CARE HOME ADULTS 18-65
Brighton Road (47-49) 47-49 Brighton Road Purley Surrey CR8 2LR Lead Inspector
Claire Taylor Key Unannounced Inspection 8 & 15 September 2006 10:30
th th Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 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.V288881.R01.S.doc Version 5.1 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.V288881.R01.S.doc Version 5.1 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.V288881.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th November 2005 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. Mrs. Lorraine Bright is the registered manager and 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. Fees range from £500 - £800.00 per week and were accurate at the time of this inspection. Additional charges may be payable for personal items and would be discussed prior to admission. More detailed information about the services provided at Brighton Road can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the home. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home has undergone ownership changes and in February of this year, Caring Homes / Consensus Healthcare took over as the registered providers. The previous two responsible individuals from THF Care Estates remain the same however. In accordance with the Commission’s “Inspecting for Better Lives” programme, all the standards considered to be key to the inspection process were assessed. The report is based on findings from two visits, as staff records were not accessible during the first inspection. A second prearranged visit was therefore undertaken on the 15th September to meet with the home manager and check records related to staffing. Total time spent in the home was seven hours. Some information was also taken from the questionnaire that the manager filled in prior to the inspection. In addition, nine relatives and six service users returned comment cards provided by the Commission. During the first visit, the deputy manager, Georgina Kyohangirwe facilitated most of the inspection and staff members on duty were also spoken to. Time was spent with several service users to seek their views on what it is like to live at Brighton Road. Various records, policies and care plans were reviewed in order to evaluate how the home is being run. The premises were viewed, as were several of the service users’ bedrooms with their permission. All those involved are thanked for their cooperation and the service users and staff for their hospitality shown throughout the inspection process. What the service does well:
The home focuses strongly on service users’ choice and independence and their rights and responsibilities around the home are clear. There is a competent and stable staff team who understand the needs of the young adults living there. Management of the home is very well ordered with the benefit of a staff team that remains largely unchanged resulting in stability and familiarity for the service users. Time was spent independently and informally with individual service users who gave favourable comments about the home and also remarked highly of the staff team and services provided at 47 Brighton Rd. They all know who to speak to if they are not happy about their care. All of them said that they like living at the home and have lots of things to do. Person centred planning is used in the home and followed appropriately. Individual plans are well structured and supplemented with photos and symbols making them more meaningful to service users and easier to understand. Records confirmed that each service user is fully supported to access relevant healthcare services and that the home maintains good communication links with service users relatives and other relevant professionals. Record keeping continues to be well organised and the manager and staff team work consistently to maintain and improve standards. Service users are encouraged to be independent and most individuals go out unaided to do their own shopping and visit places of interest, manage their own money and take responsibility for the running of their home. Relatives
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 6 were complimentary about the support given to the service users in the development of their social and daily living skills. “My son has benefited by the move to this home where he has been motivated to be more independent and to visit local leisure facilities.” There is a core group of staff who have worked with the people living in the home for a number of years, have a good knowledge of their needs, and who support individuals to have a good quality of life and good life experiences. Again, positive comments were noted from relatives. “ I have only the highest praise for the staff and conditionsmagnificent.” Also, “ I feel very privileged and lucky that they are in such a lovely and happy home.” The home is furnished to a good standard and offers attractive and homely surroundings for the people who live there. Facilities are clean, safe and well maintained. What has improved since the last inspection? What they could do better:
Two issues concerning the environment are now outstanding and the new proprietor must therefore give them priority. The hallway and landing have yet to be redecorated and the outside of the premises still requires redecoration and repair in some areas. The latter issue has been outstanding since an inspection in April 2004. Ongoing failure to meet with outstanding requirements may result in the Commission taking enforcement action. A written plan for the home’s redecoration and maintenance is also needed to show how the home monitors the upkeep of the premises and makes improvements where necessary. Although the home uses effective systems to appraise its care practices through the views of service users, an annual quality development plan for the home is needed. Questionnaires also need to be offered to each service user to evaluate their satisfaction with the services provided. This will demonstrate what action the home has taken to act upon any findings and thus, improve its quality of care. Good practice areas for the registered provider to consider are outlined as follows. Given that the majority of other organisations contribute funds
