Inspection on 27/09/07 for Brighton Road (47-49)

This inspection was carried out on 27th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brighton Road (47-49) 08/09/06

Brighton Road (47-49) 14/11/05

Brighton Road (47-49) 13/06/05

Brighton Road (47-49) 17/11/04

Brighton Road (47-49) 01/04/04

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 Brighton Road (47-49) 47-49 Brighton Road Purley Surrey CR8 2LR Lead Inspector James O`Hara Key Unannounced Inspection 27th September 2007 10:30 Brighton Road (47-49) DS0000028161.V346099.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 Brighton Road (47-49) DS0000028161.V346099.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. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brighton Road (47-49) Address 47-49 Brighton Road Purley Surrey CR8 2LR 020 8660 4078 NO FAX 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) THF Care Estates Limited Ms Lorraine Bright Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2006 Brief Description of the Service: 47/49 Brighton Road is registered with the Commission for Social Care Inspection to provide residential care for up to fifteen adults with moderate learning disabilities. The home provides residential care for younger adults aged between 18 and 65 the vast majority of whom have lived together for many years, with the result that they seem very comfortable in one another’s company. The registered manager has been in operational day-to-day control of the home for the past twelve years. The property is situated on a busy residential road close to the centre of Purley and is well placed for local shops and public transport links. Built over three-stories the homes comprises of thirteen single and one double bedroom, two separate lounges; a dining area; kitchen; laundry; office; and numerous bathroom/toilet facilities located conveniently throughout the house. There is ample space in the front garden for parking and there is a large back garden with patio and lawn area. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was carried out between 10.30am and 12.30pm on a Thursday morning/afternoon. The Caring Homes Group took over the home in February 2006. The registered manager stated that the Caring Homes Group has an arm that supports people with learning disabilities this part of the Group is called Consensus. Methods of inspection included observation of contact between staff and people who use the service, discussion with the deputy manager, one person living at the home, telephone conversations with the registered manager, the area manager and the regulation manager from Caring Homes. Records examined included care plans, risk assessments, complaints, adult protection, staffing training records, Statement of Purpose, Service Users Guide, medication, health and safety records and questionnaires from people who use the service and their relatives returned to the Commission as feedback. Requirements and recommendations from the previous inspection were also discussed with the deputy manager and the registered manager. A random unannounced inspection took place at the home on the 30th of January 2007. This report includes information from that inspection. What the service does well: There is a competent and experienced staff team who clearly understand the needs of the people living there. The registered manager and most of the staff have worked in the home for a number of years resulting in stability and familiarity for people who use the service. People are encouraged to be independent and staff support them to take risks within their daily lives by maximising their potential around self-care and promoting life skills. People hold regular meetings. Copies of the most recent meeting minutes indicated that people were able to express their wishes and plan activities. People were observed to be confident and comfortable at the home. At the random inspection one person said that staff were friendly and helpful, if we need anything we just ask. People are able to engage in appropriate social and leisure activities both inside the home and in the wider community. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 6 People have regular contact with friends and relatives. A number of comment cards were returned to the Commission from relatives as feedback. One relative commented that the home encourages people to be out in the community and is good at remembering birthdays etc but felt that staffing levels do not allow for close supervision of issues such as personal hygiene and room tidying. Another relative commented ”they provide an exceptionally attractive, clean and comfortable home for the residents. The staff are caring and cheerful with each other making a happy home atmosphere. All residents are expected to share in the running of the home, shopping etc which gives them a sense of responsibility and family. Great credit is due to the manager who organises and maintains this very happy place where our family feels privileged to be part of”. What has improved since the last inspection? What they could do better: The overall impression when visiting the home is that it is well managed. The management approach of the home creates an open, positive and inclusive atmosphere. People considering using the service are provided with all the information they need to make an informed decision about whether or not the home is capable of meeting their needs however this information needs to be updated to include details of the new owners. In general the arrangements for meeting peoples health care needs are good however the home could do more to ensure that appropriate guidelines are in place for supporting people with epilepsy. Copies of regulation 26 reports should be available in the home for inspection. There were five requirements and five recommendations set at the key last inspection. Two of the requirements outstanding from 2004 relating to repainting the landing and the outside of the home have not been met. Requirements outstanding from 2004 must be given priority. A senior manager from the Caring Homes Group stated that the external redecorations and repairs to Brighton Road had been scheduled for completion by October 2007 Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 7 however due to severe weather conditions this summer the works stalled. The senior manager anticipates that the works at Brighton Road will take approximately 4-5 weeks to complete and have been scheduled in for the May 2008. Any further movement of these dates for completing of the redecorations at Brighton Road may lead the Commission to consider taking enforcement action against the registered provider. The inspector would like to thank people who use the service, the staff and the registered manager for their support during this visit to the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brighton Road (47-49) DS0000028161.V346099.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 Brighton Road (47-49) DS0000028161.V346099.