Inspection on 12/07/06 for Bromley Road, 22a

This inspection was carried out on 12th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bromley Road, 22a 21/01/08

Bromley Road, 22a 16/08/07

Bromley Road, 22a 18/01/06

Bromley Road, 22a 20/05/05

Bromley Road, 22a 16/12/04

Bromley Road, 22a 27/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bromley Road, 22a Catford London SE6 2PT Lead Inspector Ornella Cavuoto Unannounced Inspection 12th July 2006 Bromley Road, 22a DS0000025612.V307472.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 Bromley Road, 22a DS0000025612.V307472.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. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bromley Road, 22a Address Catford London SE6 2PT 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) 0208 6906681 020 8314 0300 Mower Limited Mrs Donna Esther Brodie-Brown Care Home 11 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental disorder, excluding of places learning disability or dementia (0), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0) Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home is registered for 6 persons of whom 6 can have a learning disability, 1 can have a learning disability and be over 65 years 6 can have a mental disorder and 1 can have a mental disorder and be over 65 years Two of the service users maybe over the age of 65 years. Date of last inspection 18th January 2006 Brief Description of the Service: 22 Bromley Road is a care home for a maximum of eight women and men with mild to moderate learning disabilities, who might also have other support needs, such as certain mental health needs or physical impairments. The overall aim is that of providing care and to empower service users to make informed decisions, leading to fulfilling experiences. The philosophy is that of enabling ordinary living as members of the community, with equal rights and access to employment, training, recreation, housing, health and social services. 22 Bromley Road aims to achieve this by ensuring that the service is based on a thorough assessment of needs and delivered in collaboration with external agencies. Recruitment and training is targeted to enable staff to advance the rights of service users to privacy, dignity, independence, security, civil rights, and choice. The provider is an organisation named: Mpower Ltd represented by one of its directors. The day-to-day running of the home is delegated to a care manager. The premises are a large detached house, set back from a busy main road, with a large garden. Recent building work extended the house to provide eleven single bedrooms, 3 with en-suite facilities and to make part of the premises suitable for people using wheelchairs. At the time of this inspection the home had three vacancies. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager who was on long -term sick leave at the time the previous inspection was held did return for a short period before resigning from the post. The deputy manager who was acting manager previously when the registered manager was off sick has resumed this position until a new full time manager can be recruited. The process of recruitment was underway at the time the inspection was held. The acting manager was present for the duration of the inspection and was helpful in facilitating the inspection process. In addition, five service users were spoken to and two staff members. A tour of the premises was undertaken and inspection of care records was carried out. What the service does well: What has improved since the last inspection? The process of updating and reviewing service user plans has been started and files have been cleaned with out of date information being archived. Service users are being provided with more opportunities to participate in all aspects of the running of the home including being able to sit on recruitment panels. Regular service user meetings are held as well as weekly discussion groups to also enable service users to participate in the running of the home. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 6 Staff have received training around medication although this needs to be completed. The home has recently completed refurbishment of the kitchen. Improvements have been made to vetting procedures for staff being recruited to work in the home in that a full employment history is now obtained to ensure service users are being protected. 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. Bromley Road, 22a DS0000025612.V307472.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 Bromley Road, 22a DS0000025612.V307472.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Prospective and current service users still do not have all the information they need to make an informed choice about where to live. Service users needs were fully assessed prior to their admission to the home. Not all service users have an individual written contract in place and not all have been signed by service users, their relatives or where appropriate a representative. EVIDENCE: At the last three inspections (Dec 2004, May 2005 & Jan 2006) requirements have been made in respect to the service user guide that this needed to be revised to ensure it included all the information required by regulation and the standard. At this inspection a revised service user guide was seen but this was clearly written for a service that was different to that provided at Bromley Road and it still did not include all the necessary information. In addition, it was not in an accessible format so that service users could understand its contents more easily. This needs to be addressed. The