was evident from comments made by service users and staff that there is an expectation that service users help out with certain daily chores around the house, such as cooking and cleaning their bedrooms, as part of a structured programme to support the service users to develop and maintaining their independent living skills. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. Service users are also protected by CMG’s policies and procedures for handling medicines in the home, although protocols for ‘as required’ medication need to be reviewed. EVIDENCE: Several of the service user met all said they could choose what time they got up and went to bed. The homes incident book revealed that there had been one unplanned admission to accident and emergency since the homes last inspection, which was the result of an aggressive incident between two service users. Staff on duty appropriately dealt with the incident, which had clearly affected the health and welfare of the service user involved, at the time and the Commission notified without delay about its occurrence. However, the subsequent incident report was not sufficiently detailed, making it extremely difficult to determine its severity. The manager said she has spoken to her staff team about the importance of appropriately maintaining detailed incident reports. No recording errors were noted on individual service users medication administration sheets. As required in the homes previous inspection report it Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 16 was positively noted that the one service user who had been assessed as being capable of self-medicating had been given the opportunity to do so, but had declined the offer. The home does not stock any Controlled drugs, but does keep some ‘as required’ (PRN) medication. There were protocols for its use in place and the manager was clear when and how to administer this type of medication, although it was acknowledged that these protocols were in need of up dating. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 Complaints are handled objectively and service users met were confident that any concerns they may have about the home are taken seriously and acted upon. The homes arrangements for dealing with suspected or alleged incidents of abuse are sufficiently robust to ensure the service users are protected, so far as reasonable practicable, from avoidable harm and/or abuse. EVIDENCE: Several service users spoken with said staff were very approachable and always listened to what they had to say, especially if they were concerned about something. The homes complaints record revealed that no formal complaints had been made about its operation in the past eight months. Two significant incidents involving the same two service users have occurred at the home in the past twelve months. Both incidents resulted in the same service user sustaining serious injuries. The Commission was notified without delay about the occurrence of both these incidents and the subsequent strategy meetings convened by the Local Authority were all well attended by senior representatives of CMG. Furthermore, despite not having secured the funding from the relevant placing Authority the service providers are commended for arranging extra one to one staff support at short notice to minimise the risk of similar incidents reoccurring. As agreed at the last of these strategy meetings one of the service users involved has now transferred out of the home to one of CMG’s supported living projects. It was also positively noted that in response to these significant incidents the vast majority of the homes current staff team have now attended a suitable recognising, preventing and reporting adult abuse courses. The staff Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 18 are still waiting for their certificates of attendance to be delivered, which will be assessed at the homes next inspection. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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, 26, 27 & 28 The overall layout of the home, which is furnished and decorated to a ‘reasonable’ standard, ensures the service users have a homely and comfortable environment in which to live, although all the homes damaged radiators covers need to be repaired as a matter of urgency to ensure the service users are protected from harm. Furthermore, although the homes bathroom suites and kitchen units remain functional, they have all seen ‘better days’ and a rolling programme to replace them needs to be established to improve the homes overall appearance. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 20 EVIDENCE: There have been no significant changes made to the homes physical environment since May’05, although the manager acknowledges that both the homes bathrooms suites and kitchen units have all seen ‘better days’ and are in urgent need of up dating. The manager said that she has already discussed this matter with her line managers and some money has already been set aside in next years budget (April’06 to ’07) to refurnish and decorate these rooms. The requirement is made that CMG establish a time specific rolling programme to carry out this much needed work. CMG have their own maintenance department who are responsible for carrying out routine maintenance and repair work in the homes. The home keep a maintenance book to record all the outstanding work that needs carrying out. As required in the homes previous report the old carpet in the bedroom nearest the office has been replaced with some new wood effect laminate. The damaged radiator cover, which ran parallel with one service users bed who chose to position it this way, needs to be repaired as a matter of urgency to minimise the risk of this particular individual being burned. The radiator cover in the bathroom nearest the front door is also damaged. The under the sink cupboard in the same bedroom also needs repairing, as identified in the homes maintenance book. Having tested the temperature of water emanating from the bath nearest the front door at 14.50m it was found to be a safe 42 degrees Celsius. During a tour of the premises it was positively noted that a minipool table was available in the dinning room and a barbeque set in the garden. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 35 & 36 Overall, sufficient numbers of suitably experienced, qualified and competent staff are employed to meet the health and welfare needs of the service users. However, the homes recruitment and selection of new members of staff remains woefully inadequate and needs to be tightened up to minimise the risk of service users being harmed and/or abused by individuals who are ‘unfit’ to work with vulnerable adults. EVIDENCE: One member of staff spoken to at the time of this inspection said they felt staff morale had significantly improved in the past twelve months and that everyone was benefiting from having a management team that had remained unchanged during this period. Staff training records revealed that only two members of the homes current fourteen members of staff have achieved a National Vocational Qualification in Care, although a further six were already studying for theirs. The homes manager is aware that 50 of her staff team should have achieved the Governments training targets for care workers by 01/01/06, but acknowledges this will not be met within this prescribed timescale for action. The manager is hopeful that this target will be met by April’06. Consequently, the recommendation