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 7 towards service users’ social activities and staff costs, the new owning organisation should consider alternative ways for funding the service users activities from their own budget. It would be better if staff were provided with separate facilities for sleep in duties and given that the home has one vacant bedroom, this should be considered. One service user has guidelines for the management of epilepsy and it would be better if these were expanded upon to include details about when medical advice must be sought. Finally there should be a separate file available for recording complaints. 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. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 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.V288881.R01.S.doc Version 5.1 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 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. There is a range of comprehensive information for prospective and existing service users on how their assessed needs are going to be met and in relation to the services provided. EVIDENCE: In response to the last inspection, the Statement of Purpose and Service User’s Guide have been reviewed again and now provide the service users and their representatives with full information about the home and what services are available. Available in a book format and supplemented with photos of the premises, the documents are easy to understand. There have been no new admissions to the home since the last visit and there was one vacancy following the departure of one service user earlier in the year. All the placements in the home had been as a result of care management assessments and referrals. Suitable admissions policies are in place that ensures that the home would only admit people whose needs can be met. As part of the admission process, the home also carries out its own needs assessment, which covers prospective service users known strengths, skills, interests, and ability to take positive risks. Copies of needs assessments were seen on file for service users as well as detailed needs assessments completed by their care managers from social services. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 10 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 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. Service users know that their needs and goals are reflected in their individual plans. The service users are able to make decisions and receive good support if this is needed. They are consulted about and participate in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: A sample of care plans was examined. Records showed that service users are involved in their assessments and reviews; their personal goals and needs are reflected in their care plan and that these are reviewed at least six monthly or as needs determine. Person centred planning has progressed well. Plans are well structured and developed with the individual service user and their keyworker using pictures, photographs and symbols, to support the written text, making it more meaningful and easier to understand. Individual daily records were thorough, relevant, and gave an indication of each person’s experience of their day. Service users are encouraged to be independent and staff support individuals to take risks within their daily lives by maximising
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 11 their potential around self-care and promoting life skills. Individualised risk assessments were in place for each service user that clearly outline the required action to minimise identified risks and hazards. Staff appeared committed to ensure that service users are fully involved with the operation of the home and encourage them to contribute. Service users appeared comfortable, and staff members have clearly established positive and cooperative relationships with each individual. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 12 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, 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. The staff team ensure that service users take part in meaningful and appropriate activities both at home and in their local community. Relationships with family and friends are well supported and daily routines ensure that service users rights’ and responsibilities are recognised and respected as a means of promoting independence. Food provision allows for a healthy and varied diet based upon choice and preference; meals are enjoyed at times to suit individual service users. EVIDENCE: Service users are provided with guidance and support to make use of facilities appropriate to their interests and needs. The home informs service users about activities via meetings, informal discussions and the use of a notice board. Daily activities offered are through day centres, local community facilities, college courses and some service users are in paid employment. One person works as a chambermaid at a local Hotel and another in the mailroom at the local Council. Both service users confirmed that they like their
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 13 jobs and attend four days a week. The home does not have its own vehicle although service users have ‘Freedom Passes’ and regularly access local public transport services. The service users 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. When an outing is arranged, service users are expected to pay for staff costs as well as their own. E.g. admission fees, meals out, travel cards any other costs. Given that the majority of other organisations contribute funds towards service users social activities, the registered provider should provide a budget for staff expenses and /or social outings. During the inspection, service users were busy and occupied with activities of their choice. Records showed that service users often engage with friends outside of the home as well as friends and relatives being involved with any social events at the home. Comment card responses from relatives gave positive views about the care given, that they were warmly welcomed at the home, and felt actively involved with their respective family member. There is a varied choice of two meals that represents a range of tastes and cultural and personal preferences. Service users 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. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 14 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 and 21 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Clear guidance and the knowledge of experienced staff helps ensure that service users receive support in ways they are familiar and comfortable with. Promotion of health is well observed. Service users welfare is closely monitored to ensure that their physical and emotional needs are met. Medication is well managed to maintain maximised good health. EVIDENCE: Each service user has a nominated key staff who supports them with their plan of care. Keyworkers take responsibility to support individuals to shop for clothes and personal toiletries or go on outings of their choice. Records examined confirmed that arrangements were in place for meeting healthcare needs. Service users are supported to access a range of NHS facilities e.g. GP, Consultant, dental, chiropodist, optician and outpatient services for two individuals. Information about health conditions such as epilepsy is available in the home. Staff have received training on epilepsy to enable them to fully support those service users with such specialist needs. Prescribed medication is supplied in blister packs from a local pharmacy and is kept securely in a locked cabinet in the office. Medication records are appropriately maintained by staff and no errors were noted on the sampled administration sheets. An