statement of purpose for the service does meet with regulation and the National Minimum Standards (See Requirements). There have been no new admissions to the home for approximately the past two years. However, there was evidence within the service user files inspected Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 9 that a full needs assessment had been obtained prior to their admission ensuring the service was able to meet their individual needs. Although there is a contract that is written in a simplified format which uses pictures making it more accessible to service users, there was no evidence for two of the service users that they had been issued with a contract. The service user, their relatives or a representative where appropriate had not signed two of the contracts in place. In respect to a previous requirement that the contracts need to include more specific information regarding service user plans such as the arrangements for reviewing needs and progress and updating the plans this has not been met. At present the contracts specifies this is carried out yearly. This needs to be amended to specify that it should be carried out six monthly and yearly by the local authority. The other aspect of this requirement that a service user plan is to be attached to the contract is not to be restated (See Requirements). Bromley Road, 22a DS0000025612.V307472.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Although the home has begun the process to ensure that service user plans are updated the majority still do not clearly reflect the changing needs and personal goals of service users. Service users are supported to make decisions about their lives. Service users are now being offered more opportunities to be consulted on and to participate in aspects of life in the home. Generally risk assessments still need to be reviewed and updated. Information about service users is kept secure and handled appropriately. EVIDENCE: It was identified at the last inspection that although service user plans contained a lot of detailed information about service users in respect to their personal history and also their individual needs and support in respect to healthcare, personal and social support this had not been updated or reviewed on a six monthly basis as specified within the National Minimum Standards. Therefore, the plans did not clearly reflect service users’ changing needs or progress. Also, annual reviews carried out with service users by the local Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 11 authority had only be held for one service user although there was evidence the home had followed this up to get dates arranged for reviews to be held for all service users. At this inspection the previous requirement in respect to service user plans had been partially met although the timescale specified had not been exceeded at the time the inspection was held. Four service user files were inspected. There was evidence that reviews with the local authority had been held for three of the four service users. However, service user plans had still not been updated although as previously recommended the files had begun to be cleaned with out of date information being archived. The acting manager did provide evidence in respect to two other service users that their plans were in the process of being updated although these had not been clearly dated. This is important to ensure that six monthly review dates can be set up which should also be specified within the plans. Furthermore, it was identified that different formats for the way information was written up within service user plans was being used. One document a ‘Life Plan’ was seen within two of the service user files. This comprehensively addressed all service users’ needs and was accessible to service users being simply written and using pictures. At a previous inspection a document “ Shared Planning of Individual Needs” was seen. It is advised that a consistent approach is implemented for all service users. Daily records sheets are completed for each service user that aims to provides details on their daily routines and meals that they have eaten but these had not always been fully completed by staff or signed (See Requirements and Recommendations). In addition, at the last inspection it was identified that monthly key worker sessions held with service users to look at their individual plans and also to identify any other presenting issues /problems had not been held regularly. At this inspection for one service user there was evidence that monthly key worker sessions had been held regularly up till recently and the service user had signed these. The sessions provide useful information about the service user’s progress and changing needs and it is advised that they should be carried out regularly for all service users (See Recommendations). There was evidence that service users are supported to make decisions about their lives and are given information to assist them through the key work sessions that had been held, through the daily records and also through the weekly discussion groups that have been introduced of which records maintained were seen. These looked at different topics providing service users with information on living independently, healthy eating, exercise, food hygiene as well as talking about other topical subjects such as football and the World Cup. Other areas discussed included service users making decisions on holidays, day trips, the shopping list and use of the garden. There was evidence that service users are involved in the choosing of these topics. A previous requirement that service users are