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. People considering using the service are provided with all the information they need to make an informed decision about whether or not the home is capable of meeting their needs however this information needs to be updated to include details of the new owners. EVIDENCE: The Caring Homes Group took over the home in February 2006. The registered manager stated that the Caring Homes Group has an arm that supports people with learning disabilities this part of the Group is called Consensus. The home has a statement of purpose and a service users guide. The statement of purpose is available in a book format and supplemented with photos of the premises, the documents are easy to understand. These documents have not been updated to include details of the Caring Homes Group/Consensus. The registered manager must ensure that the homes statement of purpose is updated and includes all of the information as stated in Schedule 1 of the Care Home Regulations. No new people have moved into the home since the last inspection. All of the people living at the home have moved there as a result of care management Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 10 assessments and referrals. The home has suitable admissions policies in place; these ensure that the home will only admits people whose needs can be met. The home also carries out its own needs assessment that assesses people’s strengths, skills, interests, and ability to take positive risks. Brighton Road (47-49) DS0000028161.V346099.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. People’s care plans include detailed information on their needs and personal goals and are kept under regular review. People have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: The deputy manager stated that Consensus is in the process of introducing new administration and policies and procedures into the home. People who use the service have care plans; the care plans are currently being transferred to the new Consensus format. People’s care plans include a pen portrait, life picture, activities, strengths and needs, likes and dislikes, goal plans, action plans and risk assessments. Care plans are completed using pictures, photographs and symbols and written text. People are involved in Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 12 their assessments and reviews; their personal goals and needs are reflected in their care plan. Care plans are reviewed at least six monthly or as needs determine. Each person has a key worker. People are encouraged to be independent and staff support individuals to take risks within their daily lives by maximising their potential around self-care and promoting life skills. Individualised risk assessments were in place. Risk assessments covered areas such as road safety, fire, hot water and using the kitchen. People hold regular meetings. Copies of the most recent meeting minutes indicated that people were able to express their wishes and plan activities. People who use the service were observed to be confident and comfortable at the home. At the random inspection one person said that staff were friendly and helpful, if we need anything we just ask. They treat us pretty well if we have a problem we can talk it over with them, our key worker or the home manager. Brighton Road (47-49) DS0000028161.V346099.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Social and leisure opportunities for people to engage in both inside the home and in the wider community are well managed and age appropriate. People have regular contact with friends and relatives. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and eaten by people who use the service. EVIDENCE: People attend various activities. On the day of the visit some people had gone to day services, one person had gone to work at Sainsbury’s another person had gone to work at a hotel, some people had gone to college and some people had gone to the local library. One person said that she was very happy Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 14 living at the home and that she had plans to go out shopping then to a disco later in the day. It was reported at the key inspection that when outings are arranged people who use the service were expected to pay for staff costs as well as their own. E.g. admission fees, meals out, travel cards any other costs. It was recommended that the registered providers consider alternative ways of funding people’s activities i.e. pay towards staff expenses and/or provide a budget for social activities. At the random inspection the registered manager stated that she wrote to people’s care managers requesting extra funding for activities however none agreed an increase. It was recommended that the registered manager contact Consensus Support Service and enquire if they have a therapeutic expenses budget for activities. The registered manager stated that she had raised this issue with Consensus but that there was no possibility of extra funding. The registered manager stated that people generally go out independently so don’t always need to pay for staff. Most people have mobility benefits and it has been agreed with people that some of this benefit would be used to pay for staff to support them to go on holiday. It is recommended that the registered manager consult with her line manager to clarify the organisations policy on using people’s finances for paying for staff to support them to go on holiday and other therapeutic activities. The registered manager should pass this information onto the Commission. Records show that people often engage with friends outside of the home as well as friends and relatives being involved with any social events at the home. People make use of local community resources such as shops, pubs, bowling, and a social club run by Mencap. There are two lounge areas that offer a wide range of in house entertainment facilities such as television, videos / DVDs, music system, art and craft activities, jigsaws, computer and board games. There is a varied choice of meals that represents a range of tastes and cultural and personal preferences. People are asked to choose the meals they want to eat for each forthcoming week and a detailed record is kept of the food actually provided. Individuals are able to eat at flexible times according to their routines and social lives and are actively encouraged to be involved in the preparation of meals. At the random inspection some people were preparing sandwiches for lunch. All said that they were able to shop and choose what they like eat. The member of staff supervising in the kitchen was encouraging people to choose from a number of options. One person said that she liked chicken paste and prepared a chicken paste sandwich, she said she liked chips but not all the time because it’s not good for us. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 15 A number of comment cards were returned to the Commission from relatives as feedback. One relative commented that the home encourages people to be out in the community and is good at remembering birthdays etc but felt that staffing levels do not allow for close supervision of issues such as personal hygiene and room tidying. Another relative commented ”they provide an exceptionally attractive, clean and comfortable home for the residents. The staff are caring and cheerful with each other making a happy home atmosphere. All residents are expected to share in the running of the home, shopping etc which gives them a sense of responsibility and family. Great credit is due to the manager who organises and maintains this very happy place where our family feels privileged to be part of”. Brighton Road (47-49) DS0000028161.V346099.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. 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 knowledge of experienced staff helps ensure that people receive personal care and support in ways they are familiar and comfortable with. In general the arrangements for meeting peoples health care needs are good however the home could do more to ensure that appropriate guidelines are in place for supporting people with epilepsy. The homes policies and procedures for handling medicines ensure the people are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: People are supported to access a range of health care providers such as the General Practitioner, dentist, chiropodist and opticians. It was recommended at the key inspection that guidelines for the management of epilepsy should be expanded upon to include details about when medical advice must be sought. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 17 At the random inspection the registered manager produced updated guidelines for staff to follow for the management of epilepsy that included timescale’s for calling emergency services. These guidelines do not provide clear information about the person’s epilepsy. The guidelines should include a description of typical seizures, guidance for staff to follow i.e. when to call an ambulance and when to administer medication. The person’s General Practitioner should also agree and sign the guidelines. A staff-training matrix indicated that staff had attended training on epilepsy however it was not clear when staff attended this training. (See staffing standards). Some people self medicate and have completed/signed a form indicating that they will administer their own medication. The deputy manager stated that they are closely monitored and supported when the need arises. It is recommended that risk assessments be carried out and placed on file for those people that self-administer their medication. Prescribed medication is supplied in blister packs from a local pharmacy. Medication is stored in a locked cabinet in the office, administration records were checked on the day of the inspection and were up to date and accurate. The home receives six monthly audits from the pharmacist to further ensure safe practice. Staff have undertaken medication training provided by the home’s pharmacist again it was not clear when staff attended this training. (See staffing standards). Brighton Road (47-49) DS0000028161.V346099.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. 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 home has appropriate complaints procedure in place. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure that people are so far as possible protected from abuse, neglect and/or harm. EVIDENCE: A complaints procedure is located in the hallway; this indicates that people can complain to the registered manager and the deputy manager. The complaints procedure in the hallway needs to be updated to include details of all of the people that people can complain to or raise their concerns with. A complaints policy and procedure is in place and a clear version of this is made available to people and their representatives. A complaints log sheet is available in the home for recording any concerns or complaints. It was recommended at the key inspection that the home develop a file for recording complaints for better clarity. The home now has a file for recording complaints. A card was sent to the home from a relative thanking staff for a great party for the forty-year-old twins. An adult protection issue was raised in January this year. The home took appropriate steps to investigate the issue and the matter was resolved. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 19 A number of staff attended adult protection in November 2006. (See staffing standards). There are good procedures in place with regard to people’s financial affairs. The majority of people take responsibility for managing their own finances including collecting their money from local banks etc. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic however requirements outstanding from 2004 relating to repainting the landing and the outside of the home must be given priority. EVIDENCE: The property is situated on a busy residential road close to the centre of Purley and is well placed for local shops and public transport links. Built over three-stories the homes comprises of thirteen single and one double bedroom, two separate lounges; a dining area; kitchen; laundry; office; and numerous bathroom/toilet facilities located conveniently throughout the house. There is ample space in the front garden for parking and there is a large back garden with patio and lawn area. Requirements first set at an inspection in April 2004 that the registered provider ensures that the outside of the house is repainted and maintained on Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 21 a regular basis and that the mid and top landings are decorated are still not met Consensus Support Service took over the home in February 2006. The last key inspection report indicated that these requirements should be given them priority. The report also stated that failure to meet with outstanding requirements might result in the Commission For Social Care Inspection taking enforcement action. Despite this Consensus Support Service has not yet met these requirements. Following the random inspection the Commission wrote to the registered providers, Consensus Support Service, requesting a confirmation of when these requirements will be met. The Commission received a response from a senior manager from Caring Homes on the 5th of March 2007 stating that following the change of ownership in February 2006; Consensus Support Service is committed to ensuring that standards are improved. The letter included quotes for all of the outstanding works to be carried out. Despite this Consensus Support Service has failed to met these requirements. Following this inspection the Commission contacted a senior management at Caring Homes; the senior manager e-mailed the Commission stating that the external redecorations and repairs to Brighton Road had been scheduled for completion by October 2007. However, due to severe weather conditions this summer, the works stalled. It was not possible to extend the external painting season beyond October due to cold and wet conditions. It is anticipated that the works at Brighton Road will take approximately 4-5 weeks to complete and has been scheduled in for the May 2008 painting season. The outstanding requirements that the outside of the house is repainted and maintained on a regular basis and that the mid and top landings are decorated will stand until the works have been completed. However any further movement of these dates for completion of the redecorations may lead the Commission to consider taking enforcement action. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. There is a competent and experienced staff team who clearly understand the needs of the people living there. The registered manager and most of the staff have worked in the home for a number of years resulting in stability and familiarity for people who use the service. EVIDENCE: The registered manager was not present on the day of the inspection so it was not possible to access staff personnel files located in a locked cabinet in the office. It was reported at the last key inspection that the staff team remained consistent and largely unchanged since the previous inspection. The deputy manager stated that no new members of staff had started work at the home since then. A staff training matrix indicated that staff had attended training on food hygiene, first aid, fire safety, moving and handling, health and safety and epilepsy however it was not clear when staff attended this training. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 23 The registered manager stated that Consensus has enlisted the support of a training group. The training group has started retraining staff from scratch in order to ensure that all staff attend training on such topics as fire safety, food hygiene, first aid, moving and handling, health and safety and training required to meet the needs of the people who use the service. It was reported at the last key inspection that seven members had completed an NVQ level 2 or level 3 qualifications. The deputy manager stated that Consensus expect that all members of staff will complete Learning Disability Award Framework (LDAF) training. The deputy manager stated that Consensus was committed to improving the level and quality of staff training. The deputy manager stated that staff receives regular formal supervision at least six times per year. Staff meetings are held on a monthly basis and in depth consultations about the home’s care practices and people’s needs are routinely discussed. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. 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 overall impression when visiting the home is that it is well managed. The management approach of the home creates an open, positive and inclusive atmosphere. EVIDENCE: The registered manager has managed the home for thirteen years. Staff and people who use the service spoken to indicated that it is managed in an open and positive way. The deputy manager stated that registered manager is currently completing an NVQ level 4 qualification. The deputy manager holds an NVQ level 3 qualifications. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 25 Some regulation 26 visit reports were available in the home for inspection however the area manger confirmed over the telephone that all of the visits had been carried out. It is no longer a requirement under the Care Homes Regulations that regulation 26 reports are sent to the Commission unless it is requested, however copies of the reports must be available in the home for inspection. The deputy manager produced evidence of the homes Quality of Service Questionnaires. People who use the service and relatives and visitors had completed these. The deputy manager stated that feedback from the questionnaire would be used to improve the service. The deputy manager stated that Consensus is in the process of introducing all of their policies and procedures into the home. The deputy manager produced evidence that portable appliance testing had been carried out on 01/03/07, legionellas testing had been carried out on 02/03/07 and landlords gas safety certificate was produced dated 30/04/07. The homes fire book indicated that the fire alarm system is checked on a regular weekly basis by staff, full fire evacuations had been carried out in May, June and July 2007, the homes fire appliances had been serviced in July 2007 and engineers from Chubb had serviced the fire alarm system on the 08/06/07. All staff attended fire safety training on the 11/05/05. The registered manager stated that Consensus would expect that all members of staff attend fire safety training on an annual basis. Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 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 YA24 Regulation 23(2)(b) Requirement The registered provider must ensure that the outside of the house is repainted and maintained on a regular basis. (Outstanding from inspection April 2004). The registered provider must ensure that the mid and top landings are decorated. (Timescale’s of 31/09/05, 31/01/06 and 31/12/06 have not been met). The registered manager must ensure that the homes statement of purpose is updated and includes all of the information as stated in Schedule 1 of the Care Home Regulations. Epilepsy guidelines should include a description of typical seizures, guidance for staff to follow i.e. when to call an ambulance and when to administer medication. The person’s General Practitioner should also agree and sign the guidelines. It is no longer a requirement under the Care Homes DS0000028161.V346099.R01.S.doc Timescale for action 31/05/08 2. YA24 23(2)(b) 31/05/08 3. YA1 4 (1) c 31/12/07 4. YA20 13 (1) c. 30/11/07 5. YA39 26 (2) 31/10/07 Brighton Road (47-49) Version 5.2 Page 28 Regulations that regulation 26 reports are sent to the Commission unless it is requested, however copies of the reports must be available in the home for inspection. 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 YA12 Good Practice Recommendations It is recommended that the registered manager consult with her line manager to clarify the organisations policy on using people’s finances for paying staff to support them to go on holiday and other therapeutic activities. The registered manager should pass this information onto the Commission. It is recommended that risk assessments be carried out and placed on file for those people that self-administer their medication. The complaints procedure in the hallway needs to be updated to include details of all of the people that people can complain to or raise their concerns with. 2. 3. YA20 YA22 Brighton Road (47-49) DS0000028161.V346099.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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