made in the homes two previous reports will be repeated in Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 22 this one and progress made towards achieving this aim will be assessed at their next visit. As previously mentioned, it was positively noted that staffing levels had recently been reviewed by the home and increased temporarily to minimised a recently identified risk. This increase was reflected by the duty roster for that day and the five staff on duty, which included the homes manager, seemed ‘adequate’ to meet the assessed needs of all the service users residing at the home at the time. Since May’05 the home has employed five new members of staff. The new member of staffs’ files was examined in some depth and although most contained all the information required by the Care Homes Regulations (2001), some did not. In one case the manager was unable to locate any documentary evidence to proof that one of the homes latest recruits had been checked against the Protection Of Vulnerable Adults (POVA) register or had an up to date Enhanced Criminal Records (CRB) check. Furthermore, despite being highlighted as a major shortfall in the homes previous inspection report, it was concerning to note that only one written reference could be located in respect of this same individual, and the one reference that was available was wholly ‘unsatisfactory’. CMG will need to follow this matter up with the referee concerned and kept a record of the outcome of the correspondence. The manager believes these shortfalls occurred as a direct result of a break down in communication between the home and CMG’s Human Resources Department. This matter will need to be addressed as a matter of urgency to minimise the risk of similar incidents reoccurring in the future. In the interim, the registered manager is reminded that she is ultimately responsible for ensuring CMG’s recruitment procedures are adhered too and comply with the Care Homes Regulations (2001). It was positively noted that the one member of the homes staff team who had not attended a basic food hygiene course has finally done so. Furthermore, all the homes staff team have recently attended annual refresher courses in the appropriate use of physical intervention techniques. The home is also commended for notifying the Commission without delay about a significant incident that occurred as a direct result of a member of staff’s inappropriate behaviour and for the prompt action taken to discipline the individual concerned. Staff supervision sessions and meetings were also used to remind the homes entire staff team about their responsibilities as care workers and the rights of service users. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 23 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 & 42 The homes health and safety arrangement are in the main sufficiently robust to protect the service users, their guests and staff from avoidable harm, although the fire resistant door in the office needs to be adjusted to ensure it closes flush into its frame to enable it to form an effective barrier against smoke. EVIDENCE: The registered manager of the home has been in operational day-to-day control of Brickfield Road for just over a year and is hoping to have achieved her NVQ 4 in management and care by April 2006. Since May’05 three staff meetings have been held at the home on a bi-monthly basis and minutes taken. The manager and several service users met also said that residents meetings are held on a monthly basis, but no minutes have been taken since July’05. The manager has agreed to rectify this issue and record the outcome of residents meetings from now on. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 24 All the requirements and recommendations made by the London Fire and Emergency Planning Authority (LFEPA) in their subsequent report, following an inspection of the home, have been met in full by the home. In accordance with fire safety regulations a suitably qualified professional last checked the homes fire extinguishers in July’05. The fire resident door in the office did not close flush into its frame when released during this inspection. Food kept in a fridge in the kitchen was stored correctly in accordance with basic food hygiene standards. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 25 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 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brickfield Road (39) Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 2 X X X 2 X DS0000028229.V258156.R01.S.doc Version 5.0 Page 26 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 YA6 Regulation 15(1) & (2)(c) (d) Requirement Timescale for action 01/02/06 2 YA15 3 YA19 4 YA20 5 YA24 6 YA26 A record of all service users care plan review meetings must be appropriately maintained by the home and copies made available for inspection on request. 12(2) & Arrangements to enable one 16(2)(m) service user to visit their family, which takes into account the individuals wishes and feelings, must be recorded in their care plan. 37(1) Regulation 37 reports sent to the Commission regarding serious injuries to service users must be sufficiently detailed to enable anyone authorised to inspect them to determine the severity the incident. 13(2) Protocols for ‘as required’ (PRN) medication must be reviewed and up dated accordingly. 23(2)(b) (d) A time specific rolling programme to replace all the homes rather ‘worn out’ bathroom suites and kitchen units must be established. 13(4), All radiators covers are to be DS0000028229.V258156.R01.S.doc 01/02/06 01/02/06 01/02/06 01/04/06 15/01/06 Page 27 Brickfield Road (39) Version 5.0 16(2)(c) 7 YA26 16(2) & 23(2)(b) 19(1), Sch 2.5 kept in a good state of repair. The damaged cupboard under the sink in one of the service users bedrooms needs to be repaired. Two written references, including one from the new recruits last employer, must always be obtained in respect of any person employed to work at the home and copies of these references made avialable for inspection on request. Previous timescale for action of 1st June 2005 not met. All references obtained in respect of persons working at the home must be ‘satisfactory’ and any concerns the service providers may have followed up with the referee. Documentary evidence to show that all persons employed at the home after July’04 have been checked against the Protection Of Vulnerable Adults (POVA) register and have up to date Enhanced Criminal Records Bureau (CRB’s) checks must be kept on the premises at all times. Service users monthly meetings must be minuted. The fire resistant door in the office must be adjusted to ensure it closes flush into its frame when released. 01/02/06 8 YA34 15/01/06 9 YA34 19(1), Sch 2.5 15/01/06 10 YA34 19(1), Sch 2.7 15/01/06 11 12 YA38 YA42 12(2), (3) & (4) 23(4)(c) 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 28 No. 1 2 3 Refer to Standard YA12 YA32 YA37 Good Practice Recommendations The manager should consider including information about all the indoor activities service users choose to engage as well as just the community based ones. 50 of care staff to have achieved an NVQ level 2 or above in Care. The manager should have completed her NVQ Level 4 training in management and care by April 2006. Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 29 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 Brickfield Road (39) DS0000028229.V258156.R01.S.doc Version 5.0 Page 30 - 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!