Inspection on 21/08/06 for Brickfield Road (39)

This inspection was carried out on 21st August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brickfield Road (39) 20/12/05

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 Key Unannounced Inspection 21st August 2006 10:00 Brickfield Road (39) DS0000028229.V308242.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 Brickfield Road (39) DS0000028229.V308242.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. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: 39 Brickfield Road is owned by the Care Management Group and is currently registered with the CSCI to provide personal support and accommodation for up to six younger adults with learning disabilities and challenging behaviour. Following the resignation of the registered manager in June 2006, Pat McGarry, the homes former deputy manager has been in operational day-to-day control. Pat recently applied to become the homes registered manager and awaits a ‘fit person’ interview with the Commission. Situated on a suburban street in Norbury the home is within easy walking distance of a number of local shops, takeaways, cafes, and pubs. The home is also relatively close to Norbury town centre, which has excellent bus and rail links to central Croydon and London. This detached bungalow comprises of six single occupancy bedrooms; a main lounge; separate dining room; smoking/visitors area; two baths and a shower; a newly fitted kitchen; laundry room; and office. There is an enclosed courtyard at the rear of the property that consists of a well-maintained lawn and a concrete patio area. Service users and their reprensentatives have access to copies of the homes Statement Of Purpose, Residents Guide, CSCI reports and indviudal terms and conditions of occupancy. These documents contain all the information service users and their representatives need to know about the home, and the fees charged for facilities and services provided, which currently stands at between £1,464.39 - £1,641.74 a week. Brickfield Road (39) DS0000028229.V308242.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 new acting manager acknowledges that there is significant room for improvement in a number of key areas of practice, including some relating to management and safety. 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 Monday between 10.00am and 2.00pm. During the course of this four hour visit four service users, the homes new acting manager, and a support worker were all spoken with at length. As part of the inspection process a service users next of kin was also spoken with over the telephone and a total of five comment cards were received from residents relatives. The remainder of the site visit was spent examining the homes records and touring the premises. What the service does well: What has improved since the last inspection? Where weaknesses have emerged in the past the home has always managed them well and it was positively noted that all the requirements identified in the homes previous report have been met in full. The Commission accepts the new manager’s comments that although there is still potential for further Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 6 improvement significant progress has nevertheless been made in the past twelve months, despite all the recent changes in the management team. It was noted during this visit that care plans are being updated at more frequent intervals to reflect changes in service users needs and personal goals. The Commission is now notified without delay about the occurrence of all significant incidents at the home involving service users. Far more detailed protocols for the use of ‘as required’ PRN medication have been established to ensure staff have a better understanding of when and how to administer this type of medication. The homes rather worn out bathroom suites and kitchen units have recently all been replaced and a new shower facility installed. In addition, new carpeting has been laid in the dinning room, hallway, and office; and the second lounge supplied with new furniture. All staffs personal files now contain two written references and up to date Criminal Records Bureau checks (CRB’s) as proof that the homes arrangements for recruiting new staff are sufficiently robust to minimise the risk of service users being harmed by people who are recognised as ‘unfit’ to work with vulnerable adults. Finally, all the homes fire resistant doors tested at random closed flush into their frames in line with standard fire safety containment guidance. What they could do better: The positive comments made above notwithstanding several new requirements were highlighted for urgent action in this report and the new manager acknowledged the home could do much better in a number of clearly identifiable ways: Firstly, the home needs to ensure that all major stakeholders feel confident that any concerns they may have about the homes operation will be taken seriously and the expectation that they will be responded to within 28 days is realised. Furthermore, all the homes written response to complaints including any action taken to resolve them need to be kept in a bound single source record for ease of referencing purposes. In exceptional circumstances when a service use is subject to physical restraint as the only practicable means of securing the welfare of that or any other service staff need to ensure detailed records are kept which set out clearly the nature of the physical intervention techniques used and its duration. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 7 The homes washing machine, which has been out of order for nearly a month, needs to be repaired or replaced as a matter of urgency to minimise the risk of infection spreading. Less than 50 of the homes current staff team have achieved a National Vocational Qualification in care contrary to National Minimum training targets set for support workers employed in residential care homes. Similarly, the homes new manager does not hold a relevant NVQ level 4 in either management or care and is therefore not suitably qualified to run a residential care home. The approach of the new manager is very ‘hands on’ and has undoubtedly created a very positive and inclusive atmosphere in the home, but the fact that Pat McGarry is the fourth manager to be in charge of Brickfield Road in the past four years, has inevitably adversely affected both the service users and staff at times. The Commission hopes the home is about to enter a period of relative stability in respect of its management team. The results of satisfaction surveys carried out by the home to ascertain service users, their relatives, and professional representatives views about the quality of the service provided are not being published on annual basis. Consequently major stakeholders are not having their say about how the home is run. Finally, the homes fire risk assessment of the premises needs to be reviewed as a matter of urgency and up dated accordingly to reflect recent changes. 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.V308242.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 Brickfield Road (39) DS0000028229.V308242.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): 2&5 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 prospective service users individual needs are thoroughly assessed prior to admission to determine whether or not the home is capable of meeting them. All service users have written contracts that set out in detail their individuals terms and conditions of occupancy ensuring any interested party has access to up to date information about the range of fees they can expect to be charged for facilities and services provided. EVIDENCE: The home has accepted one new referral in the past six months. The homes most recent admission was spoken with at length and said they had been provided with a guide to the home prior to moving in, although they had not had the chance to visit because they had been placed in an emergency. The new acting manager demonstrated a good understanding of the homes admissions procedures, including CMG’s emergency placement protocols, and was able to produce a full needs assessment undertaken by the individuals placing authority on request. Furthermore, a copy of the needs assessment Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 10 undertaken by the providers was also available on request and covered every aspect of the new service users personal, social, and health care needs. The manager was also able to produce a written contract on request that set out in detail this particular individuals terms and conditions of occupancy. The statement had been signed and dated by the service user and the homes manager and was explicit about the range of fees that would be charged for facilities and services provided. Brickfield Road (39) DS0000028229.V308242.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 good. This judgement has been made using all the available evidence. Care plans are reviewed at regular intervals and are continually up dated to reflect changes in need, which includes detailed management strategies to minimise identified risks reoccurring. Suitable arrangements are in place to ensure service users have every opportunity to be consulted on, and participate in, all aspects of life in the home and are actively supported to take ‘responsible’ risks as part of a structured programme to promote independent living. EVIDENCE: Care plans for the homes two most recent admissions were examined in depth and found to contain up to date information regarding the support both these individuals would each require to ensure their needs continued to be met. Both plans had been formally reviewed in the past six months. Furthermore, the homes most recent admission, who was subject to the Care Programme Approach (CPA), had also been involved in two additional reviews involving Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 12 their Community Psychiatric Nurse (CPN) and other relevant health and social care professionals since moving in. The new acting manager said it is customary for all new referrals to have their care plans formally reviewed within the first six weeks of being placed at the home and for an induction checklist to be completed by the new arrival setting out all their personal preferences and dislikes (e.g. food preferences, social interests, personal hygiene routines etc…). A written record of the checklist for the homes most recent admission was included in their care plan. The minutes of residents meetings revealed that four had been held since the turn of the year, which had all been well attended by service users. Popular topics of discussion had included household chores and social activity ideas. All three service users asked about residents meetings said they found them useful. The manager said one service user has an advocate and they are fully aware of their role and how to contact them. The care plans developed for the homes two most recent admissions contained a number of risk assessments and associated risk management strategies. While many of these assessments had clearly been undertaken prior to these placements taking place, several had been drawn up retrospectively following a number of significant incidents involving one individual in particular. All these significant incidents involving this individual had all been reported to the Commission without delay and their care plan up dated accordingly to reflect these newly identified risks. A member of staff informally interviewed was clearly aware of the new guidance developed for this individual and knew they now needed to be supported on a one to one basis whilst out in the wider community. Brickfield Road (39) DS0000028229.V308242.