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Inspection on 12/12/06 for British Home and Hospital for Incurables

Also see our care home review for British Home and Hospital for Incurables for more information

This inspection was carried out on 12th December 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The health care needs of service users are well met with attention to mobility. There is also good liaison with a range of health care professionals such as the doctor, care home support team, chiropodists, dentist and optician. Service users are listened to when they complain. Complaints are acted on to make things better. The maintenance and catering departments operate efficiently consequently providing an environment that is clean and safe. Service users have access to a good physiotherapy section and activities area and each department has specially trained staff. Service users are enabled to do lots of different things that they want to do. All service users are admitted with a full assessment of care needs and only admitted if the home feels they are able to meet the service user needs.

What has improved since the last inspection?

There is now a registered manager.The corridors have all been decorated and bedrooms are redecorated as they become empty. The catering manager has developed a thirteen-week cycle cleaning audit programme, which will help identify any shortfalls in the cleanliness of the building so they can be immediately addressed.

What the care home could do better:

Care plans are improving but there still needs to be more detailed information about service users` life history and relationships. Care plans need to be reviewed and kept up-to-date. A more person centred approach to the way care is offered to service users should be considered. Consideration should be given as to how the management of the home can make it more attractive to service users to make them want to become involved in running the home and to encourage them to attend the service users meetings.

CARE HOME ADULTS 18-65 British Home and Hospital for Incurables Crown Lane Streatham London SW16 3JB Lead Inspector Lynne Field & Duncan Paterson Unannounced Inspection 12 , 13th & 14th December 2006 11:00 th DS0000032400.V315110.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 DS0000032400.V315110.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. DS0000032400.V315110.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service British Home and Hospital for Incurables Address Crown Lane Streatham London SW16 3JB 0208 670 8261 020 8766 6084 noelle.kelly@britishhomes.org.uk 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) British Home and Hospital for Incurables Christine Lilian Morland Care Home 127 Category(ies) of Physical disability (127), Physical disability over registration, with number 65 years of age (0) of places DS0000032400.V315110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: The British Home & Hospital for Incurables (BHHI) is a voluntary care home for 127 people. It is a registered charity with a Board of Management. BHHI provides purpose built accommodation for people who are chronically sick and physically disabled. The aim of the home, highlighted in the statement of purpose is: to provide high quality nursing care with high levels of clinical and recreational support thereby assisting each resident to achieve maximum possible independence. BHHI is 5 minutes from local shops and near to all the local transport facilities. It is close to Streatham Common and a short drive from all the amenities in Streatham. The building is a large Victorian building, which has a distinctive presence in the area. It is maintained to a high standard and an extension, which was built in 1996, is in keeping with the existing building. There are two wings on each floor known as East and West Wing. The newer wing created 48 single rooms all en suite. A kitchen was completely rebuilt in 2001 where the food is cooked and brought to each floor in portable Bain Maries. The Home has a physiotherapy department with two full-time physiotherapist and two full-time physiotherapy assistants who see all service users. DS0000032400.V315110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by two inspectors and took place over three days in December 2006. The registered manager was on sick leave but the assistant matron took part in the inspection process. The responsible individual was present for the second and third days of the inspection. Inspection methods included case tracking fifteen service users. During the course of the inspection the inspectors spoke to 27 service users, some in groups and others individually, including two service users who had recently moved into the home. One inspector met a prospective service user who had come to look at the home with his relative and social worker and one spoke to a visiting relative. The inspectors also spoke to a range of staff including the responsible individual, four team leaders, ten care staff as well as managers from the five other departments, visiting professionals, domestic and clerical staff. A tour of the premises was carried out and care records were inspected. In addition, information from the pre-inspection questionnaire and comment cards sent to the service users and relatives as well as the recommendations from two reports from two placing authorities inform the findings of the report. What the service does well: What has improved since the last inspection? There is now a registered manager. DS0000032400.V315110.R01.S.doc Version 5.2 Page 6 The corridors have all been decorated and bedrooms are redecorated as they become empty. The catering manager has developed a thirteen-week cycle cleaning audit programme, which will help identify any shortfalls in the cleanliness of the building so they can be immediately addressed. What they could do better: 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. DS0000032400.V315110.R01.S.doc Version 5.2 Page 7 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 