Inspection on 23/04/07 for Bromley Road (44)

This inspection was carried out on 23rd April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 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) 16/05/06

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 Unannounced Inspection 23rd April 2007 14:00 Bromley Road (44) DS0000038244.V334717.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 (44) DS0000038244.V334717.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 (44) DS0000038244.V334717.R01.S.doc Version 5.2 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) maxine.shaw@bromley.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.V334717.R01.S.doc Version 5.2 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. 16th May 2006 Date of last inspection 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 and the home is managed and staffed by their employees. 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 and 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. The lounge/dining room and kitchen are located on the ground floor as are three of the bedrooms, 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 £8.82 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; magazines and activities. In some cases, transport to day centres, is included in the service level agreement. Full information is available on referral and the inspection report can be provided by the home on request. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two half days, one of which occurred in the evening. The inspector undertook a brief tour of the home, viewed records, surveyed residents and relatives and spoke to two relatives, two residents, two members of staff and the Manager. What the service does well: 44 Bromley Provides a warm, comfortable and homely environment for people using the service to have a break from their home environment. There is flexibility in the service in that stays range from one night to a week at a time with opportunity for a longer stay, if required. Consistency is provided with the home continuing to support individuals in accessing their normal day centre. The Manager ensures that those wishing to use the service are provided with information on what they have to offer and that all prospective residents are assessed and care is planned according to the individuals’ needs of the person. It is positive the home involves residents and relatives in this process. This ensures that that there is enough information on whether the home is able to meet the needs of the person and that staff are provided with the information. Records are also kept of any issues that may affect the individual. Staff are generally well trained and understand the individual needs. Residents spoken to made positive comments about the way staff care for them and this was also evident in the observations made by the inspector in the way staff interacted. Whilst the person’s healthcare needs remain the responsibility of the GP service used whilst at home there are systems in place to ensure the individual has access to emergency healthcare if required. The home is also well supported by the Community Learning Disability team who provides specialist assistance and advice. Most aspects of the health and safety are addressed and the home is generally well managed, The home provides an environment where residents are able to make decisions and choices and can become involved in activities in the community during their stay. The home also tries to promote independence through encouraging Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 6 and supporting people in activities of daily living such as cooking and domestic tasks. However, this is very much dependent on the length of the stay. There are systems in place for monitoring and reviewing the quality of care provided. What has improved since the last inspection? What they could do better: Whilst the home provides individuals with a contract in respect of the service provided these are not always updated and do not therefore reflect the current position in terms of fees, obligation, rights etc. Where care plans are developed there must be a system for ensuring the home has reviewed the care required between visits to ensure the staff have the information to meet the current needs. Where medication is recorded into the home there must be clarity of recording and hand transcriptions counter-signed to ensure the accuracy of the recording. Whilst there is a record of staff competent to administer medication this must be supported with a record of the signature/initials used on the medication records. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 7 The lack of records available in respect of the way complaints are managed must be improved upon to ensure there is a clear and open process for investigating the issues and taking appropriate action to resolve the issues or concerns raised. Risk assessments must also be developed where there are identified risks to individuals. The assessment must provide staff with full information on how risks can be minimised whilst balancing the person’s independence. Staff are not always aware or do not understand/acknowledge the cultural needs of the individual, whilst they are living in the home. This is an area which must be improved and reasons for not addressing key cultural needs explored and, training provided, if required. A minority of the staff group are qualified to NVQ 2 or above. Recruitment procedures, whilst adequate must be improved to ensure all staff have been checked against the POVA register and Criminal Records Bureau checks are updated at the recommended timescales to ensure vulnerable individuals are protected. There are crucial gaps in ensuring the fire systems are checked regularly and therefore in good order. Staff also require annual training in the fire procedures. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 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 (44) DS0000038244.V334717.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Information is available to prospective resident in the form of a welcome pack called “Catch a Falling Star”. The “Pack” includes Service Users Guide, the Statement of Purpose and a template of a contract. This information has been updated to ensure it clearly states what the home offers and provides and to whom. The contract has also been reviewed to ensure rights, obligations and notice period is now included. The Service Users Guide is in text, pictures and symbols and is easy to read. The inspector discussed the admissions process with one relative whose son is due to commence respite at the home. The individual believed there to be a very good exchange of information. The Manager visited the family home and discussed the needs of the prospective service user’s needs. The family also visited the home first and then with the prospective resident. A number of future visits have been arranged to ensure the person becomes familiar with Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 10 the home and staff. They confirmed that they were provided with