Inspection on 18/01/06 for Bromley Road, 22a

This inspection was carried out on 18th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 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 12/07/06

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 22 Bromley Road Catford London SE6 2PT Lead Inspector Ornella Cavuoto Unannounced Inspection 18th January 2006 10:00 Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bromley Road, 22a Address 22 Bromley Road Catford London SE6 2PT 0208 6906681 020 8314 0300 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) Mpower 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.V278581.R01.S.doc Version 5.1 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 20th May 2005 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 would be based on a thorough assessment of needs and delivered in collaboration with external agencies. Recruitment and training would be targeted to enable staff to advance the rights 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. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over one day on the 18th January 2005. The inspection involved speaking to 3 service users and 5 staff members. The deputy manager, who is now the acting manager having stepped in for the registered manager who is on long term sick leave, was present for the majority of the inspection and was helpful in facilitating the inspection process. He has been in post since August 2005 and prior to this was informally taking on extra responsibilities in the day-to-day running of the home. The responsible individual was also present for part of the inspection. Other inspection methods used included a tour of the premises, and inspection of records. What the service does well: What has improved since the last inspection? The home has introduced a process to ensure that medication given to service users/relatives when away from the home for a period of leave is properly checked out and back into stock on their return. Training has been arranged for all staff to be fully instructed on all aspects of handling, administering and control of medication. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 6 Internet access has been arranged for the staff. The home has addressed, in respect to its recruitment procedures, that where photocopies of original documents have been made, a note is made that the original was seen. What they could do better: The home needs to ensure that a revised and updated service user guide is put in place including all the information required by regulation and the standards. The home needs to ensure that the contract between the home and service users is revised and is issued to all service users. Service user plans need to be regularly reviewed and updated at least six monthly and key work sessions should also be held on a regular basis. Service user plans and key work sessions should be signed by the service user/relatives or representatives where appropriate to show that they have been involved in the planning of their care and agree to any goals that are identified with them. Risk assessments also need to be updated and reviewed regularly. Service user meetings need to be held more regularly to give service users an opportunity to participate more fully in the running of the home. Also, the acting manager should look into other ways that service users can be involved in participating in aspects of life within the home such as the possibility that service users sit on recruitment panels and are consulted on changes in policies and procedures. The home needs to review its confidentiality policy and also its policy regarding service users’ money and financial affairs. Training needs to be arranged for all staff around adult protection and staff also need to be supported to undertake the NVQ Level 2 in care qualification. An annual training plan needs to be drawn up with staffs’ individual training needs in respect to mandatory training and more specific training to meet the individual needs of service users being assessed. Staff need to receive supervision on a regular basis. Minor repairs within the home and maintenance work to the basement need to be addressed. When recruiting staff all necessary checks and documents need to be obtained prior to allowing staff to begin working within the home. A formal and effective quality assurance system needs to be developed to ensure that self monitoring is undertaken and the home is run in the best interests of the service user. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 7 All health and safety policy and procedures need to be adhered to by all the staff working at the home to promote the health, safety and welfare of service users. 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.V278581.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Prospective service users do not currently have the information they need to make an informed choice about where to live. Individual contracts need to be revised and issued to all service users. EVIDENCE: At the two previous inspections (Dec 2004 and May 2005) a requirement has been stated with regards to the service user guide that it did not include all the information that is required by regulation and the standard. The acting manager explained that this document has not yet been revised. Due to the registered manager being on long term sick leave they were not present at the last inspection and there has also been a period that the home did not have a manager undertaking all the necessary responsibilities for the day to day management of the home. The deputy manager has only been acting manager since August 2005. This has resulted in a delay in certain requirements being followed up, as the registered manager was the main person working on them. Therefore, the requirement with regards to the service user guide will be restated in this report with a new timescale. A copy of this should be sent to the Commission for Social Care Inspection (CSCI) once completed. In respect to a previous requirement that the contract issued by the home to service users needs to be revised to include specific information relating to service user’s plans this has not been met and is to be restated as a requirement in this report with a new timescale. Also, a previous recommendation that contracts between the home and service users are Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 10 discussed with service users, their advocates and the home’s legal consultant has not been addressed and is to be restated in this report. