Inspection on 03/05/07 for Cheam Road (101)

This inspection was carried out on 3rd May 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cheam Road (101) 09/12/05

Cheam Road (101) 05/09/05

Cheam Road (101) 28/02/05

Cheam Road (101) 22/07/04

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

CARE HOME ADULTS 18-65 Cheam Road (101) 101 Cheam Road Sutton Surrey SM1 2BE Lead Inspector David Pennells Key Unannounced Inspection 3rd May 2007 12:20p Cheam Road (101) DS0000007154.V336633.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 Cheam Road (101) DS0000007154.V336633.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. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheam Road (101) Address 101 Cheam Road Sutton Surrey SM1 2BE 020 8642 0307 020 8642 1134 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Margaret Rose Ahmed Mohamed Care Home 6 Category(ies) of Learning disability (1) registration, with number of places Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents with challenging behaviour One (1) place for a service user over the age 65 years, with a learning disability, can be accommodated. 9th December 2005 Date of last inspection Brief Description of the Service: 101 Cheam Road is maintained, managed and staffed by the Care Management Group (CMG). The home, which opened in 1996, is registered with the Commission to provide residential care for up to six women with learning disabilities and challenging behaviours. The house is a large detached Victorian property situated in a residential area to the west of Sutton town centre - which is within roughly a half-mile’s walk of the home. A wide variety of shops, cafes, restaurants and numerous other social and sporting opportunities are available there, as are excellent transport links into London and away into Surrey. Local busses stop close by, almost outside the house. Cheam Village - a small suburban shopping centre - is also not far away (a bus ride or strenuous walk), in the opposite (westerly) direction - again offering many community resources. Accommodation in the home comprises: six single bedrooms, an open plan kitchen and dining area, and a separate lounge with a conservatory attached. There is also a small laundry area within a ‘cupboard’ and a small office. There are sufficient bathroom / shower and toilet facilities throughout the home to meet the needs of those who use the service. The large garden at the rear is generally well maintained, with a patio providing garden furniture for everyone’s use. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and conducted over a long afternoon of about five-and-a-half hours, during which the manager and staff were able to assist the inspector to review the three requirements from the previous inspection report - all of which were met, to examine current documentation, to speak to the people using the service and to explore any issues arising, including case-tracking / auditing specifically identified occurrences. Feedback from those who use the service was taken both directly on the day and through written questionnaires - six (out of six) were received back from these customers, whilst feedback was also received from four relative / family members giving their outsider’s viewpoint. The general opinion expressed was one of a high level of satisfaction. Those who use the service indicated they are helped to make their own decisions, can generally do what they want at all times of the day, know how to make a comment /complaint, and comment that staff treat them well, and do listen / act on what they say. Comments from family confirmed that they felt that the home meets the needs of their relative and supports them to live the life they choose, and that they are kept in touch with what is going on - and are involved in decision-making. Further, the staff are seen to have the right skills and qualifications, and meet the diverse needs of their relatives. An overall ‘high satisfaction’ rating is evident. The inspection visit revealed that the home was running to a good level of service, with a consistent and reliable staff team, and the people who use the service engaging generally well with the staff and the other people who lived there. As the service provides for just a small number of people, the culture is one of knowing each other ‘really well’ - and the general feel of the place is like an extended family unit. Such a unit is not without its tensions at times particularly between those who use the service - but staff members are skilled in generally defusing any such problems. What the service does well: The home continues to provide a warm, comfortable and welcoming service to the six service users accommodated at the home. The service provided is very individual, recognising the uniqueness of each person. The home ensures the diversity of needs are responded to, ranging from the more ‘homely’ approach for older people using the service, to the more engaging active outward-bound activities of the younger women residents. The staff team are closely involved with each service user, ensuring that life is as active and fulfilling as it can be - or as required by each person. The acknowledgment of vulnerability - and consequent setting of honest limitations / adjustments - ensures the right balance of rights and risks. The home has specifically demonstrated a commitment and determination with regard to one Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 6 person using the service - to try to respond to their specific and challenging needs. The provision of food -and involvement of those using the service is commended and staff recruitment was also noted for specific commendation after the auditing of new staff’s paperwork - evidencing a good and thorough process throughout. The home should continue to be proud of the good service that it provides to this small community that can sometimes have its challenging ups and downs. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Cheam Road (101) DS0000007154.V336633.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 Cheam Road (101) DS0000007154.V336633.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 - 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that they will have the opportunity to find out about the home, to visit (including staying for short periods) and be assured that the home can meet their needs prior to making a firm decision to stay. EVIDENCE: The service has a comprehensive Statement of Purpose together with a printed Service User Guide. These documents are well presented and include all the information required by the Care Homes Regulations 2001, including the aims of the home and the facilities / services provided. People using the service have all been given a copy. The Guide has symbols and photographs and clearly specifies the home’s room sizes, staff qualifications and other detail. The organisation has a dedicated Assessment Team that ensures that all necessary information is accrued prior to a trial period at the home, and the actual service (usually the manager) is involved in assessment, followed by familiarisation visits to the home by a prospective service user prior to admission. The home’s admission policy is conditional to a three-month’s ‘trial’ basis. In keeping with good practice, all the other service users are consulted about the Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 9 possibility of a prospective new service user eventually moving in on a permanent basis - and the permanence is confirmed after a thorough multiagency review. The home – registered for people who also have challenging behaviour – inevitably has a number of users who present also with significant elements of mental health issues. It is clear, however, that those identified in this ‘dual’ category are principally presenting with a learning disability diagnosis, secondarily augmented by some complex mental health needs / challenging behaviour. The age range of the majority of service users is between their mid-30’s to mid-40’s, and one service user is just on the ‘cusp’ of retirement age. The community at the home appears to ‘blend’ very well - despite the age differences. Length of stay at the home varies from one service user being at the home for the past ten years, with the others arriving at the home in gaps of between one to two years from then on, to the current day. This has meant that each person has been able to arrive and ‘establish’ themselves prior to another person arriving - a good thing for all concerned. People who use the service are in regular contact with both health- and social care-based professionals, including GPs, Care Managers, and community-based mental healthcare professionals, all of whom continue to assess that the ongoing needs of each individual is met. Such continuing support is vital for the home, especially if there becomes a need to ‘fall back’ on the expertise of these particular professionals. Charges at the home currently range from £1,300 to £1,700 per week; ‘extras’ include such services as private chiropody - when required, and personal grooming such as hairdressing - with attendant charges for toiletries and other small personal items such as individual magazines and papers. Cheam Road (101) DS0000007154.V336633.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, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintains care plans and assessment documents designed to ensure that the needs of service users are met in a focused and individual way. Service users can be assured that their rights to individuality and selfexpression are protected, and that consultation and sharing of information will involve and take into account the wishes and aspirations of each service user. Service users can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. EVIDENCE: Care plans seen showed full consideration of each service user’s individual needs. These plans are evidently based on assessments covering every aspect of a service user’s personal, social, emotional and health care needs. Each plan referred to service user’s likes and dislikes, and individual action plan identifies how people service users would be supported to achieve their goals. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 11 The people who use the service, care managers, and relatives are all encouraged to participate in the annual review process, and the home is ensuring service users sign, where possible, their own review documents. Day-to-day notes for each individual person are kept in a hardback book, and ‘monthly reports’ are also made by the Keyworkers – highlighting areas of significance in these ‘mini’-reviews, which then contribute to the fuller annual formal review process. The registered provider’s Finance Officer continues to act as ‘Appointee’ with regard to benefit issues for most current service users; most also have their own personal bank accounts in their own names, where they keep personal allowance monies. One person is subject to power of attorney, and another is subject to a Guardianship order. Some benefits are now paid directly into these bank accounts. Staff members encourage those - who are willing and able - to manage their own day-to-day financial affairs as far as is practicable. Shopping for the home - foodstuffs and other items - is also a shared responsibility. The home, being a small community, runs - and relies on - on a ‘cooperative spirit’ between those using the service to ensure the smooth running of the house. Service users are encouraged to participate in organising the day-today routines at the house, and also to help each other - whilst encouraging the ‘balance’ of individual activity (e.g. doing their own washing - including pegging it on the line - and the chore of ironing it afterwards). Regular monthly service users’ meeting are held and most mealtimes especially the main evening meal - when the community comes together, are ‘round table’ forums for discussion and debate about issues within the home. From the high level of positive responses in the questionnaires returned to the Commission, it is evident that individual opinions are listened to and acted upon. Risk assessments were noted for each person using the service within the home. Clearly risk assessment is an important part of the ethos / thinking of the home, and are generally well covered in associated documents. The inspector does advise that it would be useful to revisit some of the more generic, overarching, risk assessment documents - which appear in a ‘standard format’ - to ensure that each assessment is accurately reflective of the uniqueness and individuality of each person. Cheam Road (101) DS0000007154.V336633.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): 11 - 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 can be assured that this service provides opportunities for them to engage in activities both within and outside the home, and to adopt a lifestyle suited to their individual needs. Relatives / friends can expect a positive welcome from the home, within the context of respect their relative’s own choice and decision-making. People using the service can expect to be provided with a good standard of nutritious and wholesome food – meeting dietary needs and ensuring that mealtimes are a pleasant, involving and enjoyable time. EVIDENCE: All six people using the service completed and returned a comment questionnaire to the Commission; they all indicated they liked living at the Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 13 home, that thy felt well cared for, being well treated by the staff - and that their decision-making was respected. One commented that they could only do what they wanted to do: “when enough staff are on duty…”, another commenting that they would like more staff on duty - so that they could go out much more. On discussion, this is a perceived need to enable the almost regular 1:1 focus that those using the service expect; such is the individuality of the home’s programme. It is a case that staffing is provided at a higher level for identified planned appointments but not, clearly, as a matter of course. Staff members are clearly supportive of individuals seeking the best opportunity to develop and maintain their social and independent living skills. Some go out independently; others stay in more and enjoy their very pleasant home environment. Staff members encourage and accompany service users - where required - to social, shopping and activity-based locations. Service users have ‘Freedom’ travel passes, but a number really enjoy the activity of walking into the different town centres / engaging with the local community. Social activities enjoyed include going bowling, to the cinema, swimming and using pubs / cafes and restaurants - and going out to nightclubs. Due to the individual circumstances of those using the service, no formal ‘jobs’ / occupations are held by any; the majority attend some form of day centre activity, and the house provides occupational focuses when they are at home. Some people attend the Cheam Centre - and SCOLA College has provided inputs of Pottery, Cookery, Reading & Writing and Computer classes. One person attends an Asian Group to meet her cultural / religious (Sikh) needs. Another enjoys attending the Salvation Army Sunday Services. The manager confirmed that the home continues to be well accepted locally, and has a good rapport with their neighbours - sharing neighbourly activities such as an occasional summer barbecue - when they ‘invite the neighbours in’. Staff members support people who use the service to maintain personal relationships with those they have met since coming to the home - and previous friends from before moving into 101 Cheam Road. Family and friends are clearly always welcome to visit - as and when they wish. The visiting policy is expressed in symbols as well as words. Individuals can see visitors in the privacy of their own bedroom, but this is based on appropriate risk assessments; agreements can be devised with the home in respect of visiting situations, to ensure appropriate support and, where appropriate, protection. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 14 Four friends or relatives of those living at the home responded to the Commission’s comment questionnaire – all stating that they felt the home provided good care overall (“they do their very best...”), that they were made welcome when they visited, and were involved and kept informed about their relative / friend’s progress (“very satisfied…”). The home offers a high standard in regard to food. Choice of a wide range of menu options is available most evenings. The inspector has always been impressed by the variety of food available - both at mealtimes and readily available in the home in general - including fresh fruit and vegetables. Those using the service again confirmed that staff members encourage them to choose appropriately from the menus, and take it in turns to prepare the evening meal for the entire group. Food is freshly purchased from the shops on a regular daily basis, as well as those using the service assisting with the ‘big shop’ to replenish the freezer, etc. Alternative meals are offered, and a record of this is maintained. Individual care plans identify service users food preferences and specific dietary needs / requirements. Food is also readily made available to relatives or visitors (some travel quite a distance) - either eating with the others at the regular mealtimes, or having the table separately to share with their friends / relatives before / afterwards. Cheam Road (101) DS0000007154.V336633.