DS0000032400.V315110.R01.S.doc Version 5.2 Page 8 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): 1,2 3 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service users’ guide provide service users and prospective service users with details of the services the home provides enabling the service user to make an informed decision. Service users have their needs assessed by senior staff before they move to the home and know that the home can meet their needs before they move there. Prospective service users and their relatives are encouraged to come and look around the home, stay for a trial period and meet staff before they decide to move there. EVIDENCE: The matron told the inspector, copies of the home’s statement of purpose and service users’ guide were sent to prospective service users before they came to visit the home. The inspector was told these were in the process of being reviewed and updated. A draft statement of purpose is going to the Board of Directors to be ratified. The service users’ guide is being reviewed to make it more service user friendly. DS0000032400.V315110.R01.S.doc Version 5.2 Page 9 The inspector met one prospective service user who had come to look around the home with their social worker and family member. They told the inspector they had been given information about the home before their visit. They said the visit to the home had helped them decide what they wanted from the home and if the home is able to meet their needs. The registered person said they would visit a prospective service user to assess their needs before the service user came to live at the home. One of the case tracked service users’ was new to the home and they confirmed that they had been assessed, seen the home before moving in and everything had been done for them to move into the home. The inspector saw their room and they had been provided with all the equipment to meet their assessed needs. The inspector spoke to two social workers that had come to carry out a six monthly review of a service user they had placed in the home. They confirmed the placing authority assessed the service users needs and by senior staff of the home before the service user came to live at the home. During the course of the inspection 15 service users’ files were inspected and there were pre-assessments on file for each service user. This provided evidence that service user’s needs had been assessed. The inspector witnessed arrangements being made to admit a service user for a trial period to see if the service would meet their needs. The inspector was told by the assistant matron that once the service user had moved into the home there was an initial general assessment. This included background information, such as likes and dislikes, leisure and recreational information, medical history nutritional information and a physiotherapy assessment in their first week at the home. There would be a review after six weeks that would involve the service user, their family members, care staff and the placing social worker. DS0000032400.V315110.R01.S.doc Version 5.2 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. 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 available evidence including a visit to this service. Families and other professionals are involved when reviews are held. At reviews the home to ensure that the review covers whether service users are properly placed in the home or if their needs have changed, do they need to move on to a different setting or more appropriate accommodation. Service users are consulted and supported to make decisions about their lives by staff and appropriate independent professionals. There are care plans in place that reflect service users’ needs. However, these are not always as detailed as they could be or reviewed in depth consistently. Manual handling needs and risk assessments need to be reviewed. EVIDENCE: The inspectors viewed 18 service users’ files and case tracked 15 during the course of the inspection. Care plans follow the “essence of care” format, which was introduced at the home. The inspectors found these were of differing standards throughout the home. While on one unit case files were well ordered and neatly arranged with a lot of relevant information, on another DS0000032400.V315110.R01.S.doc Version 5.2 Page 11 some details in the care plans were sparse and did not state what service users could do for themselves. The care plans for two service users had not been reviewed since August 2006. However, three other care plans had been reviewed regularly and recently. Manual handling risk assessments were not always clear. For example, the inspector could not tell if it was a manual handling risk assessment. Three risk assessments had been completed but not dated or reviewed and another service user did not have a risk assessment. The nurse said this was because there was no manual handling carried out on this service user. However, it would be good practice to record that a risk assessment had been completed with a decision having been made that no manual handling assistance was needed. One example of wound management records were well kept and detailed. However, the records for another example had not been completed for a number of days before the inspection. Daily wound dressings had been recommended by the Tissue Viability Nurse. Staff completed the records retrospectively when brought to their attention. The inspector spoke and contacted four professionals during the course of the inspection, who had placed service users in the home. Two said “they were happy with the service offered to their client and the home meets their needs”. They said they held and attended reviews and confirmed service users were involved in the decisions made at the reviews. One local authority link worker, who reviews the care provided by the home, confirmed all of the service users the authority has placed in the home apart from two, have an assigned social worker, who have reviewed the service user’s placement. They said only one person expressed a wish to move so the majority of the people were happy living at BHHI. They confirmed service users were enabled to attend regular medical appointments and see the dentist and chiropodist. Service user meetings are held monthly. A copy of the minutes is put on each units’ notice board along with a poster informing service users of the date of the next meeting. The inspector saw a member of staff taking a service user to the notice board to read the latest minutes. DS0000032400.V315110.