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Service user individual plans do not clearly reflect their changing needs and personal goals. Service users are supported with making decisions about their lives. Service users are not currently being given sufficient opportunities to be consulted on and to participate in all aspects of life in the home. Risk assessments for service users need to be comprehensive and reviewed and updated regularly. Information about service users is kept secure but the home’s confidentiality policy needs reviewing. EVIDENCE: Four service user plans were inspected. The plans are generated from a full needs assessment carried out by the local authority and they contain a lot of detailed information about service users in respect to personal history and also in respect to individual needs and support required in respect to healthcare, personal and social support. However, a lot of the information had not been updated on a regular basis and therefore the plans did not clearly reflect service users’ changing needs. For example, all the plans included a document, “Shared Planning of Individual Needs” which is holistic and uses a person- centred approach in that it looks at all aspects of service users needs Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 12 including skills teaching, identifies long and short term goals, unmet needs and ensures that the service user views or where appropriate the advocates views are obtained. Yet, two of the service user plans that were looked at, this document had not been updated since 2000 and 2003 and for another service user it had not been completed. Staff spoken to confirmed that the plans and information held on service users does not presently reflect service users needs and personal preferences and interests. Only one service user plan had evidence of a review conducted by the local authority. It was reported that annual reviews have been recently carried out with other service users but documentation as yet has not been received. There was evidence that the home has followed up the issue of the need for annual reviews to be conducted by the local authorities. However, in addition to this the home needs to ensure that service user plans are reviewed six monthly as specified within the national minimum standards and this is not presently being carried out. Subject to a requirement. There is a key work system in place. This aims to hold monthly key work sessions with service users to look at their individual plans and identify any other presenting issues/problems. However, only one service user’s file that was inspected had evidence that key work sessions were held regularly. There was evidence that the acting manager is trying to introduce systems to ensure this is addressed but this had not been implemented at the time of the inspection. Subject to a recommendation. Also, neither the key work sessions nor the Shared Planning of Individual Needs documents had been signed by service users or a relative /representative where appropriate to evidence their involvement in the care planning process. Subject to a requirement. A recommendation is also to be stated that the service user plans are made more accessible by archiving all information that is out of date. There was evidence that service users are assisted to make decisions about their lives through the key work sessions that had been held. Also, all the service users had a named advocate on their files and one service user has monthly visits by an advocate who it was reported regularly discusses with staff any issues or problems the service user may be concerned about. Although, the service users are supported by the home to manage their personal finances they are given as much control over how to spend their money as possible. Although, there was some evidence that service users do participate in the aspects of life in the home such as in the day to day running of the home helping to do the monthly shop, doing the washing up after meals. One service user also commented that they were consulted about the colours their rooms were painted and they were able to choose the colour they wanted. However, Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 13 more needs to be done by the staff to ensure that service users are able to participate more actively in other aspects of life within the home. For example, it was reported that the last service user meeting was held in October. These need to be held more regularly to enable service users to be consulted on and to be able to contribute to any issues that may arise in the running of the home. None of the present service users sit on recruitment panels nor are they consulted on changes in policy and procedures. The acting manager agreed to look into ways service users could be involved in the undertaking of these matters. Subject to a requirement and recommendation. Only one service user plan that was inspected had evidence that risk assessments had been carried out with a risk assessment being completed for when the service user had been on holiday, in the undertaking activities