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. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s assessment and care planning programme. The systems adopted by the home regarding medication ensure the safety and consistent treatment and support for each service user. EVIDENCE: Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 16 Each user of the service is respected and supported in a positive way to ‘be themselves’ as much as possible, this extending to personal and health care issues. There is little in the routine of the house that is not ‘flexible’ - though of course, some service users rely on a ‘presence’ of domestic routine or positive encouragement to enable them to undertake their own activities. The idiosyncrasies of each service user are certainly acknowledged and respected. Most can undertake their own personal care and are just encouraged to pursue this. One older person will have the facility of a rising bath seat provided to ensure their continuing independence when bathing. Many of those resident at the home use a professional hairdresser who visits the home and undertakes styling on the premises. This provision is suited to the individual service user’s needs, and charges are reasonable - and more than competitive with outside services. Some people also avail themselves of a professional chiropodist; a charge of £29 per person is made in this regard. GP and other medical / health professional contacts are made as needed; records of these appointments / visits (almost invariably this is a visit to the doctor) are appropriately maintained. A single GP practice cares for all at the home - because all are out of area from their placing authority / original health care practitioner and so have had to sign up with a locally convenient GP. Specialist practitioners also monitor service user’s mental health ‘as-required’ and on a regular visit basis (the consultant psychiatrist or a colleague visits the home most months). The home’s Accident Book and Occurrences Book were both being appropriately maintained in this regard. Records of medication administration were checked and found well maintained; all medicines received, administered and disposed of (via the Chemist) being in order. Those using the service sign their agreement to their medication being managed. Medication profiles and other records were available and clearly identified service user’s current and discontinued medication regimes. The home’s procedures for administering ‘as required ’ (PRN) medication are detailed to minimise any risks associated with their misuse. Assessments of service user’s willingness and capacity to self-administer their medication are actively undertaken, but none currently do so. Cheam Road (101) DS0000007154.V336633.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 good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their comments and complaints are responded to, with appropriate action taken. The home provides adequate support to service users to ensure that they are protected from harm and any form of abuse. EVIDENCE: The CMG / home’s complaints procedure is available in symbols format to enable an alternative communication method than the written word - and it is clearly displayed in the home. The CSCI is mentioned as a route for people who use the service to take if they feel they are not satisfied with the service or a response at any time. The complaints procedure is also included in the Service User Guide, which is also available to all those living at the home in a suitable language / format (e.g. symbols). Eight complaints were declared as being investigated within the past twelve months, with one currently awaiting final resolution. The remaining seven - of varying subject matters - were not upheld on further investigation. Finances are managed by the home in respect of all service users; suitable records are maintained for all transactions, including the keeping of monies in bank or building society accounts. Two small safes are fitted in the home to ensure that valuables and monies are kept on site by the home are securely in safekeeping. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 18 Staff members attend the registered provider’s ‘Dignified Management of Conflict’ training - which prepares the staff members to appropriately deal with challenging behaviour. The home’s policy is to only use physical intervention as a ‘last resort’ - and this has only been used twice within the past year, in extreme circumstances. The procedures for responding to suspicion or evidence of abuse, including the Whistleblowing policy were openly available. Sutton Council’s Vulnerable Adult Procedures are also available in the office. Cheam Road (101) DS0000007154.V336633.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 - 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing generally a high standard of furnishings, services and domestic facilities. People who use the service can be assured that they live in a safe environment in which they may live their lives without unnecessary risk. EVIDENCE: The home is conveniently located in West Sutton, in a pleasant residential area. The location is ideal to enable access to many community resources, using local transport - busses stop close by and trains are available from Sutton station into London and into Surrey and beyond. The house is generally well maintained and kept clean and tidy. Furnishings are of good quality (that in the lounge and dining area had been recently replaced) and care is taken with the décor throughout. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 20 The communal space is more than adequate for the six service users and the staff who provide the service alongside them. There is clearly a corporate sense of ‘pride’ in the house and its surrounds - and in maintaining their general living standards. The home is pleasantly ‘ordinary’ in its general external appearance, and very much in keeping with the local ambience; those living at 101, Cheam Road can certainly feel as if they are living ‘at home’ and not in an institution. The external side-entrance path surface was noted to be breaking up - as this could be used as an emergency route, it is required that this be improved to avoid any trip hazard. Inside, the home has a spacious entrance hallway, a large dining room with open-plan kitchen attached, and a pleasant lounge with TV and music centre etc, leading out into a comfortable conservatory, which has in the past been identified as the ‘smoking zone’ for service users. Even though this was the smoking area, the ventilation provides enough that the ambience was clean enough for non-smokers to use it when smokers were not in evidence. The conservatory is often used for meetings / reviews. All service users have a single bedroom, of which all are over 12 sq metres in dimension. As this is an older building, not all rooms have an ensuite; two have personal facilities - one with just a toilet, and one with a toilet and shower cubicle. The advantage of the premises being ‘of an age’, is that each room is quite different in its shape and ‘’feel’; lending a very individualised feel to the private space. All service users again stated that they were very happy with their facilities and furnishings. All bedrooms seen were decorated to a high standard; they are well furnished, and personalised to reflect the service user’s individual tastes. The downstairs bathroom is now a shower room - this enhancing the facilities available to service users. The radiator in the shower room has now been protected to avoid the risk of burns from the hot surfaces. The home was - as ever - clean and free from any malodour at the time of the inspection. The home’s laundry facilities are located in a small room with a door off the kitchen area. The registered provider, CMG, provides a comprehensive list of policies and procedures for the prevention and control of infection within the home. All maintenance and servicing of equipment at the home was up-to-date and certificates were readily available to evidence such provision. Regular in-house checks are undertaken by staff members and the records are regularly checked during the Regulation 26 visits of the person-in-control of the home. Two extractor fans were noted to be inoperative at the time of the inspection these were to be repaired / replaced. Cheam Road (101) DS0000007154.V336633.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): 31 - 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be supported at all times by staff who are experienced and competent in their work, being provided in sufficient numbers to meet their identified needs. Service users can expect to be provided a service that ensures their safety and protection from abuse – through thorough recruitment processes and ongoing staff support arrangements. EVIDENCE: Ten staff members were providing the ongoing service to the house, with a support worker post, full time being advertised, with the vacant hours generally being covered by in-house overtime. Six staff members were noted to have ‘moved on’ since the last inspection in December 2005, most due to promotion within the organisation. The staff team consists of women only, providing the service to this women-only service. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 22 Staff job descriptions are comprehensive and linked to achieving service users goals as identified in their care plans. Staff members are familiar with the Codes of Practice set by the General Social Care Council (GSCC); they have been issued with a copy of the Code, which they have signed for. Staffing is provided at an absolute minimum of two care staff being available at all times, day and night. Some people who use the service are also identified as requiring a certain number of hours of ‘1:1’ attention. The manager / senior staff are ‘on call’ on a rota basis when not in the building. The pre-inspection questionnaire confirmed that no agency staff had been used in the home over a period of eights weeks; one vacant shift only had been covered by a ‘bank’ worker, the others being covered ‘in-house’ - thus ensuring the all-important continuity for the people who use the service. CMG do not permit new members of staff to start work until the company has obtained two satisfactory references from third parties, including their previous employer, and a Criminal Records Bureau / PoVA check is undertaken. Staff files hold signed acknowledgment letters from CMG’s Regional Director as proof that staff members’ CRB checks have been carried out - and these declarations - due to data protection considerations - are held at CMG’s Head Office. Checking the file by the inspector of a new staff member employed at the home, showed that full documentation concerning the application / referencing / CRB checking and interview of the applicant was held - evidencing them to be a very suitable candidate for