provided with opportunities to participate in all aspects of life within the home has been met. As mentioned service users are now provided an opportunity to discuss some areas about the Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 12 running of the home in their weekly discussion groups. Service user meetings are also held monthly. Dates of these are provided in advance which were seen on the service users’ notice board in the dining room. Copies of minutes demonstrated these are well attended by service users. A service user meeting was held the day the inspection was held and included obtaining feedback from service users about a new more user-friendly complaints policy being developed. Also, it was reported by the acting manager that one of the service users is to sit on the recruitment panel for the forthcoming interviews for a new manager to be appointed. Subject to a previous requirement that risk assessments need to be reviewed and updated on a regular basis had not been met although the timescale specified had not been exceeded. Only one service user had risk assessments in place that had been reviewed and updated. Also, where service users had recently been away on holidays no risk assessments had been completed to identify any potential risks/hazards and measures /action to address these (See Requirements). In respect to confidentiality, the previous requirement that the service ‘s policy be revised to address more clearly when confidentiality may be breached and was in line with the Data Protection Act 1998 has been met. Service users files are kept secure and information regarding service users being able to have access to their personal records was seen to be included in the contracts issued by the home. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users are supported to continue their education/training and/or partake in valued and fulfilling activities. Service users are supported to participate actively in the local community. Service users are enabled to pursue their own interests and hobbies and to go on an annual holiday of their choice. Staff support service users to maintain family links and friendships inside and outside the home. Generally the daily routines and the house rules promote independence and individual choice but staff need to be reminded that they should only enter service user rooms with their permission. Generally the meals provided to service users are nutritious but they could be more varied. EVIDENCE: It was evident from service user files and also in speaking to service users that they are supported to continue their education and training, for example one Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 14 service user has attended adult education classes in Maths, English and computers whilst another service user has attended Bromley College where they were doing several courses including creative skills and home management. Both are due to re-commence their courses in September. In addition, all the service users attend a number of local day centres where they are supported to undertake a range of different activities such as horse riding. Service users are very much encouraged to become part of and participate in the local community by making use of the local facilities such as shops, leisure centres, pubs and restaurants, attending church and for one service who is Muslim they attend the local mosque. Also, some of the service users had recently attended Lewisham’s People’s day, a day of free festivities held locally. There was evidence within the daily records, service user files and also in talking to service users that service users are supported to pursue their leisure interests and hobbies. One service user attends yoga and goes rambling whilst another service user has attended dance and music classes. Furthermore, all service users are supported to go on an annual holiday that they choose and plan for. At the time the inspection was held three service users had just returned from a break at Butlins in Bognor Regis. Other service users had holidays planned. All service users are supported to maintain family links and develop friendships inside and outside the home. One service user has been in a long- term relationship, which has been very sensitively supported by the staff team at Bromley Road. There was also evidence that family members of service users are very much involved and are able to visit them at the home regularly and also a number of the service users spend weekends at home with their family. Generally routines and house rules do promote independence, individual choice and freedom of movement with service users being observed as being able to choose to spend time in their rooms alone or in the company of others. It was also evident that service users get up at different times depending on their routine for the day as service users were observed making their own breakfast at different times. Service users spoken to confirmed this and that they are able to go to bed when they want. Service users are able to have a key to their rooms although service users spoken to chose not to have one. However, some of the service users spoken to stated staff do not always knock before entering their rooms or wait for permission to be given to enter. This needs to be addressed to ensure service users’ privacy is maintained (See Requirements). As previously mentioned service users are consulted about the food that is bought and are involved in helping with the weekly shop. On the day of the inspection suppertime was observed. Service users appeared to enjoy the food and those spoken to apart from one expressed they were satisfied with the meals provided. In addition, there is a fridge where service users can help Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 15 themselves to food/snacks outside of meal times. However, for one service user who has specific cultural needs it was noted that they had been provided with the same meal three times in one week. Although it was recognised that this meets the preference of the service user it is advised that the staff look into how to prepare other meals that meets their cultural needs so they can be provided with more variety. Also, it is advised that the menu for the other service users is also reviewed so it is more varied as it mainly consisted of meat such as pork chops, burgers or fish with boiled or mashed potatoes (See Recommendations). Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users are flexibly supported with personal care. Service users’ physical and emotional health needs are met. Service users retain and control their own medication where appropriate and generally are protected by the home’s policies and procedures for dealing with medicines although staff must ensure that they record that leave medication is checked back in on the return of a service user to the home. EVIDENCE: The home operates a key worker system to ensure there is consistency of support provided to service users. It was evident in talking to service users that they are provided with personal support in the way they prefer and that they are encouraged to do as much for themselves as possible. There was evidence within key worker sessions and also service users’ files that their emotional and physical needs are met and that there is close liaison with a range of different health professionals such as psychologists, mental health teams, neurologists, occupational therapists, speech and language therapists (SALT) physiotherapists, G.P’s, nurses, dentists and opticians. One service user has been supported in collaboration with SALT to purchase Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 17 sensory equipment for their room and guidelines for staff on how to use the equipment effectively with the service user have been drawn up. In respect to medication, a sample of Medication Administration Record (MAR) sheets were checked and found to be accurate. One service user selfmedicates and there was evidence that regular spot checks have been carried out to ensure this is being taken as required. A previous requirement that the home must revise the medication policy to include a section for medication that is taken on social leave has been met. This now includes the process for making certain that service users are issued with medication whilst away from the home and how medication is checked out and back into stock on their return. The recommendation stated at the last inspection that relatives should be reminded to return the photocopies of the MAR sheets used to record administration of leave medication has been met. Yet, the recommendation that leave medication should be checked and signed by two staff members when issued as well as when returned has not been undertaken and it was noted that for one service user that there was no record that their leave medication had been checked back in (See Requirements). Also, a previous requirement in respect to staff having training on medication has been partially met although the timescale had not been exceeded at the time the inspection was held. There was evidence that all staff have completed module one of basic administration training. The training, which is provided by Lewisham Partnership consists of two modules (See Requirements). In addition, the requirement in respect to staff ensuring that the fridge and room temperature where medication is stored are both monitored and recorded has been met. However, it was noted that the temperature of the room had exceeded the recommended 25c rising up to 30c. It was reported that a portable air cooler had been placed in the room to keep the temperature down but this had been removed to a service user’s room. It was advised that another air cooler be purchased and kept in the medication room in order to help maintain the required temperature (See Recommendations). Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Service users generally did not have any complaints about the home but were aware of whom to speak to if they did have issues they were unhappy about. Staff are still to receive training on adult protection. EVIDENCE: The home has a robust complaints policy and procedure and at the time the inspection was held a new complaints policy in an accessible format using pictures was in the process of being developed. It was reported that a copy of this was to be placed in every service user’s room. It was noted that as part of the key worker sessions service users are asked if they have any complaints. Service users spoken to generally did not have any complaints about the home and stated they would talk to a member of staff or the manager if they had issues they were unhappy about living in the home. There have been no complaints recorded since the last inspection. However, the home does not have a complaints log in place in which all complaints formal and informal are documented, details of any investigation held and the outcome of this is recorded. This needs to be put in place (See Requirements). The home has a robust policy and procedures on adult protection and whistle blowing. The home has not had any adult protection investigations held in relation to the home since the last inspection. Subject to a previous requirement that all staff must attend adult protection training this has been partially met. The timescale for this requirement had not been exceeded at the time the inspection was held. Evidence was seen that staff are due to attend a training day provided by Lewisham Partnership on Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 19 27th September (See Requirements). In addition the requirement that the home’s financial policy needed to be reviewed to ensure that it included that staff should not accept gifts or be involved in the drawing up of service user wills or benefit from bequests of wills has been met. Service user finances were not inspected at this inspection and will be looked at in more detail at the next inspection. Bromley Road, 22a DS0000025612.V307472.