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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence. The social, leisure and recreational opportunities service users have to engage in, both at home and in the wider community, are well managed, ‘age’ appropriate, and provide people who use the service with daily variety and stimulation. Suitable arrangements are in place to enable service users to maintain appropriate relationships with their family and friends, whilst daily routines and house rules promotes freedom of choice and independent living. Dietary needs and preferences are well catered providing daily variation, choice, and interest for the people who use the service. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 14 EVIDENCE: All the service users were at home on arrival and were either watching television in the main lounge or listening to music/playing computer games in their bedrooms. All three service users spoken with at length said staff usually allowed them to purse their own leisure interests. During the course of the visit one service user when out to buy a snack from the shop next door, another was observed getting ready to go to the local launderette with staff, and a third service user was heard making arrangements with the manager to go out shopping with staff in the afternoon. The homes most recent admission said they were looking forward to starting an art and life skills course at a local college in the autumn which their new keyworker had helped set up. Two service users who had recently been on holiday to France with staff said they both had a great time and had particularly enjoyed going out in the evenings to the local social club. Staff maintain a record of all the activities service users have the opportunity to participate in each day. The record showed that service users lead relatively active lives and are actively encouraged to purse all manner of social, recreational and leisure activities. The new manager said three service users currently attend local day centres on a regular basis. The home continues to operate an open visitors policy and all the service users spoken with about visiting times said they were not aware of any restrictions. One service users relative spoken with over the telephone said staff always made them feel welcome when they visited their love one at their home. The new manager demonstrated a good understanding of the importance of supporting service users to maintain appropriate relationships with their families and partners, providing it was in their ‘best interests’. During the site visit, as previously mentioned, one service user said it was their designated day to do their laundry, while another said it was their day to do their weekly food shopping with staff. This expectation that service users are responsible for undertaking certain household chores on designated days was clearly noted in care plans sampled at random. Service users met seemed to take pride in these chores and one individual said he liked to prepare his own meals. The kitchen remained open throughout the course of this visit and service users were observed on several occasions helping themselves to hot and cold drinks as and when they required. One service user pointed out their designated kitchen cupboard and said they had decided to cook some noodles for their lunch. Another service user who said they did not like cooking said staff would always help him prepare his meals. This same individual said they liked sandwiches, which was what they had chosen to have for their lunch that Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 15 day. A third service user was observed receiving support from a member of staff heat up a steak and kidney pie in the oven. All three service users asked about meals agreed that their food preferences were always well catered for because they were not only actively encouraged to go shopping for their own food each week but also received help from staff to prepare their own meals each day. During a tour of the premises it was positively noted that a wide variety of nutritionally well-balanced foodstuffs were correctly stored in fridges and freezers. Service users met said they could choose to eat their meals in the privacy of their bedrooms if they wished, although staff would also encourage them to sit together for roast dinner on a Sundays. Brickfield Road (39) DS0000028229.V308242.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. Suitable arrangements are in place to ensure service users physical and emotional health care needs are recognised and met. Sufficiently robust systems are in place to ensure medication records are appropriately maintained and monitored to safe guard and protect the best interests of the service users. EVIDENCE: All three service users spoken with at length said they are able to choose when they get up and go to bed. One service user who had chosen to get up late that morning said before they got dressed they would prepare themselves a cooked breakfast. A record of all the health care appointments service users keep is appropriately maintained in their care plans. According to the homes accident and incidents books 25 significant events involving service users had occurred in the home in the past six months. One of these accidents resulted in a service user being admitted to casualty, but not hospital. All the other significant events involving Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 17 service users, which varied considerably in their severity, were all reported to the CSCI without delay and appropriate action taken at the time to minimise the likelihood of similar incidents reoccurring in the future. All the relevant care plans were up dated accordingly to include detailed risk management guidance for staff to follow. Two medication administration sheets sampled at random for the previous 28 days had been appropriately maintained by staff authorised to handle medication in the home with no recording errors noted. Both these records accurately reflected the current medication stocks held by the home on these two particular service users behalves. All medicines held by the home on service users behalves are securely stored in a locked metal cabinet located in the office cupboard. Protocols for the use of all ‘as required’ (PRN) medication were made available on request, which set out in detail when and how staff should administer this type of medication. Furthermore, a Controlled drugs register, which two appropriately trained staff always signs and date each time this type of medication is handled, is also being appropriately maintained. Brickfield Road (39) DS0000028229.V308242.