appointment. Induction records were also complete, with contract letters and details and other documents showing a fully followed-through process of induction and employment. This evidences the excellent care taken in recruiting staff for the service. The inspector was provided with documentary evidence, in the form of a full matrix record of training - as proof of staff members’ competency; training in the ‘statutory elements’ (Basic Food Hygiene, First Aid and working with people with mental health issues) were up to date with all staff currently holding a First Aid certificate, therefore, providing First Aid cover to the home 24/7. NVQ training - at minimum level 2 - is on course to be over the required standard in a short while; three have almost completed the work - and will join two who already have the qualification. All current staff had also undertaken the TOPSS induction / foundation course and new members of staff receive a structured induction within the first six weeks of their appointment and signed and dated records are kept to evidence they have read / understood the wide variety of policy and practice contents. It is compulsory for all members of staff to attend the organisation’s ‘Dignified Management of Conflict’ training - equipping them to handle incidents of challenging behaviour - and members of staff are not allowed to undertake any form of physical intervention with a service user until they have been trained. Cheam Road (101) DS0000007154.V336633.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 - 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates management systems that ensure that people using the service benefit from a well-run and well-lead service. People using the service can be assured that their rights and interests are well served and protected through the home’s approach to record keeping, policies, procedures and the day-to-day administrative conduct of the home. People using the service can be assured that their welfare, health and safety is safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: The Registered Manager - Mrs Margaret Mohamed, previously worked at the home before returning to the full management role in September 2004. She Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 24 has worked for CMG for seven or more years. She has completed her NVQ in Management and Care at Level 4, leading to the Registered Manager’s Award. The Deputy Manager and Senior Support Workers also support the management role within the house, holding delegated areas of responsibility. The home has a Quality Assurance folder which focuses the service on the many aspects of “QA” by gathering together all the varying audit documents and focusing on a service user’s own experience of the home through an auditing exercise using ‘their eyes’. The home also has an active role to play within the CMG Company’s quality audits each year - with people who use the service as representatives alongside staff members attending a meeting where the quality of input at the homes is discussed. The registered provider also regularly surveys both service users and their relatives / advocates on paper - to elicit feedback about the quality of the service provision. There are also CMG Residents and staff broadsheets - which keep everyone abreast of developments. Reports compiled by the home’s Regional Operations Manager following monthly, unannounced visits to the home, are regularly being forwarded to the Commission, in line with Regulation 26 of the Care Homes Regulations 2001. CMG has a comprehensive set of policy and procedure manuals which cover the broad spectrum of needs identified under the headings of: Mission Statement / Staff Policies / Service Management / Service & Care Delivery / Health & Safety / Residents Welfare, and Emergency Procedures. Service users are welcome to view their own files and any personal information held about them by the home - should they so wish - in line with Data Access and Protection principles. The registered provider is duly notified with the information Commissioner under the Data Protection Act 1998, thus ensuring adherence to good practice in general. Records seen at the home were generally well kept, accurate and up-to-date. Health & Safety issues were dealt with at the home in a well-organised and audited way; maintenance and service documentation was readily available and evidenced that all routine safety checks were up-to-date in their execution. The CMG Company has a team of maintenance staff who undertake many of the principal checks and audits as a matter of course, year-on-year. Cheam Road (101) DS0000007154.V336633.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 3 4 3 5 X 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 X Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA24 Regulation 23(2)(b) Requirement The concrete surface leading along the side of the house to the garden gate must be resurfaced to ensure there is no trip hazard for those who may need to use this outside access. Broken extractor fans in toilets must be checked - and replaced as appropriate - to ensure the most pleasant and hygienic environment for those who use these services. Timescale for action 21/10/07 2. YA27 23(2)(p) 21/10/07 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 YA9 Good Practice Recommendations Risk assessments should be reviewed to ensure that ‘standardised’ formats and approaches do not obstruct the individualised approach to such processes. Cheam Road (101) DS0000007154.V336633.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cheam Road (101) DS0000007154.V336633.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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