Inspection on 22/11/06 for Camden Park House

This inspection was carried out on 22nd November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Camden Park House 10/04/08

Camden Park House 01/08/07

Camden Park House 09/12/05

Camden Park House 21/07/05

Camden Park House 12/03/05

Camden Park House 25/10/04

Camden Park House 20/06/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Camden Park House 57-59 Camden Park Road London NW1 9BA Lead Inspector Pearlet Storrod Unannounced Inspection 22 November 2006 10:00 nd Camden Park House DS0000010339.V287982.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 Camden Park House DS0000010339.V287982.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. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Camden Park House Address 57-59 Camden Park Road London NW1 9BA 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) 020 7267 7503 0207 485 8182 camdenparkhouse@hotmail.co.uk Umbrella Ms Catherine Alborough Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 9 service users with mental disorder, one of whom is over the age of 65. 09/12/05 Date of last inspection Brief Description of the Service: Camden Park House provides twenty-four hour support for up to ten people with complex mental healthcare needs. The home does not automatically provide personal care i.e. physical intimate care is not within the admission criteria; however the potential is there if required. The service is operated by Umbrella, which is a mental health charity, which provides a full range of care and support service in North London. The building is owned and maintained by Community Housing Association and service users have license agreements. The house is situated approximately 10-15 minutes from Camden Town Tube station and there is access is the 253, C10 and 29 bus routes. Within the local area are a variety of local shops including a supermarket, hairdressers, newsagent, florist, chemist as well as cafés and public houses. A post office is sited within walking distance. The home is spread over three floors. It comprises of two houses adjacent to each other, which have been adapted to provide registered accommodation for ten people. On the ground floor there is a main office, managers office, staff toilet, a single bedroom, a kitchen-cumdining area, a main lounge and a non-smoking lounge. There is also a single toilet. The laundry is located in the courtyard, which is formed by the two properties and has been developed into a communal outdoor space. The average fee charged to service users is £548.19 for Camden clients and an upper limit of £700 for clients outside Camden. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of unannounced inspection conducted for Camden Park House, which took 11 hours to complete. The process involved meeting with the manager and going through the inspection plan. A sample of service users records were examined and for staff also. A discussion was held with a service users and brief discussion occurred with two staff members. A number of policies and procedures were scrutinized and a tour of the home was undertaken. On arrival to the home the manager was working solely on her own due to staff shortages. Nevertheless, the manager portrayed professionalism and aptitude in managing a home that is presently experiencing various challenges. The Commission issued a survey to each service user and seven were completed and returned; one service user indicated a willingness to speak with the inspector. Comment cards were also received from key personnel. The inspector also left behind a comment card so that feedback on the inspection process could be given to the Commission. What the service does well: Service users health and care needs are well met and medication at this home is appropriately managed, promoting good health. One service user selfmedicates and it is favourable to note the comment of the visiting pharmacist that, “I feel confident that the home is run well. I have no concerns regarding medication”. Staff are appropriately trained to provide the support that service users need and regular monitoring and recording of service users likes, dislikes and wishes ensures appropriate support to individual service users. Good risk assessments are in place. A variety of ways have been designed to take into account each risk identified and then these are used to support individual service users in their developmental needs, with the emphasis of bringing about outcomes to indicate whether improvements are made in respect to service users abilities. The monthly visits conducted to monitor the service are clearly recorded and they indicate where improvements are required with action plans for the staff team to address. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Environmental standards require attention to improve aspects of safety in the home for service users and staff. The registered provider is asked to attend to the requirements made in this report, some of which are outlined below. • The registered person must ensure that agency staff supplied to the home is appropriately skilled to meet the needs of service users and that appropriate checks to validate the agency workers suitability for working in the home. The registered provider must also ensure that the vacant post is recruited to and that specialist supervision is provided to staff as directed by service users assessed needs Action must be taken against the risk of fire and for containing, extinguishing and reviewing fire precautions, including the need to ensure that all fire doors have the capacity to properly close to provide half an hour protection in the event of fire. Recommendations outlined in the report of the London Fire Defence Authority dated 16th August 2004 must be immediately addressed. • • • 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. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place that provides information about the home to prospective service users but an improvement is required in respect of the statement of purpose cum client information document. Service users all have an assessment of their needs conducted but these assessments are not all kept up to date. EVIDENCE: The statement of purpose cum client information document requires updated information in respect of the names and qualifications for the registered manager and responsible individual, together with the range of qualifications for care workers. Any reference to the National Care Standards Commission must be changed in the process to read, Commission for Social Care Inspection. The requirement for an assessment of needs prior to moving in must be stated together with clearly defined aims and objective of the service. In relation to the compliment and complaints procedure this must also reflect the new address for the registered provider. Thought should also be given to include an exclusion criterion to demonstrate those service users for whom the home could not provide a service. For example, prospective service users with mobility problems would not be suitable because of the design and layout of the building. It is clear that each service user has had a full assessment of their needs conducted. The sampling of three service users files demonstrated that service Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 9 users assessments of needs reviews are not up to date. In the case of one service user there is information to show that a review date was set for 6 months and that the date set for the review was 2nd August 2006, this review did not occur and was outstanding to be done. Another service user had a reassessment of their needs performed in May 2004 and a review of their accommodation happened in 2005. The inspector noted that there are issues surrounding the suitability of the service for this individual and it was further observed that the care co-ordinator previously allocated to the service user left. This is compounded with the fact that the service user is no longer a remit of the care programme approach. The manager explained that the service user should now be in receipt of placement reviews conducted by the individual’s social worker and that staff have omitted to chase these up on behalf of the service user. Staff confirmed that another service user is in a similar position. It is a requirement that all outstanding reassessment of needs for service users are chased up for action. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place, which demonstrates that choice and independence are the key objectives for service users living at the home though some operational practices need review. EVIDENCE: The file of a service user fairly new to the home was examined as part of the case tracking process and all aspects of the records for this individual were scrutinized. From observation, discussion with staff and examination of the information held, challenging behaviour is clearly exhibited, which have had an impact on service users residing at the home. Service users abstained from using the lounge when this particular individual had presence. At this home, three service users project different kinds of challenging behaviours, which have had adverse affects on the atmosphere in the home and such behaviours are demanding on staff time. Staff are continuously monitoring and recording the behavioural traits performed by these service users and are exploring ways to manage the situation when individuals begin to express their individual characteristics and the basis for such behaviour. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 11 The information stemmed from service users assessment of needs is used to generate service users care plans and risk management plans. Care reviews occur but the care plans are not updated to reflect the changes made where it is appropriate to do so. Risk assessments are carried out for each identified need which indicate the ways in which individual service users are to be supported to eliminate or reduce any identified risks. The other observation is that staff do not use the information gathered in respect of improvements made by individual service users to demonstrate any changes in the care plans. The care plans must be modified to portray whether service users abilities have improved in an activity and the effects on the service user. This is a particularly important factor since the ethos of the home is to develop service users skills, abilities or self-esteem with the emphasis of rebuilding individuals’ self-autonomy. Service users’ progressions in all aspects of their care and support must be recorded so that a holistic picture could be gained to ascertain their individual achievements. Staff and service users are aware of the need for confidentiality and a statement in this respect is signed and contained in each service user’s file. The confidentiality statement was drawn up in 1997 and needs updating by replacing the words Registration Officer with Regulation Inspector. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are making strong efforts to understand service users support needs and service users are encouraged, supported and enabled to develop their personal skills. Service users dietary needs are met but some improvement is required in menu planning. EVIDENCE: Service users personal development is essentially the home’s philosophy. Service users at this home have diverse needs in terms of race and culture and where appropriate, staff have engaged service users family members and interpreters to assist as necessary with understanding the needs of those service users whose first language is not English. There is evidence of social inclusion and as mentioned earlier, each service user has an activities chart, which encompasses service users social, educational and life skills developmental needs. A room is available predominantly for artwork, which is facilitated by a volunteer. The service also supports service users to use the computers available and to use community services such as day centres, cafes, pubs and other community links. As stated earlier, three service users portray Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 13 challenging behaviour; of these three service users, one individual behaved in a disruptive and volatile manner in an attempt to procure a key to replace one that the individual has lost. Staff also reported that this individual generally isolate themselves from staff and other service users by not communicating with staff and others in the home. Staff are presently attempting to find ways to appropriately support this individual but this is proving to be very difficult since the service user does not appear to be appreciative of the support that staff provides. Another service user told the inspector that, “they do voluntary work at the provider’s head office and that they often visited the local zoo, although today, they were going to buy a new coat instead”. This individual also declared their need for staff to support them to keep their room in a tidy state. When asked about the food the service user said that, “they do not usually participate in food selection and menu planning because they are often out of the house when the house meetings take place on a Wednesday”. The service user confirmed that the meals were enjoyable but that they would like an opportunity to have a choice of meals too. There individual has an eating disorder and staff have had to introduce various measures to support the individual including attending a food hygiene course for one day. Restriction on service users freedom to use the refrigerator as and when they choose has been instituted as a course of action associated with the service user’s characteristics. The action was taken in consultation with all service users at the home. This matter concerned with food selection and menu planning was discussed with the manager who asserted that they had, had discussion about changing the house meetings to an alternative day and time to accommodate more service users in this respect. Staff stated that ex service users are often invited to Sunday lunch, which was initially to motivate service users who were faced with challenging behaviour from an individual, necessitating restrictions in using the lounge. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and care needs are met and medication at this home is well managed promoting good health. EVIDENCE: Staff themselves do not provide support in personal care to service users and there is evidence to demonstrate that personal care needs in respect to one service user is carried out by Camden Home Care, three times per week. The service user’s care plan needs to be updated with this information. Prevailing issues around whether this individual is suitable for the home is being discussed, to a point where the service user has already visited another of the provider’s services with the possibility of moving to more alternative suitable accommodation in the community. The medical assessment indicates that the individual is no longer to be prescribed medication for diabetes must be recorded in the individual’s care plan. A health professional commented, “It is sometimes hard to see service users in private as when interviewing in the lounge area, other clients sometimes enter….” “Regarding the needs of the service users, staff sometimes differ in their opinion of what is the best way of addressing a particular problem with Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 15 the service user”. In discussion with staff they accepted the point made about being able to see service users in private and have given an undertaking to perhaps make the other office available for interviewing individual service users in private when necessary. They also concur with the comments made about staff differential opinions regarding a service user with a particular problem. As stated earlier, some service users display challenging behaviours and staff appear to be making strong efforts to discover a variety of ways to provide appropriate support to the service users. There is some evidence to demonstrate that remarkable progress is being made in respect to one individual. The medication policy and procedures were examined together with service users medication administration records and these were found to be in good order; one service user self-medicates and it is favourable to note the comment of the visiting pharmacist stating, “I feel confident that the home is run well. I have no concerns regarding medication”. The inspector observed from the records of another service user the displaced activities conducted by the individual and staff continues to work closely with the multi disciplinary team and have put systems in place, which enables them to support this individual more appropriately. Constant surveillance is required by staff to protect this individual from self-abuse. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that service users are listened to and encouraged to give their views. Staff are trained in respect to the protection of vulnerable adults though the existing policy needs review. EVIDENCE: Essentially, complaints made by service users are taken seriously and acted upon without delay. Evidence is available to demonstrate that staff manages complaints proactively with written responses issued to complainants within reasonable timescales. The record log indicates the nature of the complaints and the date that each complaint was made. Service users are also asked to raise any concerns they may have at house meetings and key-work sessions. It emanated from discussion with staff that they have received adult protection training and this was substantiated from evidence seen in the training records. From observation of the adult protection policy and procedure the document was drawn up in 2002 and now needs to be reviewed in line with the host authority’s adult protection policy and procedure and the Department of Health’s guidance in respect to Safeguarding Vulnerable Adults. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Environmental standards require attention to improve aspects of safety in the home for service users and staff. Staff continues to address cleanliness and hygiene standards in the home. EVIDENCE: The environmental standards generally present a homely and attractive appearance at this service. It is apparent that some furnishings in the home need attention so as to prevent potential risks of harm to service users. For example in the office the door to a cupboard in which cleaning materials are stored was missing and needs to be fixed and locked in line with COSHH regulations. Two base cupboard doors in the kitchen were broken off and these too need fixing; one cupboard appeared to expose cleaning materials. Damp is visible on a wall in the WC room on the ground adjacent to the dining room and lounge areas. The wc room has no heating and the damp wall needs attention. On the second floor of the premises the hot and cold taps in a bathroom were damaged and these must be fixed or replaced. A large amount of plaster was missing from the wall in a bathroom where a towel rail was Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 18 previously affixed. The hole in the plaster must be filled, and the repaired area painted. A number of fire doors in the property do not effectively close to protect against the spread of fire, including the doors to cupboards on the upper floors in the corridor areas of the home, which are ill fitting. These cupboards contain pipes and electrical equipments and as such the doors must be able to properly close so as to comply with fire regulations. In addition a number of fire doors were wedged opened and a fire extinguisher was used in one occasion. These practices contravene fire regulations and health and safety standards, notwithstanding a number of broken wooden furniture were contained in the corner of a floor landing causing a hazardous situation as it affects the means of escape in the event of a fire. Some of the doors to some service users rooms do not effectively close shut for compliance with fire regulations also and poses a risk of harm in the event of fire or other emergency situation in the home. The recommendations outlined in a fire safety report conducted by the London Fire Civil Defence Authority (LFCDA) conducted on 16th August 2004, has not been acted upon and the fire doors kept opened by wedges must cease. Staff stated that the newly purchased desk in the main office is broken and soon to be replaced; the four-draw filing cabinet in the other office must also be replaced, as the filing cabinet is broken and allows ease of access to two draws when locked. All the safety aspects outlined above must be immediately addressed so that a safer environment is provided for service users and staff to live and work in. The home was found to be generally clean with no offensive odours. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedural practice in respect of agency staff supplied to the home needs to be reappraised to ensure that service users are fully protected. Staff are offered appropriate training and refresher courses as necessary to meet service users’ individual and joint needs. EVIDENCE: There is one vacant post at this service and presently a support worker from another of the provider’s services is providing cover in this respect. On the day of the inspection the support worker on placement reported to be sick and the home was reliant upon the use of agency staff. On examination of the information available for agency staff, there was no information available for the vetting of agency staff supplied to the home. Having discussed this matter with the manager, who then requested information in respect to the agency worker allocated to work in the home, information were faxed through to satisfy the vetting process. The manager must continue to seek up to date information from the agency approved by the provider, for agency staff scheduled to work in the home. Satisfactory references, photographs and CRB reference numbers acquired to demonstrate validation, must be issued to the home via faxes if necessary to ensure safeguard and protection of service users. It was established at the provider’s headquarters and in the home that Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 20 the CRB checks for some staff have passed the expired timescale of 3 years and these now needs to be refreshed. The manager for the home must ensure that all CRB checks are up to date to meet statutory compliance. In discussion with staff, it was confirmed that staff meetings had lapsed for two months due to holiday arrangements amongst other things and that these were now back on course with effect from 7th November 2006. There is evidence of foundation training and certificates are apparent to support this. Though the filing cabinet was not accessible on the inspection day, the inspector was able to see the supervision notes for one staff member. There is evidence that staff at this home are working hard to ensure that service users assessed needs are appropriately met, in doing so, staff are experiencing difficulties with the support needs and wishes of an individual, whose first language is not English. The individual’s exhibition of aggression and other behavioural traits are compounded, making it difficult for staff to know and understand the best way to support this vulnerable individual. The provider must invest in specialist supervision so that support staff are appropriately supported and equipped to effectively manage service users needs; staff also demonstrated an interest in receiving clinical supervision as an aid to the tasks that they undertake. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well run by an experienced and registered manager. Service users have opportunities to comment on the service and on the individual care. The health and safety of service users is compromised by potential hazardous situations relative to the environment. EVIDENCE: The home is managed well by a manager who appears knowledgeable and experienced. The manager has a good understanding of the areas in which the home needs to improve and planning appears to be in place to deal with these matters. Service users views are sought at the weekly house meetings and at key work sessions. Other self-monitoring mechanisms are used by the home to generate information about the home to effect an improvement in the quality of the service. It should be said though that a number of Umbrella wide policies evident at the inspection are in draft format, which now needs to be Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 22 formalised and implemented as a catalyst for improving the service. These draft documents are: Draft Draft Draft Draft Performance Monitoring and Objective Settings Management Responsibility and Delegation (devised 7.12.05) Policy Development and Review Procedure (devised 7.11.05) Strategic Planning (devised 7.12.05) The provider needs to develop robust policy and procedures in respect of checks that staff in the home is required to undertake so that agency staff supplied to the home are suitably skilled, qualified and appropriate to work in the home. A statement in respect to race awareness is available though staff confirmed that the document is incomplete and requires enhancement to include information and guidance relative to equality and diversity. Examination of the incident and accident records demonstrates that more robust reporting in respect of Regulation 37 is required since the Commission had no awareness that a service user had been admitted to hospital until this inspection occurred. A restriction faced by service users in using the lounge was a notification to be reported to the Commission. The monthly monitoring reports required under Regulation 26 are informative and are of good standards with identifiable actions to improve the service. Improvements in respect of the health, safety and welfare of service users are already outlined under Environmental outcomes and will not be repeated here. The home has dealt effectively with the requirement made in the last inspection report. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 23 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 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 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 2 x 2 x Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 24 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 4/5 Requirement The registered person must ensure that the statement of purpose cum client information document is revised with clear details of the aims and objectives of the service, qualifications of the responsible individual and the manager and range of qualification for staff. Also the necessity for an assessment of needs to be conducted prior to service users moving into the home. The registered person must ensure that service users assessment of needs are regularly reviewed The registered person must ensure that service users care plans are updated when changes in their care and support needs occur. The registered person must also ensure that risk assessment outcomes are used in conjunction with the care plans Timescale for action 05/01/07 2 YA2 14 (2)(a)(b) 28/02/07 3 YA6 YA9 15, (2) (a)(b)(c) and 13(4) 28/02/07 Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 25 4 YA23 13(6) 5. YA24 23(2)(c) The registered person must ensure that the adult protection policy is updated and that a copy of the host authority’s policy and procedure is obtained and used in alignment The registered person must ensure that all broken furniture are removed from the corner in the upper floor landing 29/12/06 08/12/07 6 YA33 YA32 YA36 18 and 18 (2) and Sch.2 7 YA42 8 YA42 The registered person must ensure that the agency staff supplied to the home is appropriately qualified, skilled and properly vetted to meet the needs of service users and that the appropriate checks to endorse the agency worker’s suitability are conducted. The registered provider must also ensure that the vacant post is recruited to. Specialist supervision must also be provided to staff as indicated by service users assessed needs 23(4)(a)(b)(c)(i) The registered person must and (v) ensure that arrangements are adequate against the risk of fire and for containing, extinguishing and reviewing fire precautions as outlined under Environmental outcomes in this report and ensure that compliance with the fire report dated 16/8/2004 is adhered to. 13(4) (a)(b)(c) The registered person must ensure that cupboard doors in the office, kitchen and landings are attended to enhance appearance and DS0000010339.V287982.R01.S.doc 28/02/07 28/02/07 08/12/06 Camden Park House Version 5.2 Page 26 prevent potential risk of harm and improve safety in the home; the must also ensure that the damped wall in the toilet mentioned in the report is addressed 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 YA40 Good Practice Recommendations The registered person should ensure that the number of policies outlined under Conduct and Management of the Homes are formalized and implemented for staff guidance and direction in development in the provision of services. Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Camden Park House DS0000010339.V287982.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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