Inspection on 16/05/06 for Bromley Road (44)

This inspection was carried out on 16th May 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bromley Road (44) 01/04/09

Bromley Road (44) 07/04/08

Bromley Road (44) 23/04/07

Bromley Road (44) 04/10/05

Bromley Road (44) 10/05/05

Bromley Road (44) 13/01/05

Bromley Road (44) 26/07/04

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

CARE HOME ADULTS 18-65 Bromley Road (44) 44 Bromley Road Beckenham Kent BR3 5JD Lead Inspector Wendy Owen Key Unannounced Inspection 16th May 2006 15:00 Bromley Road (44) DS0000038244.V290564.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 (44) DS0000038244.V290564.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 (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bromley Road (44) Address 44 Bromley Road Beckenham Kent BR3 5JD 0208 658 7829 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) valerie.beazleyromley.gov.uk London Borough Bromley Mrs Maxine Shaw Care Home 7 Category(ies) of Learning disability (6), Physical disability (3), registration, with number Sensory impairment (6) of places Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered as a (CRH) Care Home, with a service category of (PC) Care Home only, with a Service User Category of (LD) Learning Disability 6, (PD) Physical Disability 3 and (SI) Sensory Impairment 6 of both sexes for all categories. Date of last inspection 4th October 2005 Brief Description of the Service: 44, Bromley Rd is a purpose built care home owned by the London Borough of Bromley. The Registered Provider is the London Borough of Bromley Adult Division. The home is managed and staffed by employees of the London Borough of Bromley. It is located within a residential area of Beckenham and is close to transport links and Beckenham town centre, with its range of shops and leisure facilities. The home has recently been registered to provide respite care to a total of 7 adults. The home provides care to adults within the following groups; 6 with a learning disability; 6 with a sensory impairment and 3 with physical disabilities. One of the beds remains open for any emergency situation within the borough, whilst there is one placement for residents in receipt of intermediate care for up to a period of six months. Communal and private accommodation is set on three floors accessed by stairs. A lounge/dining room and kitchen are located on the ground floor as are three of the bedrooms and one bathroom and one shower room. The home has a registered Manager and support staff working during parts of the day and all night. No ancillary staff are employed. The fees for respite care are £8.52 per night. The Service Level Agreement details that accommodation, staffing to the agreed level and food is included in the fees charged. Residents are expected to pay for all toiletries; activities, in some cases transport not included in service level agreement and magazines. Full information is available on referral and the inspection report can be provided by the home on request. Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days lasting a total of six hours. During the inspection the inspector received written feedback from two relatives and four residents and verbal feedback from one Care Manager. The inspection process also included a tour of the home, discussions with one resident, three staff and the Manager and viewing records in the home. What the service does well: What has improved since the last inspection? Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 6 Since the last inspection last inspection medication practices have improved. The home is also now undertaking the temperature checks required in relation to the fridge and freezer checks. The home now has a Manager in post who has been successful in their application for registration with the Commission. 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 (44) DS0000038244.V290564.R01.S.doc Version 5.1 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 (44) DS0000038244.V290564.R01.S.doc Version 5.1 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): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a sound referral and admissions process for admitting prospective residents in the home which includes assessments of needs and visits to the home ensuring staff to have the information which enables them to meet the individual’s needs. EVIDENCE: The home has produced a Statement of Purpose and Service Users Guide which gives information on the home and what to expect in order that individuals can make a decision on whether they wish to live there. These are both being updated at present to ensure they reflect the provision of care offered. All residents are referred to the home through Social Services for planned respite care. The Manager is part of a panel of Social Services staff who make decisions on whether the referred resident meets the criteria for respite care. Discussions with the Manager and viewing of the home’s records showed that the home has a sound admissions procedure with assessments by the Care Manager and the home taking place before any decision is made to admit a new resident. Three files were viewed and all contained comprehensive information relating to the individual’s need from Social Services and the home’s assessment. The admissions procedures also encourages the prospective resident and their family member to visit the home on a few occasions to ensure they can make a decision on whether the home is right for them. The feedback from residents, relatives and Care Manager provides Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 9 positive comments regarding the care provided. One resident said; “ I can choose what I want to do” and “Staff are kind and good carers.” There is evidence of the residents or their family members being provided with information about the home during the course of these visits. Residents or their family members are provided with Social Services Service Level Agreements detailing the agreement between Social Services and the resident. The home as the registered provider also provides contracts which detail the terms and conditions of their stay at 44 Bromley Rd. The contract does not provide information relating to any notice periods, except if the resident cancels the stay at short notice. There is no statement regarding termination of the stay for other reasons eg challenging behaviour of resident The Provider is aware of this and is currently reviewing it to ensure they provide the residents with such information. It is also relevant to note the relationship between the Purchaser and Provider and the control the Manager has over who is to be admitted in the home in the event of any disagreement. Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home has developed care plans and risk assessments relating to the individual residents’ needs, these should be more detailed, specific and reviewed regularly to ensure staff have the full information and guidance to ensure their health, safety and welfare. EVIDENCE: Care plans are developed from the initial assessments and three such records were viewed on the day. They generally contained a good deal of information. However, there also a number of gaps and a lack of specific guidelines to ensure the required care is provided. This included residents’ needs in respect of the support or issues relating to personal care, communication and eating and drinking although one record contained some good information in respect of communication. Specific information in relation to culture, diet and health was missing from one record. Although, it was evident from other records viewed that such information is available but was not included in the care plan or risk assessments. For one resident who suffers with epilepsy the guidelines must also reflect the current healthcare risk assessment guidance provided by the PCT. Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 11 There was also a lack of information required relating to advocacy and the management of resident’s monies. The home is currently developing a Pathway to Independence plan which focussing on promoting independence and the support required. Risk assessments were in place for a number of areas however, these must reflect current risks, including challenging behaviour issues. A previous report identified the need to develop individual risk assessments, where there is a potential for residents to go missing, such as residents who leave the home unsupervised or the likelihood of absconding. These have yet to be developed. Need evidence of reviewing of care plans. (See requirements 1 & 2) Despite the lack of information and guidance in some areas staff spoken to had a good knowledge and understanding of the residents currently in the home. Feedback from residents reflected an environment where residents are able to make decisions for themselves according to their abilities and competencies. Residents’ meetings, inspector’s observations and discussions with residents during the course of the day gave evidence that residents benefit from involvement in decision making. The inspector recommends that the residents’ meeting minutes include any actions to be taken as a result of the issues raised and who is responsible for taking the action. (See recommendation 1) Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully supported to engage in leisure; educational and community activities which ensures their continued well being and social inclusion. The home generally provides residents with a healthy diet with meals and their preparation seen as a social occasion in relaxing setting. EVIDENCE: Residents and relatives’ feedback confirm activities are taking place but are very much dependent on the individual’s wishes. The Service Level Agreement details that the residents continue to attend their usual day centre during the stay and with transport provided. The home’s Statement of Purpose also states that they provide day care activities. However, this must be clarified with more details on how they would address this. In general residents choose what leisure activities they would prefer with decisions made during residents’ meeting. Activities include Gateway Club one evening per week; lunches out at the weekend; visits to the park etc. One resident said; “ I have a choice in what I do when I stay at Bromley Rd.” and “I can travel to where I want as long as I inform staff on duty the time I Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 13 will be home.” This is generally reflective of the written feedback from residents One relative wrote that their family member goes shopping and visits restaurants and during the course of the inspection one resident was arranging a trip to the cinema with a member of staff. These activities must be paid for by the resident and information relating to the amounts of personal allowances to be brought for the duration of the stay is included in the information. The inspector also observed a member of staff playing a board game with a resident whilst others were watching TV or listening to music in their room before the evening meal. Some residents were involved in preparing the meal. Menu choices are decided on the previous week in order that the shopping can be bought. The residents’ meeting is used for these discussions. However, there must be a record made of the decisions made as not all residents feel they are given enough variety or choice. The meals should also take into consideration the individual’s race and culture and health issues which should also be reflected in their individual plan. Records should be maintained for each individual to enable a decision to be made on the whether the nutritional needs of the residents are being met. (See recommendation 2) The meal being prepared for that evening smelled delicious and was being made from required ingredients with some residents being involved according to their abilities. This was a very relaxed and enjoyable time of the day. Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home tries to ensure the healthcare of the residents in the home, improvements must be made to ensure the full information is available to staff enabling the individual healthcare needs to be met. EVIDENCE: Staff spoken to had a good understanding of the needs of the residents. There was also some comprehensive guidance in place for the personal support required in relation to the mobility of one of the residents. This included an OT assessment and a risk assessment carried out by the Service Manager. The records also contained information on the personal care support but as commented earlier these were not as comprehensive and as detailed as they could be. An example of this was where a resident had specific personal care guidelines highlighted in a PCT epilepsy risk assessment this was not detailed in the personal care support required. (See requirement 1) Residents’ files viewed highlighted the health care needs of the residents, covering areas such as diabetes and epilepsy. These were not as detailed as they should be. For instance, there was no risk assessment relating to the resident with diabetes and little information regarding how this is to be managed, including the undertaken of blood checks. Whilst staff are currently doing these checks there is no evidence of who provided the training and what Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 15 they should be looking out for and any action to be taken in circumstances, such as high or low blood sugars. There was also little information relating to the diet required. (See requirement 3) The records contained evidence of health checks being carried out and this was confirmed through discussions with a resident and observations made during the visits to the home. The files viewed showed evidence of blood checks in relation to diabetes; dental visits for one resident appropriate action being taken in relation to seizures. The home has the specialist support from the Community Learning Disability Team including behavioural management, CPN and epilepsy advice, speech and language and psychiatric support. All residents are known to the team and therefore provide ongoing support. Due to the nature of the respite service in general residents access their home GP. However, in emergencies the local GP is contacted and temporary registration arranged. Other NHS health care is accessed by family on return home. An audit of the home’s medication practices found them to be of a good standard. There were some areas which required improvement, including the keeping of medication in rooms, in particular creams. These must be kept locked or risk assessments produced detailing what is appropriate. The Manager must also ensure that, where there is medication stating “as directed” full instructions for administration are given and where they are used as an “as required” medication, this is discussed with the GP and the label detailing the administration changed to reflect this. The last report detailed the need to develop policies and procedures for self-administration of medicines and homely remedies. Staff receive documented training in relation to these and staff audited ont heir adherence. Some auditing now in place. (See requirement 4) Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home listens to complaints an concerns raised by residents or their families who feel that they are responded to appropriately. The adult protection procedure provides information on how to protect vulnerable individuals from abuse, although the systems in place could be improved to ensure staff and management are clear regarding how they should be managed and have the full information on how to manage these issues. EVIDENCE: The home has a complaints procedure which is also included in a simple format in the information provided to prospective residents and their families. The pre-inspection questionnaire received from the home showed that there have been two complaints since the last inspection relating, not to quality of care issues, but how the service was being currently operated. Records of the complaints were in place as were letters responding to the complaint. The Manager aware of the importance of how complaints are responded to and has taken on board comments made by the inspector. It is good practice to record the investigation route, outcome of such investigations; the actions taken and whether the complaint has been resolved satisfactorily. (See recommendation 3) Of the four residents who provided written feedback, three said they know how to raise any concerns or complaints and one said they did not. All said they knew who to speak to if they were not happy in the home. The home also has procedures in place relating to the protection of vulnerable adults. The staff training records provided evidence that some staff had attended training in relation to the protection of vulnerable adults. This Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 17 training should be provided to all staff. (See recommendation 4) The home has recently been involved in an incident requiring input from the Community Learning Disability Team Adult protection Officer. The adult protection related to two residents and not staff members. This has now been resolved but raises concerns regarding the lack of training provided at this time regarding such issues. The staff were supported during this time by the IBIS team and some training provided with arrangements in place for all staff to receive the required training. Some staff have also undertaken personal safety awareness and practical strategies for working with people with autism. The home must also ensure that