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27,28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Overall the home is maintained to a high standard. Service user bedrooms meet their needs although not all the rooms were personalised. There are sufficient toilets and bathrooms but these were not all in working order. Shared spaces complement and supplement service users’ individual rooms. Generally, the home is hygienic and clean. EVIDENCE: The home is a large spacious property. It is suitable for its stated purpose, is accessible safe and is generally very well maintained and meets service users’ individual and collective needs in a comfortable and homely way. It is also well decorated, bright and airy. At the last inspection some repairs that needed to be carried out were identified. These included a shower on the first floor needing to be repaired due to a leak, the area by a hand basin in one of the service user’s room needing to be re- painted and the flooring replaced after a leak had occurred. Finally, the basement had a problem with damp. At this inspection, it was identified that all these repairs had been carried out. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 21 However, another problem had arisen in the basement in that it had become flooded a few days before the inspection took place after heavy rain. It was reported that the drainage system outside the basement needs attention to prevent a reoccurrence and estimates were in the process of being obtained. This will be looked at the next inspection. All service users’ bedrooms were inspected and these all included the required furniture. All the rooms were personalised with personal effects. It was noted in one of service user’s bedroom that the blinds were broken potentially affecting their privacy and so were in need of being replaced (See Requirements). The home has sufficient toilets and bathrooms to meet the needs of the service users. However, it was identified that one of the toilets on the first floor where a shower is also situated did not flush and so was in need of repair (See Requirements). There is a range of comfortable, safe and fully accessible shared spaces for service users. There is a lounge at the front of the house and another lounge and dining area at the rear, which has doors that lead outside to a terrace where service users can sit outside. A ramp leads down to a large rear garden, which is attractive and very well maintained. There is another dining area by the kitchen. The kitchen was recently refurbished to a good standard and is domestic in nature. There is another small kitchen on the ground floor where service users receive skills teaching. The home was generally very clean and hygienic the day the inspection took place and free from offensive odours apart from the smell of damp in the basement area where the carpets had got wet in the flood. It was reported that these would be cleaned once they had fully dried out. The home has appropriate laundry facilities, which are sited away from the preparation of food. Bromley Road, 22a DS0000025612.V307472.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Although a competent staff team supports service users the home is still to meet the required target that 50 of the staff team need to be qualified at National Vocational Qualification (NVQ) or in the process of studying for the qualification. Service users are still not being completely protected by the home’s recruitment practices. The home still needs to ensure that an annual training plan is drawn up detailing all the training to be provided to staff to ensure that the individual and collective needs of service users are met. Staff are still not receiving regular supervision. EVIDENCE: A previous requirement that staff need to be supported to achieve the NVQ level 2 or 3 to ensure that the home can meet the required 50 target required by National Minimum Standards (NMS) remains unmet although the timescale set had not been exceeded at the time the inspection was held. At present four staff including those working as bank have achieved a NVQ Level 2 and one of these staff is presently studying for a NVQ Level 3. One staff member has completed a NVQ Level 3. It was reported that a further two staff Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 23 members should be starting their NVQ Level 2 or 3 in September which would bring the home up to the required target of 50 (See Requirements). At the last inspection it was identified that for two of the most recent staff working in the home that not all the necessary documents had been obtained with Criminal Bureau Record Checks having been used from a previous employer and POVA First Checks had not been carried out. An immediate requirement was issued shortly following the inspection that new CRB applications needed to be completed as well as POVA First checks for those staff in