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 15 appropriate healthcare professional reviews medication regularly and each service user has a written profile to specify what medication is required. Staff have undertaken medication training provided by the home’s pharmacist. The home receives six monthly audits from the pharmacist to further ensure safe practice. Areas for improvement had been actioned from the most recent visit in February 2006. One service user has guidelines concerning the management of epilepsy and it would be better if these were expanded upon to include details about when medical advice must be sought. I.e. a timescale should be included that identifies when staff need to call emergency services. In response to a previous requirement, the service users and their respective families have been consulted about their wishes concerning terminal care and death, including religious and cultural customs to be observed, in the event of a service user’s death. Written acknowledgment of these discussions was seen on service users’ files. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 16 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 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. Arrangements for complaints and protection from abuse are well managed to help ensure that service users feel listened to and safe. EVIDENCE: A complaints policy and procedure is in place and a clear version of this is made available to the service users and their representatives. A complaints log sheet is available in the home for recording any concerns or complaints. It is suggested that the home develops a file for recording complaints for better clarity. Comment cards received confirmed that relatives have confidence that the home would deal with any concerns. During interviews service users were clear about who they should speak to if they are unhappy. Records confirmed that staff are properly inducted on abuse awareness and policies and procedures regarding the protection of vulnerable adults. The manager advised that staff were also due to attend formal training on adult protection in November of this year. There are good procedures in place with regard to service users’ money and financial affairs. The majority of service users take responsibility for managing their own finances including collecting their money from local banks etc. Personal expenditure sheets were sampled and balanced correctly with amounts held in the home. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 17 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, 28 and 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. Overall the home is comfortably decorated and furnished enabling service users to live in welcoming and homely surroundings but some redecoration work remains outstanding for some time now. Service users bedrooms appeared comfortable and pleasantly decorated, reflecting their personal identities, and being suited to their individual needs. EVIDENCE: Following the last inspection, the hallway and landing have yet to be redecorated and the outside of the premises still requires redecoration and repair. These two issues are now outstanding from 2004 and the new proprietor must therefore attend to them without delay. Ongoing failure to meet with outstanding requirements may result in the Commission taking enforcement action. The providers also need to develop a written plan for the home’s redecoration and maintenance. This will show how the home monitors the upkeep of the premises and makes improvements where necessary. Aside from this, the home appears very homely and comfortably furnished. It is suggested that the proprietors review the current staff sleep in arrangements as one staff sleeps in the office with the second member in the small lounge
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 18 that is used by service users. It would be better if staff were provided with separate facilities for sleep in duties and given that the home has one vacant bedroom, this should be considered. Since the last inspection, the deputy explained that some work had been carried out in the summer to tidy the rear garden. During this visit however, the garden appeared rather run down again with overgrown hedges and grass and would therefore benefit from some development. The service users are supported to do their own housework and arrange their rooms as they wish. Rooms viewed clearly reflected people’s individuality and identified needs. One service user takes great pride in keeping her room neat and tidy and said that she enjoys helping out with domestic chores around the house. In her room, she pointed out how she had chosen the colour décor and furnishings, as she preferred. The service users who live in the home are very independent and staff support them to take responsibility with daily living skills. During the inspection, service users were busy doing personal laundry, ironing and meal preparation. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 19 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 and 35 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Recruitment is robust and provides safeguards and protection for service users. The needs of service users (both individually and jointly) are met by appropriately trained staff who have worked in the home for some time and are well supported. EVIDENCE: To check a previous requirement concerning staff records, a second prearranged visit was carried out on the 15 September to meet with the home manager. The staff team remains consistent and largely unchanged since the last inspection. Staff duties are organised around the service users activities and daily routines so that support is available at the most appropriate times. Rota allocation allows for two to three members of staff on each day shift with two staff on sleep in duty at night. Recruitment procedures are robust and ensure that staff are vetted correctly so that service users are safeguarded from people who should not be working there. Several staff files were randomly sampled and contained all the relevant legal documentation as well as other records required to demonstrate their fitness to work. As previously required, the manager had obtained the required employment checks for the outstanding staff members. I.e. proof of identification and two job references for another staff. Staff induction is provided via the Learning Disability Awards Framework training. Learning topics include the particular needs of the service