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in appropriate activities and leisure activities. More could be done to develop services to meet service users’ cultural needs such as through activities and meal provision. Service users are encouraged to and are part of their local community. Service users are able to maintain relationships with friends and family. EVIDENCE: There is a large well-equipped activities area, which consist of several large rooms. This includes a kitchen with a dining area. The inspector was shown the minutes of the senior clinical meeting held in November 2006. This covered discussion of meals where the residents committee had said the potions of food were too large. They had requested DS0000032400.V315110.R01.S.doc Version 5.2 Page 13 they be reduced because they were concerned about the amount of weight some service users had gained since coming to live at the home. A discussion took place about the number of cooked meals offered and it was decided to cut out a cooked meal in the evening and replace it with a more healthy option as well as stop the cooked breakfasts. A group of service users had joined together to form a Healthy Eating Group called the “Chubby Club”. On the day of the inspection the service users were cooking a turkey as part of a healthy meal option. Several service users complained to the inspectors about the meals the home was serving. Feedback from other service users was that service was good but some service users felt the food was poor. The issue here was a reported lengthy time taken to get the food from the kitchen to the table. Two service users were unhappy about not having a hot meal in the evening. The inspector spoke to the matron and the catering manager, separately about the menu. Both felt the dissatisfaction about the food on the menu could be because of the changes made and the matron said the meals are freshly cooked, placed in Bain Maries, with no delay in transporting the food from the on-site kitchen and served directly from the Bain Marie. The inspector was shown a copy of the menu, which was varied and had many healthy options. The inspector suggested to the matron and catering manager that they ask the service users for their views on what they type of meals and food they want by doing a specific survey and planning the menu around the results as well involving staff in the menu planning. The staff of the home are all entitled to meals when they are on duty. The inspector was invited to have a meal with the staff and found the meals wholesome and tasty. The inspectors spoke to service users that were in the hairdressing room. They said they enjoyed having their hair done and they could also have a manicure. The inspector was told staff went to service users to ask them if they wanted to take part in the different activities that were held each day. The inspectors spent time in the art room, speaking to service users who were their taking part in a variety of art projects. Two service users showed the inspector a number of models and paintings they had made over the years they had lived at the home. The inspectors were told the home had recently had an exhibition of the artwork service users had produced. One inspector noted that there was not a lot representation of black cultural arts. As the staff group is diverse, they could assist to widen the range of activities to incorporate the cultural diversity of the service users. The activities coordinator told the inspectors they had arranged for off duty police to assist them in taking service users out in the mini bus and they had a number of volunteers who run the shop, twice a week as well as help take service users into the community. One service user said they often went out to the local shops in their motorised wheel chair. Another service user DS0000032400.V315110.R01.S.doc Version 5.2 Page 14 described how much they enjoyed attending the local Darby and Joan club, where they particularly enjoyed the karaoke. The home needs to make sure individual activities are developed that cater for service users needs. The inspector met two service users families, who said they felt very welcome and were encouraged to take part in the home. The inspector met one mother and son who said they were very happy with the service. DS0000032400.V315110.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support, in the way they prefer. A more person centred style of care could be considered for introduction. EVIDENCE: 15 care plans were inspected. There is an assessment form used to develop the care plans. These continue to improve but are of differing standards thoughout the home. Not all were dated and signed by staff. Changing needs were not always recorded, but on the whole daily records, which are kept in a separate book, were found to be well kept. These short falls have already been identified by the home’s managers. Care files contain information for staff on service users who need personal support with their preferred personal care routines. From the files inspected it was found that nursing needs were well met. The majority of service users who spoke to the inspectors were saying positive things about the home and the staff. The inspector had received a copy of a Wandsworth Council review report before starting the inspection. This report stated areas for improvement and recommendations. This inspection has verified these. They include matters DS0000032400.V315110.R01.S.doc Version 5.2 Page 16 such as concerns about service users being left on the toilet for too long and the need for a holistic approach to the service users care. One way could be to develop the person centred planning approach in which the social and emotional needs and not just the nursing needs of the service user are identified and met. Medication was inspected at a different day by the pharmacy inspector. The report on the findings of that inspection will be sent separately. DS0000032400.V315110.