question. This was met although a requirement was still specified as one staff file checked only included one reference. At this inspection only one new member of staff had been recruited and although an appropriate CRB check had been obtained only one reference could be identified (See Requirements). In respect to the requirement that as part of vetting procedures the application form used by the home needed to be amended to ensure that a full employment history was requested not just for the previous ten years as was previously specified on the form, this has been met. Timescales for the previous requirement regarding the training needs of staff had not exceeded at the time the inspection was held. Yet, staff records still indicate that mandatory training has not been updated in respect to manual handling, infection control, health and safety, first aid. There was evidence that permanent staff apart from one did have food hygiene in place. There was also some evidence that staff have completed more specific training to support them in meeting the individual needs of service users in areas such as diabetes, abuse training for two staff and challenging behaviour. However, other training to ensure the individual and collective needs of service users needs to be identified and an annual training plan drawn up. There was evidence that an induction had been carried out with the new staff member (See Requirements). In respect to supervision the acting manager acknowledged this has still not been carried out regularly although the time scale for the requirement had not been exceeded at the time of the inspection (See Requirements). Bromley Road, 22a DS0000025612.V307472.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service The home has experienced a period of instability with the registered manager having left the home but the acting manager is very experienced and has worked at the home for many years to ensure the home is well run. The home still needs to implement effective quality assurance mechanisms to ensure service users views are obtained as part of self-monitoring. Not all aspects of the health, safety and welfare of service users are protected. EVIDENCE: After returning to work for a month after a period of long- term sickness the registered manager decided to cease their employment with the home. The deputy manager has taken up the position of acting manager again. They have worked for the home for many years and are very familiar with the needs of the service users. The home is in the process of recruiting a new manager. Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 25 Although the timescale for the previous requirement regarding quality assurance had not been exceeded at the time of the inspection, there have been no measures as yet taken to ensure that the views of service users, relatives and other professionals involved in the home are obtained through the use of customer satisfaction questionnaires and that these underpin selfmonitoring, reviews and development of the home. Monthly provider reports also need to be carried out monthly and copies sent to CSCI (See Requirements). In respect to health and safety the previous requirement has been partially met. The home has addressed some of the areas identified within the fire inspection report carried out earlier this year in February 2006. Defective fire doors have been repaired and there was a recent fire equipment maintenance certificate in place. However, a fire risk assessment has not been fully completed. It was also identified that fire alarm call points have not been tested weekly and fire drills have not been carried out on a regular basis. In addition, a building /environment risk assessment has still not been completed and up to date maintenance certificates for electrical wiring and for the gas system and boiler were not in place. Correspondence was received by CSCI following the inspection that specified dates for the gas system and the electrical wiring systems to be checked. Portable electrical appliances (PAT) were tested earlier this year. Copies of maintenance certificates for those areas that were not available need to be sent to CSCI once obtained. The home does report incidents to CSCI. Also, an up to date certificate for the testing of Legionella was seen and water temperatures are tested regularly (See Requirements). Bromley Road, 22a DS0000025612.V307472.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 HOICE OF HOME Standard No Score 1 1 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 27 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. 1. Standard YA1 Regulation 5 Requirement The registered provider must ensure each service user is provided with a service users guide to the home. The information to be up to date and to include all that is required by the relevant standards and regulations. (Previous timescales of 01/08/05 & 31/05/06 not met) The registered provider must ensure that contracts/statements of terms and conditions -Are issued to all service users presently living in the home and -That they are signed by the service user, a relative or a representative where appropriate. - Include the arrangements for reviewing needs and progress and updating the service users plan. - Be given to each service user or, if not appropriate to do so, be accessible to each service user at any reasonable time. DS0000025612.V307472.R01.S.doc Timescale for action 28/02/07 2. YA5 5 28/02/07 Bromley Road, 22a Version 5.2 Page 28 3. YA6 15(1) & (2) 4. YA6 12 (1) 5. YA9 13(4)(a) & (b) 6. YA16 12 (4) (a) 7. YA20 13 (2) (This is an updated requirement. Previous timescales of 01/08/05 & 