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 20 user group, the worker’s role in the home and general principles of care. Records confirmed that the home easily meets the required standard for numbers of trained NVQ staff; seven members have completed the level 2 qualification including two staff also trained to level 3. Specialist training has been provided in epilepsy, person centred planning, communication, disability and equality. Discussion with staff confirmed that management supports them to undertake further training as needed. Staff demonstrated a good knowledge of the service users needs, likes and dislikes. Service users expressed a liking for the staff team and spoke favourably about them. Regular staff meetings are held on a monthly basis and in depth consultations about the home’s care practices and service users needs are routinely discussed. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 21 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, 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. Service users have the benefit of a home that is run by an experienced manager who has relevant qualifications and good leadership qualities. Some minor improvements are needed with the quality assurance systems to ensure that quality of care is regularly appraised and the home is meeting its objectives. Previous health and safety concerns had been addressed; improved health and safety practices ensure that service users live in a safe environment and the welfare of service users and staff is protected. EVIDENCE: Lorraine Bright has run this home for many years and discussions with service users and staff indicated that Brighton road continues to be managed in an open and positive way. Staff members spoke positively about her leadership abilities and felt well supported. This was also reflected by the low turnover of staff and continued stability of the running of the home. The manager has
Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 22 acquired relevant training and experience and explained that she was due to complete the NVQ level 4 management qualification by 2007. Although the home does have good quality assurance systems in place, some improvements are still needed to fully meet the standard. For this year, questionnaires have yet to be offered to the service users and other representatives. An annual quality assurance action plan for the home also needs to be drawn up and implemented. This will further show that the views of the service users, their relatives and other interested parties influence the running of the home. Questionnaires from the previous year were seen and included very satisfied responses from service users and their relatives. The home has good systems in place that aim to promote the health, safety and welfare of service users, staff and visitors. In addition, there is policy guidance for staff to follow regarding a range of health and safety activities, use of cleaning products, and control of infection. Mandatory training is provided by the owning organisation and records were available to show that staff attend training to update their skills and knowledge as needed. Certificates seen included basic food hygiene; first aid; fire prevention; moving and handling; epilepsy and abuse awareness. Previous requirements from the last inspection concerning fire doors and hot water temperatures had been addressed. I.e. suitable magnetic door closures have been fitted to the necessary doors and the hot water temperature adjusted to the required safe limit. Accurate records are kept for accident and incidents and the home keeps the Commission promptly informed of any reportable events. All services, equipment and facilities are regularly checked and maintained in a safe state to maximise protection for all those living and working in the home. Maintenance and servicing records were sampled and up to date. Fire drills are organised at regular intervals and fire alarms and equipment had been checked. Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 23 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 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 3 X Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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. Standard Regulation Requirement Timescale for action 31/12/06 2. YA24 23(2)(b) The registered provider must ensure that the outside of the house is repainted and maintained on a regular basis. (Now outstanding from inspection April 2004). The registered provider must ensure that the mid and top landings are decorated. (Timescale of 31/09/05 and 31/01/06 not met). The registered provider must develop and maintain a written plan for the home’s maintenance and redecoration programme. A written annual quality assurance development plan needs to be developed for the home that is based upon the views of service users and other relevant parties. The provider must seek the views of residents, their family members / representatives and other interested parties to
DS0000028161.V288881.R01.S.doc 3. YA24 23(2)(b) 31/12/06 4. YA24 23(2)(b) (d) 30/11/06 4. YA39 24 31/12/06 5. YA39 24 31/12/06 Brighton Road (47-49) Version 5.1 Page 25 ensure that the home is meeting its aims, objectives and stated purpose. Results of these surveys must be made available in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA14 YA20 Good Practice Recommendations The registered providers should consider alternative ways of funding service users activities i.e. pay towards staff expenses and/ or provide a budget for social activities. Guidelines for the management of epilepsy should be expanded upon to include details about when medical advice must be sought. I.e. a timescale that identifies when staff need to call emergency services. The home develops a file for recording complaints for better clarity. The rear garden is in need of attention due to its overgrown condition. The proprietors should review the current staff sleep in arrangements so that staff are provided with a suitable separate facility. 3. 4. 5. YA22 YA24 YA28 Brighton Road (47-49) DS0000028161.V288881.R01.S.doc Version 5.1 Page 26 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
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