staff are provided with information relation to the records required where restraint may be used. However, the Manager and Services Manager’s decision-making powers regarding the residents continued stay is somewhat limited due to Purchaser and Provider relationship. (See requirement 5) Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 18 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): 24,25,27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and comfortable home which provides them with relaxed and pleasant surroundings in which to live. EVIDENCE: The environment is well maintained and of a satisfactory standard of décor. The communal areas are comfortable and homely and residents’ bedrooms are also of a satisfactory standard. The home has some equipment such as hoists; parker baths, hand – rails and grab rails, giving those residents who require it, the assistance needed. There are bedrooms and bathrooms/WCs the ground floor for those who are not able to manage the stairs. Residents’ bedrooms are adequately decorated and furnished with personal touches such as TVs/DVD players in some rooms. Due to the nature of respite service it would be impractical to give residents choice on colour and furnishings to suit each individual. The home was clean and fresh although the laundry area requires handwashing facilities including a soap dispenser and hand towels. Also note the comments made later in this report regarding the need to increase the Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 19 temperature of the hot water in the kitchen area where dishes are washed. (See requirement 6) Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 20 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 this service. The recruitment procedures need to be more robust and do not fully protect individual within the home. Whist there is some comprehensive training in place, the undertaking of NVQ qualifications has been limited and more specific training could improve the quality of care. EVIDENCE: The staff roster shows an adequate number of staff employed during the day and night. There has also been a reduction in the number of agency staff used over recent months with the home now having two staff vacancies. The staff roster must be amended to ensure full staff names; job roles and whether staff on duty is agency staff. The agency staff used are those that have been regularly used and provide continuity of care to residents. Discussions with the newest member of staff confirmed the recruitment procedures and induction training provided. The staff member confirmed that they did not start working until their Criminal Records Bureau check had been received and was satisfactory and that a proof of identity had been provided. The records relating to this individual were viewed and whilst some of the checks were evidenced some were not. Gaps include evidence of qualifications; no investigation of gaps in the application form; references not as recorded on the application form with discrepancies in the dates and no written Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 21 confirmation from the previous employment as to why the staff left their previous employment in the care sector. (See requirement 7) All staff are inducted into the home during the first week or more, dependent on the needs of the individual. All new staff undertake LDAF training, unless undertaken in previous employment, and attend core training through social services over the course of the first few months. This includes health and safety; First Aid; food hygiene; moving and handling; medication and fire training. Staff spoken to also told the inspector that SCIIP (non-physical intervention and restraint) training had been provided. The home accesses training through social services and can therefore plan for staff to attend the training offered, if needed. The core training for some staff should be updated, as one member of staff had not received updated for a few years. Staff spoken to told the inspector that, training in communication, such as makaton and more in depth training relating to learning disabilities and epilepsy would also be beneficial. Another member of staff would also benefit from computer training in accordance with the job role. Some of this training is available through Social Services training department and therefore should be highlighted during the supervision process. Please note the comments made in Standard 23 regarding restraint. (See recommendation 5) Of the seven support staff currently employed one has a nursing qualification but no member of staff has NVQ 2 or above. This has been an ongoing problem within the home as some staff are reaching retirement age and do not wish to undertake such a qualification at this stage in their lives. The Manager assured the inspector that all new staff must agree to undertake the qualification and to this end two staff are registered to commence NVQ in September 2006 and are currently undertaken the LDAF Foundation Certificate. Discussions with staff confirmed that regular supervision takes place and there was evidence from the staff records that this is the case, although the recording of the formal supervisions could be improved to ensure records are accurate and up to date. Staff spoke of a very supportive and approachable line manager who is readily available to provide advice and guidance to staff. The home has policies and procedures relating dealing with physical aggression with some staff having attended training covering this area as well as personal safety awareness. Discussions with the Manager confirmed that all staff will undertake this training as part of the training programme Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 22 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): 37,38,39,42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home provides leadership and guidance