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 adequate. This judgement has been made using all the available. In the main home has sufficiently robust arrangements in place to ensure service users and their representatives concerns about the services operation are listened to, although complainants are not always being kept informed about the outcome of their complaint within 28 days. Suitable arrangements have also been established to enable staff to effectively deal with incidents of aggression and ensure service users are, so far as reasonably practicable, protected from harm or abuse. However, the recording of incidents where physically intervention techniques are used are not always sufficiently detailed to enable anyone authorised to inspect them to determine whether or not the nature and duration of the restraint used was justified. EVIDENCE: All the service users spoken with said staff were on the whole very approachable and would always listen to any concerns they may have. During the course of this inspection all the staff on duty, including the new amanger, were observed responding to service users questions and queries in an extremely friendly and informative manner. The office door remained unlocked throughout this visit and service users were frequently observed coming in and out of this space to ask the manager for advice. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 19 The complaints log revealed that two formal complaints had been made about the homes operation since its last inspection. The first of these was made regarding service users behaviour and was not substantiated following an internal investigation and the matter was resolved to the complainant’s satisfaction. The second complaint was made by a service users relative and concerned a breakdown in communication regarding medication. However, although this complaint was upheld by the home who accepted full responsibility for the error the complainants were not informed about the outcome until nearly three months later when they raised the matter again. The new manager was very aware that all complaints and or more informal concerns made about the homes operation must always be responded to as soon as reasonably practicable or within at least 28 days of the complaint being received. Furthermore, no bound single source record of all the action taken by the providers in the past six months to the aforementioned complaints was being maintained by the home. Instead loose copies of all the written responses sent out to complainants were being kept in various files, which made case tracking the action taken by the home far more difficult than it should have otherwise been. The new manager said there had not been any allegations of abuse made within the home in the past six months and demonstrated a good understanding of her responsibilities with regard the Local Authorities vulnerable adult protection protocols. A relatively new support worker who was informally interviewed at the time of this site visit said they had read the providers whistle blowing policy and were very clear about their duty of care to report actual or suspected service user abuse. The member of staff also demonstrated a good understanding of what constituted abuse and said this matter formed part of their initial induction training. No allegations of abuse have been made within the home in the past six months and the new manager demonstrated a good understanding of the Local Authorities protocols regarding vulnerable adult protection. Similarly, a relatively new member of staff spoken with at length also demonstrated good understanding of what actually constituted abuse and whom they needed to inform if they suspected or witnessed abuse. The manager said that he current staff team had all recently attended CMG’s own British Learning Disability (BILD) approved managing conflict training. Incidents sheets revealed that in the past six months staff had used approved physically intervention techniques to restrain a service user whilst they were out in the wider community. The Commission was notified about the incident at the time of its occurrence and concurred from the information received that the action taken by staff was probably the minimum necessary to prevent further escalation of an already volatile situation. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 20 However, the record of the incident kept in the home was not sufficiently detailed to enable anyone authorised to inspect it to determine the exact nature and duration of the physical intervention techniques that used to restrain this particular individual. The manager acknowledged this reporting shortfall and has agreed to remind her team about the importance of maintaining far more detailed accounts of any incident where physical intervention techniques were used. The manager and the member of staff who was informally interviewed were both very clear that physical intervention techniques should only be used as a ‘last resort’ when all other attempts to deescalate a potentially ‘hazardous’ situation had failed and providing it was clearly in the service user(s) ‘best interests’ to do so. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is good. This judgement has been made using all the available evidence, including a site visit to this service. The interior décor and some of the homes fittings have recently been upgraded, which has included two new bathroom suites and kitchen units, to ensure service users live in a far more comfortable and homely environment. The home is also kept clean, although the washing machine will need to be repaired/replaced as a matter of urgency to control the spread of infection, in accordance with the relevant legislation. EVIDENCE: All the outstanding maintenance issues identified in the hoes last report have been addressed in a timely fashion. There have been changes made to the interior of the home since it was last inspected with two new baths, WC’s, and a shower unit, installed in both the homes bathrooms; new carpeting laid in the dinning room, hallway and office; and new furniture bought for the second lounge/smoking room. Furthermore, it was positively noted that arrangements had also been made for the rather worn out cupboards in the kitchen to be replaced with new units by the end of the month. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 22 Two service users gave their permission to view their bedrooms. The two rooms seen were both decorated to a reasonable standard and were very personalised. One service user who had just finished rearranging his bedroom furniture said he had been allowed to bring a lot of his personal effects with him from his previous placement, which included a wide variety of electrical goods. This individual said they could do with another table to keep all their personal home entertainment equipment on, and it was decided that they might want to discuss this matter with the homes new manager. The temperature of hot water emanating from the homes new bath nearest the office was found to be a safe 40 degrees Celsius at 12.30. Similarly, the homes new shower outlet was also found to be a safe 40 degrees Celsius five minutes earlier. The manager explained that service users had been going to a local launderette because the homes washing machine has been out of order for nearly a month. The washing machine is an integral part of the homes infection control systems and as such the providers should have made more of a concerted effort to repair it in a timely fashion. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 23 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 good. This judgement has been made using all the available evidence. In the main sufficient numbers of suitably competent and well supervised staff are employed on a daily basis to ensure the collective needs of the service users are met, although more staff will need to achieve an NVQ in care to make the staff team far more effective staff team. Sufficiently robust recruitment arrangements are in place to ensure the risk of service users being harmed or abused by individuals who are ‘unfit’ to support vulnerable adults is, so far as reasonably practicable, minimised. EVIDENCE: All the staffing requirements identified in the homes last report have been met in full. All the service users met said they got on well with staff and knew who their keyworkers were. The manager and the other staff on duty at the time of this visit were always observed taking their time to deal with service users questions. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 24 On arrival three members of staff, which included the new acting manager, were all on duty in the home. The number and skills mix of the staff on duty matched the morning’s duty roster and was adequate to meet the assessed needs of the service users. The new manager said staffing levels during the day never fell below three and two waking staff were always on duty at night. The new manager said the home has a deputy manager’s vacancy following her internal promotion, which she hopes to fill by the end of the month. No new staff have been recruited since the homes last inspection and two staff files sampled at random contained two written references, proof of the these individuals identities, and their most recent Criminal Records Bureau (CRB’s) checks. The manager also said her current staff team, which has remained relatively unchanged in the past twelve months and have all successfully completed their fire safety, first aid, health and safety, food hygiene and significant management of conflict training. However, the manager acknowledged that with only two members of staff having been awarded a National Vocational Qualification in care the home falls well short of the 50 required by the standards. The Commission is aware that four other members of staff are currently enrolled on a suitable NVQ course and the percentage of support workers holding this vocational qualification will have improved by the end of the year. As the new acting manager has only been in post for a relevantly short period of time it is strongly recommended she carry’s out a thorough assessment of her staff teams training needs and strengths. The homes staff team is ethnically and culturally very diverse and is reasonably reflective of the area, although the manager conceded that the team was not particularly representative of the service users backgrounds, the majority of whom are white British. The manager is mindful of this ethnic and cultural imbalance and will take this into account when recruiting new staff. The one member of staff spoken with at length said they continue to be supervised at regular intervals by a senior member of staff. The manager said staff receive at least one formal supervision every two months and this process will be made easier when the new deputy starts. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 25 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 & 42 Quality in this outcome area is good. This judgement has been made using all the available evidence. Service users and staff have all benefited from the new managers approach whose leadership style has created a very positive and inclusive atmosphere within the home. Suitable arrangements are not currently in place to ensure service users and their representatives views about the quality of the care being provided are ascertained and published at regular intervals to ensure they have a say about the way the home is run and develops. Sufficiently robust health and safety arrangements are in place to minimise the risk of service users, their guests and staff being harmed, although the current fire safety assessment of the premises will need updating as a precautionary measure against the risk of fire. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 26 EVIDENCE: The new acting manager has been in operational day-to-day control of the home since August 2006, although Pat McGarry has been working at Brickfield Road as the deputy manager for the past couple of years. Pat has a wealth of experience working with adults with learning disabilities in a senior management capacity, although she does not currently hold a National Vocational Qualification Level 4 in either management or care. The manager is aware that she will need to enrol on a suitable NVQ Level 4 course as soon a reasonable practicable since the deadline for all residential care homes managers to hold this qualification experienced at the end of 2005. All the staff spoken with said they liked the approach of the new manager and felt her ‘hands on’ style of leadership was a very open and inclusive one. Records revealed that both staff and service users meetings continue to be held at regular intervals and the new manager demonstrated a good understanding of the importance of these forums for initiating debate and empowering services users and staff to have their say about how the home should be run. The new manager was aware that CMG had developed a quality assurance system, but acknowledged that limited progress had been made by the home to distribute satisfaction questionnaires to all the major stakeholders, including service users, their relatives and other professional representatives (e.g. Care managers, psychiatric nurses, GP’s ect…), to ascertain their views about the standard of care being provided at the home. As part of this quality assurance system unannounced inspections continue to be carried out be senior representatives of CMG and a copy of their findings forwarded to the Commission each month. Fire records revealed that the homes fire alarms continue to be tested on a weekly basis and that two fire drills involving all the homes current staff team have been carried out since the beginning of the year in accordance with recommended good fire safety practice. Based on advice given by the local fire authority a fire evacuation risk management strategy is in place for staff to follow in respect of one service user who frequently declines to participate in fire drills. As identified by the homes Regional Operations Manager at their last unannounced visit the new manager is aware that a fire risk assessment of the premises needs to be up dated. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 27 Up to date Certificates of worthiness were in place to show that the homes gas (Landlords) installations, fire alarm system, extinguishers, portable electrical appliances and water tank had all been checked by suitably qualified engineers in the past twelve months in accordance with good health and safety working practices. During a tour of the kitchen and one service users bedroom it was noted that all items of food being kept in fridges were correctly stored in accordance with basic food hygiene standards. Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 28 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 3 X Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 29 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 YA22 Regulation 22(4) Requirement A person(s) who have made a complaint about the homes operation must be informed within at least 28 days after the date on which their complaint was made of the action (if any) that is or has been taken in response. A single bound record of any action taken by the providers in respect of any complaint made about the homes operation must be appropriately maintained for ease of referencing purposes. On any occasion on which a service user is subject to physical restraint staff must record in detail the nature of the physical intervention techniques used, and more specifically the duration. Homes washing machine must be maintained in good working order. Timescale for action 01/09/06 2. YA22 17(2), Sch 4.11 01/09/06 3. YA23 13(8) & 17(1)(a) Sch 3.3(p) 01/09/06 4. YA30 23(2)(c) 08/09/06 Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 30 5. YA32 18(1) A time specific action plan setting out how the providers propose to ensure at least 50 of the homes support workers have either achieved an NVQ Level 2 in care or are at least enrolled on a suitable course must be established. A time specific action plan setting out how the providers propose to ensure the new manager either achieves an NVQ Level 4 in Management and Care or at least is enrolled on a suitable course by the end of the year must be established. The results of satisfaction surveys undertaken by the home to ascertain the views of major stakeholders must be published at least annually and a copy supplied to the Commission. 01/01/07 6. YA37 9(2)(b)(i) 01/01/07 7. YA39 12(3) & 24(1,2 & 3) 01/01/07 8. YA42 23(4) The homes fire risk assessment 15/09/06 of the building must be up dated. 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 YA33 Good Practice Recommendations The manager should be mindful of the cultural and ethnic imbalance that currently exists between her staff team and the service users when she next recruits. The manager should carry out a thorough assessment of her current staff teams training needs and strengths. 2. YA35 Brickfield Road (39) DS0000028229.V308242.R01.S.doc Version 5.2 Page 31 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. 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