31/05/06 not met) The registered provider must ensure that service user plans are regularly updated and reviewed at least six monthly. Also that individual plans are signed by service users, their relatives or a representative where appropriate to evidence their involvement in the planning of their care and goals that are identified with them. (Previous timescale of 31/07/06 not exceeded) The registered provider must ensure that staff consistently completes the daily record forms and that staff ensure they sign the forms. The registered person must ensure that all service users have a comprehensive risk assessment in place that is reviewed and updated on a regular basis. Also that when service users are undertaking activities such going on holiday risk assessments are completed to ensure their safety and well being. (This is an updated requirement. Previous timescale of 31/07/06 not exceeded) The registered provider must ensure that staff are made aware of the importance of respecting service users’ privacy and not entering their rooms without their permission. The registered provider must ensure that staff follow procedures with regards leave DS0000025612.V307472.R01.S.doc 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 Bromley Road, 22a Version 5.2 Page 29 8. YA20 13 (2) 9. YA22 22 10. YA23 13(6) 11. YA26 16 (2) (c) & (d) 12. 13. YA27 YA32 23 (2) (j) 18 (1) (c) medication consistently and ensure that medication is checked in on a service user’s return to the home and this is recorded. The registered provider must ensure all staff that administer or handle medication have formal training in medication use, control and administration. (Previous timescales of 01/08/05 partially met & 31/07/06 not exceeded) The registered provider must ensure that all complaints informal and formal are recorded in a complaints log and that details of any investigation carried out are noted and the outcome specified. The registered provider must ensure that all staff receive training in adult protection. (This is an updated requirement. Previous timescale of 31/07/06 not exceeded) The registered provider must ensure that the broken blinds are replaced in one of the service user’s bedroom to ensure their privacy is maintained. The registered provider must ensure that the toilet on the first floor is repaired. The registered person must ensure that all staff are supported to achieve the NVQ Level 2/3 qualification to ensure the home meets the required target of 50 of staff being qualified. (This is an updated requirement. Previous timescale of 31/10/06 not DS0000025612.V307472.R01.S.doc 28/02/07 28/02/07 28/02/07 30/09/06 28/02/07 30/04/07 Bromley Road, 22a Version 5.2 Page 30 exceeded). 14. YA34 19(4) & Schd 2 The registered person must ensure that all necessary documents and checks are obtained prior to allowing staff to work in the home. (Previous timescale of 31/05/06 not met) The registered person must ensure that an annual training plan is drawn up and that all staffs’ individual training needs are assessed including those for mandatory training and specific training to ensure that the individual and collective needs of service users are met. (This is an updated requirement. Previous timescale of 31/07/06 not exceeded). The registered person must ensure that all staff receive regular supervision (Previous timescale of 31/07/06 not exceeded). The registered person must ensure that the quality assurance systems for the home are developed. An effective system where service users ‘ views underpin all self-monitoring, reviews and development of the home. (Previous timescales of 1/10/05 not met & 31/10/06 not exceeded) The registered provider must ensure that all health & safety issues are addressed including: -An up to date fire risk assessment and a building /environment risk assessment is completed. - Fire alarm call points are tested weekly and fire drills DS0000025612.V307472.R01.S.doc 28/02/07 15. YA35 18 (1) 31/07/06 16. YA36 18 (2) 28/02/07 17. YA39 24 30/04/07 18. YA42 13(4)(a)& (c) 23(4) 28/02/07 Bromley Road, 22a Version 5.2 Page 31 are regularly carried out. - Up to date maintenance certificates are obtained for electrical wiring and the gas system and boiler and copies of these are sent to CSCI. 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. 3. Refer to Standard YA6 YA6 YA6 Good Practice Recommendations The registered provider should try to ensure that key work sessions with service users are held monthly and staff and the service users sign the forms. The registered person should consider removing all the out of date information on service user files and archiving this to make service user files more accessible. The registered provider should try to ensure that there is a consistent format used to record information about service users, for example that the “Life Plan” is used for all service users The registered provider should try to look at alternative meals that still meet the specific cultural needs of one of the service users living at the home to provide them with a more varied diet. The registered provider should look at reviewing the menu with service users to provide a greater variety of meals. The registered person should try to ensure that when medication is given to service users/relatives for a period of leave away from the home two staff should check and sign the medication given and also when it is returned. 4. YA17 5. 6. YA17 YA20 Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bromley Road, 22a DS0000025612.V307472.R01.S.doc Version 5.2 Page 33 - 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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