to ensure staff provide consistent quality care and ensures the health, safety and welfare of residents and staff in the home. EVIDENCE: The Manager has recently been successful in her application for registration with the Commission. She has achieved the Registered Manager’s Award and has NVQ 4 in Care. She has experience of managing other homes within the service provision. Feedback from staff and residents show that the Manager has an open and inclusive approach to managing the home who understand s the need to encourage residents to make decisions on how they wish to be treated during their stay and to actively promote independence and thinking for themselves. Raising concerns is encouraged with opportunity for feedback arranged through resident’s meetings and the resident’s survey. The Manager has also ensured that residents are provided with the information they require in relation to their stay. Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 23 The inspector noted the required registration certificates in place, although the home is awaiting the registration certificate in respect of the Manager. There was also evidence of the required insurances in place. The Manager is aware of her responsibility in respect of the health, safety and welfare of the residents and staff and has there ensured the required servicing of equipment used in the home is regularly undertaken. There were some areas which need to be addressed including the work in relation to the fixed wiring; ensuring the hot water in the kitchen area reaches the required temperature for infection control and ensuring the fire drill records include the names of staff involved and night staff are involved in the drills. (See requirements 8 & 9 and recommendation 6). Induction training is also provided at the earliest opportunity for new staff with core health and safety training provided during training courses and within the home. The last inspection reports required the Registered Provider to carry out their monthly visits to the home as required under Regulation 26. This has improved and the Commission has received some reports detailing the outcome of the visits. However, these are not undertaken as regularly as they should be. A quality review of the service is undertaken each year which includes sending out surveys to residents and their relatives. This information is collated and analysed with a short report written on the outcome. This identifies shortfalls but there is no evidence of any action plan detailing how the shortfalls are to be addressed. Residents meetings are also held weekly and are an important part of ensuring the service meets the needs of the clients. These meetings are more focussed on day to day decisions such as meal choices and activities but are crucial to the quality of life experienced during the stay. The home also undertakes monthly monitoring a number of areas including medication; health and safety and finances. (See recommendation 7) Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 24 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 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 3 X X 2 3 Bromley Road (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 14 Requirement The Registered Person must ensure that care plans reflect the assessed needs of the residents. These must be regularly reviewed and updated to reflect current needs. The Registered Person must develop individual risk assessments for residents who are likely to go missing. This is an outstanding requirement. Previous timescale 1/08/05 The Registered Person must ensure that the health care needs of the individual are fully recorded with appropriate risk assessments and interventions required. The Registered Person must ensure all prescribed medication are provided with full details of administration. The Registered Person must ensure that the staff in the home have a full understanding of the records required in relation to the use of restraint. The Registered Person must ensure there are hand-washing DS0000038244.V290564.R01.S.doc Timescale for action 01/08/06 2 YA9 13 01/08/06 3 YA19 12 & 13 01/08/06 4 YA9 13 01/07/06 5 YA23 13 01/08/06 6 YA30 13 & 23 01/07/06 Bromley Road (44) Version 5.1 Page 26 7 YA34 17 & 19 8 YA30 13 & 23 9 YA42 23 facilities located in the laundry. The previous timescale has expired. 1/11/05 The Registered Person must ensure that adequate recruitment checks are undertaken on all new members of staff prior to their employment. The Registered Person must ensure that the hot water in kitchen discharges to approximately 60 degrees to reduce the risk of infection. The Registered Person must ensure that the urgent work required in relation to the fixed wiring is undertaken without delay. 01/07/06 01/07/06 01/07/06 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 2 3 4 5 6 7 Refer to Standard YA8 YA17 YA22 YA23 YA32 YA42 YA39 Good Practice Recommendations The home should ensure that outcomes and actions arising from residents’ meetings are recorded. The home should make records of the food provided to individuals. The complaints records should include the investigation route, outcome, action taken and of the complaint is resolved. All staff should receive adult protection training. The home should provide training specific to the residents identified needs and should include makaton, epilepsy and computer training. Records of fire drills should include the names of staff involved and should incorporate night staff involvement The Provider should produce a report on the outcomes of surveys undertaken which should include an action plan for improvement. DS0000038244.V290564.R01.S.doc Version 5.1 Page 27 Bromley Road (44) Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 (44) DS0000038244.V290564.R01.S.doc Version 5.1 Page 28 - 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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