an information pack including a copy of the contract. They believed that they had good information on which to base their decision. The home had recorded details of the process, including the core assessment by social services and the home’s assessment. There was evidence that family have been asked for information on how they can meet son’s needs. The support plan had already been developed prior to the service commencing. Discussions with a member of permanent staff showed that they had a sound understanding of the process and where information is held to ensure they are able to support the residents when they visit. There is a system in place for reviewing the care. Prior to next visit the home contacts the individual or their family for updated information. Individuals also provide an information sheet when they visit detailing any changes that the home needs to be aware of. This is good practice. This information sheet (in text and symbols) is also used for recording possessions, clothing and medication on admission. Two were viewed and found incomplete nor signed and dated. - When used appropriately this is a good form. One other file viewed showed an “old” contract which had not been updated and not signed or dated. (See requirement and recommendation) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 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. 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 this service. Care plans are developed to provide staff with the information on how to provide individual care to people living in the home. The home involves residents in making decisions and choices on how they wish to live during their stay encouraging and promoting independence. Risk assessments are completed but they do not fully ensure that there is appropriate guidance on how the risks promote independence and safeguard the individual. EVIDENCE: Two care plans were viewed, One of an individual who has respite regularly and one of a new user of the service. Both had the STAR system in place which recorded in a simple format (and included symbols and pictures) how their needs are to be met. Both were individualised. The cultural needs of one individual had been clearly stated to ensure staff were aware of how these needs are to be met when the user visits. There is little evidence of the care being reviewed either by the home or by Care Management. The Manager Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 12 stated that the day centre is the key agency for arranging and reviewing the care once a year. However, there was no evidence that this had taken place. The inspector spoke to two residents who provided positive feedback on their stay at Bromley Rd. They said that that staff are very good and understand the support they require. Both appeared relaxed in the home and with the staff and the inspector observed staff encouraging residents who were more able to undertake normal tasks such as making a cup of tea. One relative did, however, state that staff do not always meet the cultural needs of their family member and whilst some things were not as important in the persons life there were others that they wish were addressed. This is one area that could be improved though staff being fully aware of the meaning of the cultural issue, ensuring they followed the care plan or through training. (See requirements) The home also identifies where there are particular risks to individuals and this was evident in one of the files viewed in the form of a risk checklist. However, these were very basic and should be elaborated on to ensure staff have the full information on what to look out for and how to minimise as well as ensuring they balance the risks with promoting independence. Regular residents meetings are held, although this is more difficult due to the transient nature of the service with people staying for short periods of time. However, the home does try and involve residents in any decisions where, possible. Discussions on activities, food, staff etc are included and minutes taken of the discussions. Two residents provided the inspector with information on this confirming involvement in regular meetings during their stay in the home. Two residents spoken to were happy with the care provided by staff. In general residents are not able to fully manage their monies. Information provided before admission for respite care, includes the amount of spending money that would be appropriate for stays of various durations. This money is held by the home however residents are able to manage their own, if appropriate, with a secure lockable unit available. Three residents’ monies were checked and found to be accurate with records maintained of any monies brought in and being spent. However, the admissions sheet had not been completed in respect of money brought in to the home. (See recommendation) Bromley Road (44) DS0000038244.V334717.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are involved in day to day activities that promote independence and provide a stimulating environment. Residents are provided with a healthy diet and enjoy their meals in a relaxed environment, although the home does not always ensure the specific needs of residents are met. EVIDENCE: Discussions with a member of staff and two residents provided information on how the home involves residents in daily tasks such as cooking and cleaning, whenever possible and depending on the dependency of the individual. On the first evening one resident was being supported to make the evening meal by a member of staff. They had provided information on each step in the form of a pictorial guide. There was evidence from the residents meeting minutes that Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 14 discussions had been held on the meals for the following week and the sort of activities that they would like to attend. One resident said that during their stay they go shopping for foodstuffs and also do things such as cinema, swimming, cycling, pub meals etc. As individuals are for short stay only they continue to visit their day centre as usual with arrangements made for transport during the duration of the visits. The home supports individuals to access community activities including social evenings at the Gateway Club in Penge and Orpington. Other evenings are spent in the home watching “soaps” on TV or listening to music. There are board games available but not all wish to be involved in these activities. All residents are able to have keys to their rooms with one resident showing me their room (which was locked). A lockable space is also available to keep items secure. The two residents spoken to told the inspector that they were able to get up (bearing in mind commitments) and go to bed when they wanted. There were signs of positive interactions with some residents particularly those who were more able or who initiated conversation more. The rules of the home are documented in the service agreement. The lounge whiteboard details staff on duty for the day and what the meal is for that evening. As stated previously the menu choices