and in respect to skills teaching. Other plans did not include a recent or reviewed risk assessment. For example, for one service user the only risk assessment that could be identified within the service user plan was dated 2002 and had been completed by social services. Subject to a requirement. Service users information is kept secured and it was reported that service users do have right to access to their personal files. However, subject to previous recommendations the home’s confidentiality policy is still in need of being reviewed and updated to ensure that it is drawn up with reference to the Data Protection Act 1998. It should also state clearly the circumstances in which confidentiality may have to breached (i.e.) where there may risk of harm to service users or harm to others and that in all other situations where information is to be shared with partner agencies this will only be done on a need to know basis. Subject to a requirement. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 14 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): 11,12,13,14, 15,16 &17 All the above standards were assessed as met at the last inspection and therefore were not inspected on this occasion. At the last inspection the following judgement was made :Residents were supported in maintaining independence and in achieving a fulfilling lifestyle in and outside the home, so that they would have opportunity for personal development and inclusion in the community, consistent with their aspirations, cultural and spiritual needs. EVIDENCE: Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20&21 Service users retain and administer and control their own medication where appropriate but are not completely protected by the home’s policies and procedures for dealing with medicines. The home needs to ensure that all service users are consulted on their wishes about dying and death. EVIDENCE: The home’s medication system and policies and procedures were checked and found to be generally satisfactory. A sample of MARS (Medication Administration Record Sheets) was inspected and found to be accurate. One service user self- administers their medication. This is stored appropriately in a locked tin in their room and staff do random weekly checks to ensure that the service user is self - administering correctly. In relation, to medications that require refrigeration although these were stored correctly and temperature of the room where all medication is kept was being checked this was not being recorded nor was the temperature of the fridge being checked or recorded to ensure the temperature is maintained between 2–8 C. Subject to a requirement. A previous requirement that the medication policy should include a statement that medication must be retained for 7 days in the event of the death of a Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 16 service user has been met. Yet, the requirement that specified that the policy include a section for leave medication in that there is a documented procedure for making sure that users are to be issued with medication to be used while away from home has not yet be done and is to be restated in this report. This requirement also specified that the home must ensure that a process to ensure medication is checked out and back into the medication stock on their return is put into place and this has been met. However, it was noted that although two staff members always check and sign the medication returned, two staff members do not always check and sign for medication given out to relatives / service users for a period of leave. A recommendation is to be stated that two staff members should always sign and check for medication that is given out to service users/relatives when going on leave as well as when it is returned. In addition, it was reported that despite issuing a photocopy of the MARS (Medication Administration Record Sheet) for relatives/representatives to record the administration of medication this is not always returned. Therefore, a recommendation is to be stated that staff emphasise the importance of returning this to the home and explain that it is a legal record that needs to be kept by the home. A further requirement in respect to medication that all staff that administer and handle medication should have formal training has been partially met. Evidence was seen that the acting manager has arranged for all staff to receive medication training that is accredited and is to be provided by Lewisham Training Partnership. It consists of two modules and is due to commence on 27th January. In respect to the home consulting service users about their wishes around death and dying although there was some evidence in service users files that this had been discussed with relatives there was no evidence that those service users whose individual plans were inspected had been consulted and a clear plan in respect to their wishes had been put in place. It was reported by the acting manager that this has been completed for one service user who is now elderly. However, a recommendation is to be stated that this is addressed with all service users and that it is discussed in service users’ reviews so that relatives/representatives where appropriate are also able to contribute their views. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Not all staff have received training in adult protection/abuse to ensure service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has robust policy and procedures on adult protection and whistle blowing. The home also has a copy of the procedures as used by one of the local authorities. A previous recommendation that the registered provider arranges Internet access and electronic mail facilities to access extracts of placing authority adult protection procedures has been met. Staff spoken to did have some working knowledge around adult protection, the different types of abuse and what action to take if abuse was suspected. However, only two of the five staff members had received training in this area. Subject to a requirement. In terms of the service users’ money as previously mentioned the home supports all the service users with managing their personal allowances. This is kept secure in a locked cabinet by the manager’s office. Larger sums of money are kept in the home’s safe and are used to top up their allowances as required. All money stored for services users is individualised with records detailing transaction and receipts are kept. Where possible, service users sign the receipts themselves. A sample of records was checked and found to be correct. However, a recommendation is to be stated that two staff should sign when a transaction is carried out and money is issued to service users or a deposit is made to top up their personal allowance. The acting manager reported that a self -audit check is carried out every other day and the responsible individual may carry out a random check every month-two months. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 18 The home’s policy and procedure regarding service users’ money and financial affairs was checked. This needs to be reviewed and more information included about protecting service users finances in relation to staff not accepting gifts and that there should be no staff involvement in the making or benefiting of service users’ wills. Subject to a requirement. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 28 Overall the home is very well maintained but there are some repairs and maintenance work that needs to be carried out. The home needs to ensure that a risk assessment is carried out to ensure the safety of service users whilst refurbishment to the kitchen is being carried out. EVIDENCE: The home is a large property that has recently had an extension completed which has been done to a high standard and has made part of the home wheelchair accessible. Overall, it is bright, airy and spacious providing a safe comfortable and homely environment to service users. However, in a tour of the premises it was noted that a few minor repair/maintenance issues require attention. For example, in one service user’s room a leak had occurred by the hand basin that had made the area damp causing the room to smell slightly musty. Also, a shower on the first floor was not in use due to a leak. The acting manager reported that these were to be addressed in due course. In addition to this, the basement has a problem with damp that has meant that access can no longer be given to service users who used the area previously to do activities. The area is still used by staff to have meetings such as handover and there is also a staff office situated in the basement. However, the area is very cold and poses a health and safety risk. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 20 It was reported that there are issues to do with liability in that the contractors who carried out the work on the extension may be responsible for the damp problem occurring and this has delayed maintenance work be carried out. However, a requirement is to be stated that the registered provider looks into addressing the problem as soon as feasibly possible. In respect to communal areas the home has a two spacious lounge areas and a dining area. One of the lounge areas forms part of the new extension that has double doors that lead onto a small patio/terrace area. There is also a ramp to give wheelchair access to the garden, which is large and well maintained. It was reported at the inspection that the home was due to start work on refurbishing the kitchen in the next couple of weeks and should be completed by the end of February 2006. At the last inspection a requirement was stated that the home should do an action plan detailing exactly when this work would be undertaken and arrangements made for the safety of the service users whilst the work is carried out. It was reported this had been sent to CSCI but had not been seen by the present inspector. Temporary arrangements to use the kitchen that was built as part of the extension and is used for skills teaching whilst the work is being carried out were outlined and it was explained that disruption to service users should be minimal. As a further precaution to maintain service users’ safety it was advised that a risk assessment should be carried out on the kitchen area where the work is to be carried out and a copy of this submitted to CSCI. This has been completed since the inspection and received by CSCI. Therefore, this is not to be stated as a requirement in this report. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 34 35 & 36. Although service users are supported by a competent staff team not all the staff have obtained the required National Vocational Qualification (NVQ) Level 2 in care. Service users are supported by an effective staff team. Staff are not presently fully supported and protected by the home’s recruitment practices. The home needs to provide more evidence that service users individual and joint needs are met appropriately by staff. Staff are not presently receiving regular supervision. EVIDENCE: Generally, service users are supported by a competent staff team. Handover was observed and staff demonstrated good knowledge and awareness of service users needs 2. It was reported and evidence was seen that two staff members have alternative qualifications that are at a higher level than the NVQ Level 2 and staff are supported to complete the Learning Disability Foundation Award the (LDAF) which it was reported qualifies as an equivalent to part of the NVQ Level 2. One worker has completed NVQ Level 2 and is to go onto to complete the NVQ Level 3 whilst another staff member is to complete the NVQ level 2 in March. However, not all staff have achieved the NVQ Level 2 in care and the home has not achieved the required 50 of staff obtaining this qualification by end of 2005. Therefore, a requirement is to be stated that all staff must be supported to achieve this qualification. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 22 In terms of the numbers of staff working within the home the rota was checked and was accurate in reflecting those that were working within the home. There were sufficient numbers of staff to adequately support service users and the acting manager who is surplus to staff on the rota reported that staffing levels are regularly reviewed and the rota will be arranged according to service users needs and to support activities that may be arranged for service users. The home uses bank staff for day shifts and the waking night shifts to ensure that service users have continuity and staff are familiar with service users needs. A sample of staff files were checked to ensure that the home had obtained all the necessary documents and checks prior to allowing staff to begin work in the home. It was identified that for two of the most recent staff that had been recruited Criminal Record Bureau checks from a previous employer had been accepted. This is a breach of the Care Standards Act 2000. After July 2004 portable CRB checks were no longer deemed acceptable. An immediate requirement was issued shortly following the inspection that new CRB applications should be completed as well as a POVA First check for the staff in question. Notification from the home has been received to inform CSCI that this has been completed meeting this requirement. However, as one staff file checked also only included one reference a requirement is still to be stated that the home must ensure all documents and checks are obtained before allowing staff to begin work. A previous requirement that as part of vetting procedures for recruiting staff a complete history of work experience and education needs to be obtained and any gaps explored has not been met. The application form used by the organisation still only asks for the previous 10 years of employment and this has not been amended. Therefore, this is to be restated as a requirement in this report. However, a previous recommendation that when photocopies of original documents are done in relation to recruitment a note is made that the original was seen this has been addressed. There was limited evidence that staff training needs have been assessed and training in respect to mandatory training or specific training to ensure the specific needs of service users are met. There was also limited evidence that staff have been in receipt of an induction. The acting manager did state that he was in the process of drawing up an annual training plan. Subject to a requirement. Evidence indicated that staff have not received regular supervision. The acting manager reported that he has begun to ensure that regular supervision sessions are arranged and to introduce supervision contracts. Subject to a requirement. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42. The acting manager is very experienced and ensuring service users benefit from a well-run home. The home does not have adequate quality assurance systems in place to ensure self –monitoring is taking place. Not all aspects of the health, safety and welfare of service users are promoted and protected. EVIDENCE: The acting manager is very experienced and has worked for the home for many years both as a support worker and as the deputy manager. It is not known as yet when the registered manager who has been on long term sick leave will be returning to work so this arrangement will continue for the fore see able future. A previous requirement that an effective formal quality assurance system is developed where service users’ views are obtained through the use of user satisfaction questionnaires and that these underpin self monitoring, reviews and development of the home has not been met and will be restated as a Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 24 requirement in this report. In addition it is to be stated that monthly provider (Regulation 26) reports are sent to CSCI, as there was no evidence of these being completed. The home has health and safety policies and procedures in place and although some areas are being addressed such as safe use and storage of hazardous substances and water temperatures being tested regularly, a number of areas were evidenced as not being adhered to. For example, maintenance certificates for the central heating system/gas boiler and electrical equipment were not available on the day of the inspection although evidence that the gas boiler has been serviced was sent onto CSCI following the inspection. The home had a recent fire inspection that identified a number of areas that the home needs to address by 20/02/06. These include ensuring a fire safety risk assessment is completed, fire-testing equipment is regularly tested and defective fire doors are repaired. In addition to this, an environment/building risk assessment has not been completed. Subject to a requirement. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 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 2 2 2 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 2 3 X 2 X X 2 X Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 26 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Timescale for action 2. YA5 5 3. YA6 15(1) & (2) The registered person must ensure each service user is 31/05/06 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 timescale of 01/08/05 not met) The registered person must 31/05/06 ensure that contracts/statements of terms and conditions between the home and each service user need to: - Include a copy of the service users plan. - 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. (Previous timescale of 01/08/05 not met) The registered person must 31/07/06 ensure that service user plans are regularly updated and DS0000025612.V278581.R01.S.doc Version 5.1 Page 27 Bromley Road, 22a 4. YA8 24 (3) 5. YA9 13(4)(a) & (b) 6. YA10 12(4)(a) 7. YA20 13 (2) 8. YA20 13 (2) 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. The registered person must ensure that service users are provided with opportunities to actively participate in all aspects of life in the home specifically that service user meetings are held regularly. 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. The registered person must ensure that the home’s confidentiality policy is reviewed and is -drawn up in accordance with the Data Protection Act 1998. - it should also clearly state the circumstances in which confidentiality may have to be breached. The registered person must ensure the medication policy includes: i) A section for leave medication. This must ensure that: - there is a documented process for making certain that users are issued with medication, to be used while away from the home - there is a process to ensure medication is checked out and back into stock on their return. (Previous timescale of 01/08/05 partially met) All staff, who administer or handle medication, to have formal training in medication DS0000025612.V278581.R01.S.doc 31/07/06 31/07/06 31/07/06 31/05/06 31/07/06 Bromley Road, 22a Version 5.1 Page 28 9. YA20 13 (2) 10. YA23 13 (6) 11. YA24 23 (b) & (c) 12. YA32 18 (1) (c) 13. YA34 19(4) & Schd 2 use, control and administration. (Previous timescale of 01/08/05 partially met) The registered manager must ensure that the temperature of the fridge in which medication is stored is monitored and recorded and stays between 2-8 c. Also that the room temperature where medication is stored is recorded and stays at 25 c. The registered person must ensure that all staff have received training inn adult protection. Also, to ensure service users are fully protected form financial abuse the home’s financial policy needs to be reviewed to ensure that it includes that: - staff should not accept gifts or be involved in the drawing up or benefiting of service users wills. The registered person must ensure that all repairs and maintenance work is carried out, specifically that: - the damp area in the service user’s bedroom is addressed -the leak in the shower on the first floor is repaired. -maintenance work is carried out on the basement to address the damp problem. The registered person must ensure that all staff are supported to achieve the NVQ Level 2 qualification. The registered person must ensure that as part of vetting procedures for assessing the suitability of staff all previous work and education history is obtained and gaps explored. The application form needs to be amended to address this. (Previous timescale of 1/08/05 not met). DS0000025612.V278581.R01.S.doc 31/05/06 31/07/06 31/08/06 31/10/06 31/05/06 Bromley Road, 22a Version 5.1 Page 29 14. YA34 19(4) & Schd 2 15. YA35 18 (1) 16. 17. YA36 YA39 18 (2) 24 The registered person must ensure that all necessary documents and checks are obtained prior to allowing staff to work in the home. The registered person must ensure that an annual training plan is drawn up and that all staffs’ individual training needs are assessed. The registered person must ensure that all staff receive regular supervision. 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 timescale of 1/10/05 not met) The registered person must ensure that all health & safety issues are addressed including: -the recent specifications outlined in the fire inspection are met. - that a building /environment risk assessment is completed. - all maintenance certificates are in place. 31/05/06 31/07/06 31/07/06 31/10/06 18. YA42 13(4)(a)& (c)23(4) 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations The registered person should consider the contracts between the home and service users being discussed with the service user, their advocates and the homes legal DS0000025612.V278581.R01.S.doc Version 5.1 Page 30 Bromley Road, 22a 2. 3. 4. YA6 YA6 YA8 5. YA20 6. YA20 7. YA21 8. YA23 consultant. This would be to ensure that contracts include all the necessary information, that they legally protect service users rights, that they clearly state the respective rights and responsibilities of the user and the provider. The registered person should try to ensure that key work sessions with service users are held monthly. 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 person should consider involving the service users in sitting on the recruitment panel for the home and also consulting them on changes in relation to policies and procedures. For example, in updating the home’s Statement of Purpose. The registered person should try to ensure that when photocopies of MARS sheets are given to relatives/service users to use when a service user is away from the home that this is always returned back to the home. It should be explained to relatives that this is a legal record. 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. The registered person should try to put in place clear plans for all service users their wishes in respect to death and dying and ensuring service users and relatives/representatives are sensitively consulted on this. The registered person should try to ensure that when transactions are carried out on service user finances two staff signatures should be obtained. Bromley Road, 22a DS0000025612.V278581.R01.S.doc Version 5.1 Page 31 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.V278581.R01.S.doc Version 5.1 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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