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted on but the home needs to ensure all service users are enabled to have their views known. The adult protection procedures in use should be reviewed in the light of a recent report from the local authority. EVIDENCE: Although there are service users committee meetings held monthly the attendance is low with typically only 10 service users in attendance. Notices of forthcoming meetings are displayed on the board. Development work should be undertaken to encourage service users to attend. The complaint book was checked and two complaints were recorded. The matron deals with the complaints immediately and both were dealt with by following the homes policy and procedure. There have been two adult protection investigations since the last inspection. The local authority has been involved in responding and has been able to share findings and recommendations with the registered person. It is recommended that the local authority recommendations are responded to as well as a review carried out of the internal adult protection procedures in order to maximise learning and shared experience. The inspector spoke to the finance officer who keeps a record of service users’ finances. Each service user has a personal account, which is recorded on an DS0000032400.V315110.R01.S.doc Version 5.2 Page 18 individual spreadsheet and every transaction is on these. Statements are given each month to either the service user or their relative. The deputy matron and the finance officer monitor all the accounts. DS0000032400.V315110.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is well maintained, attractive and homely. It is well liked by service users. EVIDENCE: The home is large and spacious with lifts to all floors. Many of the service users have electric wheelchairs with controls that are adapted to suit each service user. This enables service users to be able to move around the home independently. The environment is generally good. There is a difference between the older and newer parts of the home with more en suite facilities, for example, within the modern extension. However, the extension blends in well within the overall style of the building and there are lots of spaces for activities. The inspectors identified two matters that need attention. A toilet handrail needed to be repaired. The matter was raised with the estates manager who had been aware and was waiting for an agent to repair. Welding was needed DS0000032400.V315110.R01.S.doc Version 5.2 Page 20 which had added to the time taken to repair. Secondly, a bath had a broken hydraulic system, which would make it higher. They are waiting for repairs and can still use but can’t adjust the height. The inspectors also identified that there was a variation between each floor about the number of mobile hoists available. Staff felt that three hoists per unit was suitable but the equipment in use needs to be in accordance with the needs of service users. A comprehensive review may be needed of service users manual handling needs as well as the provision of equipment. There is a rolling maintenance programme, managed by the estates manager who is responsible of the building and the grounds. The inspector spoke to both the estates manager and the catering and domestic services manager, separately. The records of each department were up to date and well kept. Health and safety was a priority high lighted by both managers. The estates manager showed the inspector the works plan matrix that identifies when and what when services and equipment have been checked, serviced and maintained. The London Fire, Emergency and Planning Authority (LFEPA) have issued guidance notes for care homes and the estates manager has had discussions with the local fire brigade about this. The philosophy is fire prevention. Each floor has an individual fire risk assessment in place and discusses this in staff fire training sessions. Service users are not allowed to smoke in their bedrooms and the inspector noted one service user had a letter on file about this. There are designated communal areas where service users can smoke rather than smoking rooms. This was because the home felt it was safer to have service users smoking where staff could see them rather than in a room. The catering manager is responsible for the catering and cleaning in the home. All staff take the food hygiene course each year. Eleven staff has gained NVQ level 1 in domestic cleaning and are going on to take NVQ level 2. The inspector was given a tour of the kitchen that is divided into different areas of food preparation. The catering manager has developed a thirteen week cycle cleaning audit program which will help identify any shortfalls in the cleanliness of the building. DS0000032400.V315110.