are decided the week previously and often do not affect those already in the service. Staff oversee this process to endure that those residents coming in the following week will have choices that they prefer and meet their needs. Residents told the inspector that they have refreshments often and can where able make these for themselves. This was evident from observations on the two days. Both residents were able to tell the inspector of their input into the menus. Where residents attend day centre a packed lunch is provided. The home provides a short stay service for people using Bromley social services. This is an opportunity to be away from home for short while and therefore, whilst family and visitors are welcome, it is rarely part of the individuals identified needs at this time. Comments made in previous standards show that staff do not always observe the cultural needs of the residents. One relative spoke of their son not eating pork due to their religion. However, staff continue to provide ham sandwiches for his packed lunch. This may be because staff have not read the support plan, lack full understanding or require training in these areas. (See requirement) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services have access to healthcare and remedial services, and staff make sure that those residents who are fit and well enough are encouraged to be independent. However, risk assessments developed do not always provide full guidance on how the risks to the individual are minimised. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. EVIDENCE: The records relating to one resident was viewed. The home had identified a number of risks including epilepsy, falls, moving and handling. These were quite basic in some areas and need to be improved upon to ensure there is full information and guidance on what action is required to minimise the risks and information on the support that is required in relation to moving and handling. (See requirement) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 16 The home has a variety of aids and adaptations, including ceiling hoists etc to ensure staff are able to support those with physical disabilities. As residents have access to healthcare though their own GP and PCT service the home only accesses the local GP in an emergency. The home is well supported by the CLDT who are on hand for advice and support, when needed. The manager stated this is regularly available and at short notice, if required. The records in relation to two residents were audited. In both cases the medication administration records were hand transcribed. There were two signatures in one case and none in the second. The handwriting was not very clear or tidy and therefore the need to ensure accuracy is vital. This is why a counter signatory is required. One had details of allergies, whereas in the other this had been left blank. There were supporting records detailing medication coming into and leaving the home. The records had been completed as per the administration and in the case of one medication prescribed as required (prn) there were guidelines in place. Further details should be included as to the maximum dose to be administered. At the front of the medication file the medication procedures regarding Bromley Rd are maintained and a list of staff authorised to administer meds with corresponding signatures. However, the list should also record the initials or “signature” used on the “MAR” to enable ease of identification and auditing. (See requirement and recommendation) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home listens to and investigates any concerns raised by people using the service or their relatives. However, the records do not detail how the complaints are investigated, outcome or action taken to resolve the issues raised. There are systems in place to protect individuals who are vulnerable to abuse and require protection. EVIDENCE: The home has a copy of London Borough of Bromley’s (LBB) complaints’ procedure that covers all services. The procedure is also in pictorial format for easy reading. Details of CSCI have been added in the form of a label. Basic information is also included in the Statement of Purpose. The document also states the procedure can be made available in other formats such as audio or visual tape. Three complaints have been registered since May 06 and have been dealt with by home. There were limited records to ensure a clear audit trail of how complaint was investigated and whether the complaint is resolved. (See requirement) Two service users and one relative spoken to, said that they would tell staff or the manager if they had a concerns and written feedback from three residents confirmed this. “Staff listen to me” one wrote. One staff member spoken to said that she would listen to any issues raised by residents and would try and resolve them, if within her remit, or would pass it over to the manager. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 18 There have been no adult protection issues over the last twelve months although one of the complaints had been referred to the CLDT Care Manager in respect of “bullying” by one resident to another. The Care Manager did not believe this to be adult protection and steps have been implemented to address the issues. Staff attend POVA training and have been provided with training on managing challenging behaviour and SCIPP. The Manager is aware of the need to ensure there is clear documentation, if there is a need to use some form of restraint. Comments in relation to the staffing outcome group have identified the need to ensure that all staff have been checked against the POVA register when making employee checks. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25, 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. The home provides a comfortable and homely environment for people living there. The home is clean and free from malodours. EVIDENCE: The home is clean and fresh with no malodours. Rooms are furnished in a homely and comfortable way. Equipment has been serviced as per regulations. Two residents spoken to were happy with the standard of accommodation with bedrooms containing much of what they require for a short stay. The kitchen has low counters for those with disabilities who use a wheelchair. The water temperatures in the bathroom on the first floor were found to be satisfactory with records in place. The last inspection highlighted the need to fix a toilet seat and this has been done. This has now been fixed but now there is no lid on the seat. (See recommendation) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 20 The laundry was also found to be satisfactory with adequate equipment and hand-washing facilities. COSHH items were found to be kept safe and the procedures for infection control and dealing with clinical waste are in place and implemented. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedures must be more robust to protect people living in the home. Staff are adequately skilled to provide care to individuals although there is a lack of staff qualified to ensure competency. EVIDENCE: Two members of staff are on duty at each shift, while residents are in the home. The home is generally not staffed during the day except at weekends or unless a resident is poorly and cannot attend their day centre commitments. There is flexibility within the staffing, if agreed by the Care Management team who would be responsible for funding. The home is not “open” in the day unless resident poorly. During the night two night staff-are on duty with one waking and one sleep-in. The personnel files of two new staff were viewed to check the thoroughness of the recruitment procedures. One staff member had recently transferred from another home (LBB employer). A Criminal records Bureau check (CRB) was in place from 2004, however this did not show evidence of a check against the POVA register. The manager must ensure a POVA check is completed, Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 22 especially as it is almost three years last CRB. A new CRB is also recommended. The file contained very few records for this individual as most documentation is maintained by the Social Services Personnel Department. The second record viewed was of a new staff member. All records, including CRB, POVA, references, proof of ID and application form were in place. The Regulations also require that the home verify the reason for leaving previous employment in care. This had not been completed. (See requirement and recommendation) Copies of certificates relating to previous training were also included. Details of all training undertaken since commencement of the role, including induction and other training, were also evidenced. The records were comprehensive with variety of core and specific training taking place. There was evidence from the files and from discussions with one member of staff that formal supervisions take place regularly and that staff feel supported in their role. The inspector also viewed the training records of two other staff. Bromley Training Consortium provide training to staff covering core and specific training, including challenging behaviour, visual impairment, epilepsy, SCIIP and effective communication. All staff have LDAF induction and all new staff recruited must have NVQ 2 or above. Previous inspection reports have highlighted the need to improve on the number of staff with NVQ 2 or above. This has not been improved upon with only one staff achieving the qualification. (See requirement) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and, qualified and competent to manage the service and ensure a consistent quality of care is provided. However, the lack of checks in relation to the fire systems means that the home is not ensuring the health and safety of people using the service. EVIDENCE: The manager is qualified to NVQ 4 in Care and has also completed the Registered Manager’s Award. She has a number of years experience in workig with people with learning disabilities and in a management role. She has open and inclusive approach to managing the service and to ensure that residents receive individualised support. She is approachable to staff, residents and families. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 24 There is also regular monitoring by the Provider through monthly visits, although the reports are not always sent to the Commission. The Manager also monitors some key areas, such as care plans and medications. The Service Manager arranges an annual review of the service with last one being undertaken the previous year. Monies were checked in relation to current residents and all were found to be accurate with receipts in place. The inspector sampled a number of service contracts and health and safety check records. All were satisfactory, except the weekly fire checks had not been completed by staff for three weeks. Fire drill records viewed also need to have details of those staff attending with full names and times of drills to enable determination of correct number of drills for day and night staff. The inspector also found no evidence of regular fire training taking place at least yearly. (See requirement) Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 3 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 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 3 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 X 15 N/a 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 X X 2 X Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 26 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement Timescale for action 01/12/07 2 YA6 15 3 YA19 12 & 13 The Registered Person must ensure that people using the service are provided with up to date information on the terms and conditions of residency. The Registered Person must 01/07/07 ensure that the individuals care plan is reviewed regularly to ensure staff have the information they require to provide the support required. The Registered Person must 01/07/07 ensure that the health care needs of the individual are fully recorded with appropriate risk assessments and interventions required. This remains outstanding with the previous timescale of 1/8/06 and 01/12/06 not met. The Registered Person must ensure that the cultural needs of the individual are understood and met during the individuals stay in the home. The Registered Person must ensure that where hand transcriptions are made the DS0000038244.V334717.R01.S.doc 4 YA6 15 01/07/07 5 YA20 13 01/06/07 Bromley Road (44) Version 5.2 Page 27 6 YA22 22 7 YA32 18 8 YA34 17 9 YA42 23 writing is legible and that there are recording is counter-signed to ensure accuracy of the recording. A list of the signatures used when recording on the medication record must be maintained to enable proper checks to be made. The Registered Person must ensure that complaints records are kept in the home showing the complaints, details of investigation, outcome, action taken and whether the complaint had been resolved satisfactorily. The Registered Person must provide an action plan of how they intend to ensure staff are qualified to NVQ 2 (or above) standards to ensure staff are competent. The Registered Person must ensure that staff working in the home have had the required check against the POVA register. The Registered Person must ensure that fire alarm checks are carried out weekly to ensure the system is in safe working order. Staff must be provided with fire training at least yearly. 01/07/07 01/07/07 01/06/07 20/05/07 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 YA17 Good Practice Recommendations The home should make records of the food provided to individuals. The manager should ensure that the medication records record allergies and where there are none known this is DS0000038244.V334717.R01.S.doc Version 5.2 Page 28 2 YA20 Bromley Road (44) also recorded. 3 YA34 Criminal Records Bureau checks should be made on staff every three years. Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bromley Road (44) DS0000038244.V334717.R01.S.doc Version 5.2 Page 30 - 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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