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels at the home are adequate but need to be reviewed to ensure service users needs are being met. Service users are supported by competent staff that can meet the needs of the service users. Records indicate the staff team is qualified but need supervision to complete daily tasks. EVIDENCE: The inspectors spoke to 20 staff and checked ten staff files during the course of the inspection. These included two written references, a signed copy of their contract stating terms and conditions and Criminal Records Bureau checks as required including confirmation of training that has been undertaken. Two files were for new staff and both had induction training booklets of the training they had undertaken. There were copies of one to one supervision on file but this was not carried out regularly. More regular supervision of all staff would support staff in their daily tasks and professional development. DS0000032400.V315110.R01.S.doc Version 5.2 Page 22 The staff the inspectors met were all very friendly, helpful and positive. The home is large with many staff within the various units. Staff said they felt supported by the management of the home. The staff team is very stable and had worked for the home for many years. The inspectors did not see any evidence of poor quality work or poor practice. Service users feedback was that staff varied in their abilities, although some mentioned some very good care practice but other staff were seen as not so good. By far the inspectors found the majority of service users were saying positive things about the home and the staff. The rota was inspected and staffing levels were adequate. On one unit there were five staff including a RGN in morning and four staff including the RGN on the late shift. The nurse in charge said four staff on the late shift was adequate but not three. The matron told the inspector and the rota confirmed this, that each unit had a number of ancillary / support staff that have no hands on role with the service users who support the nursing staff. The inspectors observed that the staff always appeared to be busy with service users and on one unit the inspector was told most of the 23 service users needed help with their personal care and with moving and handling. This may indicate there is a need to review the staffing overall and how they are deployed. Staff told the inspector they had access to a range of training. This included medication administration for the trained staff. The home has a rolling programme on fire prevention training and moving and handling with staff going in rotation. The care home support team offer training to care home staff, which they are encouraged to take up. Staff files had copies of the training undertaken by the staff. This included fire training, safe handling and control of medication, communication difficulties and swallowing difficulties. The recommendations in the report from Lambeth’s safeguarding adults coordinator that the home should prioritise adult awareness and reporting training and manual handling training for all staff should be followed. DS0000032400.V315110.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well run and managed. Senior management roles in the organisation promote clarity, accountability and promote the best interests of users. Health and safety checks are good and promote and protect the service users from risk. EVIDENCE: All the departments of the home have competent managers who have many years of experience, both in their speciality and in managing staff. DS0000032400.V315110.R01.S.doc Version 5.2 Page 24 Staff and service users said they have confidence in the matron and individual department managers. Service users and staff told the inspector they felt that their views were listened to at service users meetings and staff meetings. Most service users felt they could speak to the staff about any concerns they had at any time. All the records the inspector viewed indicated the homes health and safety services and equipment have been checked, serviced and maintained at the appropriate intervals. Working practices and associated records ensure that the health and safety of service users is promoted. The inspector has been sent copies of the homes monitoring report (regulation 26) that are carried out each month by a member of the board. This is responded to by the registered provider, who makes comments and informs the board of actions taken to address any service deficits. DS0000032400.V315110.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x 3 X 3 X X 3 x DS0000032400.V315110.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(2)(b) Requirement The registered person must ensure that service users care plans have more information about what is important to the service user including life history, preferences and relationships. Care plans to be regularly reviewed and kept upto-date. The registered person must ensure that the assessment of the service users needs is kept under review and revised at any time when necessary. The registered person must review all service users manual handling needs and risk assessments. The registered person must make sure individual activities are developed that cater for service users needs. The registered person must ensure that staff working at the home are appropriately supervised. Timescale for action 28/02/07 2 YA6 14 (2)(a)(b) 28/02/07 3 YA7 13 (4) (c) 28/02/07 4 YA12 16 (m)& (n) 18(2) 28/02/07 5 YA36 28/02/07 DS0000032400.V315110.R01.S.doc Version 5.2 Page 27 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 YA17 YA19 Good Practice Recommendations The registered person should ensure that service users and staff are more involved in the meal type and menu planning for the home. The registered person should ensure that a more holistic approach to the care they offer service users is introduced. Care planning that looks at social and emotional needs as well as health needs could be initiated. The registered person should ensure that senior managers consider ways they can enable service users to feel comfortable in confiding personal disclosures to them. The registered person should ensure that the recommendations made in the two reports from the Lambeth Council’s Safeguarding Adult’s Coordinator and the Wandsworth Council’s link social worker are addressed. The registered person must ensure that there is a reassessment of the needs of the service users with staffing levels adjusted so as to meet those needs. The registered person must ensure that there is a review of the smoking arrangements to comply with the new smoking laws that come into effect in July 2007. 3 4 YA22 YA23 5 6 YA35 YA42 DS0000032400.V315110.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000032400.V315110.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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