Inspection on 05/09/05 for Cheam Road (101)

This inspection was carried out on 5th September 2005.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cheam Road (101) 03/05/07

Cheam Road (101) 09/12/05

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 Unannounced Inspection 5th September 2005 13:45 Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 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.V251122.R01.S.doc Version 5.0 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.V251122.R01.S.doc Version 5.0 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) Care Management Group Limited Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 28/02/05 Brief Description of the Service: 101 Cheam Road is maintained, managed and staffed by the Care Management Group (CMG). The home, 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, within a half-mile’s walk of the home. A wide variety of shops, cafes and restaurants and other opportunities are available there, as are excellent transport links. Busses stop close by outside the house. Cheam Village is also not far too away (a bus 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 (for smoking) attached. There is also a small laundry cupboard and an office. There are sufficient bathroom / shower and toilet facilities throughout the home to meet all service users’ needs. The large garden at the rear is well maintained and there is a patio with garden furniture for service users’ use. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was conducted from later lunchtime into the evening of a weekday – with the senior staff assisting the inspector – and the manager, who was off duty, calling in to check that all was well. The Inspector was persuaded to participate in the evening meal by the home – so stayed for a very pleasant supper, engaging informally with all the current service users. During the visit the inspector had the opportunity to discuss the quality of the care provided with most service users (some in private), and to also engage with both the morning and afternoon shift staff members. A review of the previous requirements and recommendations was undertaken, with just two recommendations being brought forward into this report. Three new requirements have been set this time, all relating to health and safety issues (see below). Two new recommendations stem from the need to revisit the issue of service users being more involved (or at least actively engaged) in decision-making at the home, and the home needing to ensure that all policies and procedures are held on site as required by the Commission. What the service does well: What has improved since the last inspection? Two small safes have now been fitted in the office to ensure that valuables and monies are kept securely in safekeeping. The office also has new filing cabinets - which ensure the security of service user records. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 6 The downstairs bathroom has been transformed into a splendid new shower room – enhancing the facilities available to service users. The inspector was told the new facility was being used well. Both the kitchen and conservatory has been provided with new flooring, and one of the bedrooms has been provided with new furniture and flooring. On the administration side, the home now has a policy and procedure concerning pressure areas and the home now ensures greater involvement of service users in signing their review / care plan notes. A requirement about regularising the fire alarm testing to ensure a certainty of what is and what isn’t a fire system test has now also been taken on board. 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. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 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.V251122.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. 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 home has produced a comprehensive Statement of Purpose together with a 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. Service users have all been given a copy of the guide. The guide has photographs and clearly specifies the home’s room sizes. The recommendation that staff qualifications be more full described in this document was ‘in process’. The population at the home had changed by only one service user since the inspector’s last personal visit to the home in July 2004. A full assessment and comprehensive documentation was available to evidence that the home had clearly looked in to whether they were capable of offering this new service user an appropriate service. It appeared that the service user was settling in well, and the inspector was impressed by the way in which the new service user had been ‘absorbed’ into the daily routine / culture of the home. A six-week review of the placement indicated a very positive scenario developing. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 9 The home’s admission policy is conditional to a three-month’s ‘trial’ basis. In keeping with good practice, all the other service users would be consulted about the possibility of the prospective new service user eventually moving in on a permanent basis - and the permanence is confirmed after a thorough review. The home – registered for service users who also have challenging behaviour – inevitably has a number of service users who present also with elements of mental health issues. The inspector is satisfied that the three identified by the management as in this ‘dual’ category are principally presenting with a learning disability diagnosis, secondarily augmented by complex mental health needs / challenging behaviour. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. 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; consultation and sharing of information will involve and take into account the wishes and aspirations of the 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, though attention must be paid to ensuring that such risk assessments are introduced / kept upto-date at all times. EVIDENCE: Care plans inspected showed full consideration of service user’s individual needs. It is evident that these plans are based on assessments covering every aspect of a service user’s personal, social, emotional and health care needs. Individual plans referred to service user’s likes and dislikes, and individual action plans identified how service users would be supported to achieve their goals. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 11 Service users, their care managers, and relatives are all encouraged to participate in the annual review process, and the home is now ensuring service users sign, where possible their own review documents. Day-to-day notes were consistent and ‘Monthly reports’ are also made by the Keyworkers – highlighting areas of significance in these mini-reviews. The registered provider’s Finance Officer acts as ‘Appointee’ with regard to benefit issues for most current service users. Service users have their own personal bank accounts in their own names, where they keep personal allowance monies - and other sums. Some benefits are now paid directly into these bank accounts. Staff members encourage service users - who are willing and able - to manage their own financial affairs as far as practicable. The home, being a small community, runs - and relies on - on a cooperative spirit between the service users to ensure the smooth running of the house. Service users are encouraged to participate in organising the day-to-day 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 ironing it afterwards). Regular monthly service users’ meeting are held (minutes seen for the three most previous meetings in 2005) and most mealtimes - especially the main evening meal, when the community comes together, are also forums for discussion and debate about issues within the home. Half of the respondents to the Commissions Comment cards stated that they would like to be more involved in decision-making at the home; perhaps this is an area the home should revisit? A conversation concerning the rights of an individual to smoke, when in fact they had successfully given up for a number of years, was discussed with a service user. It is clearly their right to recommence such an activity (especially as some staff do smoke on the premises – in the conservatory) if they so wish – though this decision should be made, as with all decisions which may be detrimental to one’s health, within the context of fully exploring and understanding the ‘knock-on’ consequences to their health. Risk assessments were generally noted for each long-term service user within the home - specifically created to reflect the assessed situation for that individual. Clearly risk assessment is an important part of the ethos / thinking of the home, and are well covered in the associated documents. The home was appearing to rely somewhat too heavily on documentation from the previous placement in regard to the new service user at the home; staff admitted that the new service user’s care plan and risk assessments were yet to be fully created in the CMG / Cheam Road format. This was a sad omission Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 12 in an otherwise good aspect of the home’s administration. Clearly when a new service user is admitted, there should be a new, up-to-date summary of the risk assessments in particular – informed by up-to-the-minute information. This is vital to be able to support the newcomer as precisely as possible – and to ensure the safety of practice of staff and the protection of the individual and all service users at the home. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 – 17. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home, and to adopt a lifestyle suited to the individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choice and decision-making. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. EVIDENCE: All service users completed and returned a comment card to the Commission; all indicated they felt they liked living at the home, that thy felt well cared for, being treated well by the staff and they felt safe, with their privacy being respected. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 14 One service user had candidly stated on their comment card returned to the inspector: “I only like living here when there is no arguing.” The staff members are clearly supportive of individuals having the best opportunity to develop and maintain their social and independent living skills. Some service users were noted to go out independently; others stayed in and enjoyed their very pleasant home environment. Staff members encourage and accompany service users - where required - to social, shopping and activitybased locations. Service users have ‘Freedom’ travel passes, but a number really enjoy the activity of walking into the different town centres - and engaging with the local community en route. Due to the specific conditions of service users, there are no ‘jobs’ undertaken by any service users. The majority attend some form of formal day centre activity, and the house provides occupational focuses when they are at home. Some service users attend the Cheam Centre - and the SCOLA College has provided inputs of Pottery, Cookery, Reading & Writing and Computer classes. The staff confirmed that the home continues to be well accepted, locally, and has an excellent rapport with their immediate neighbours - sharing neighbourly activities such as an occasional summer barbecue - when the neighbours are ‘invited in’. Staff members support service users to maintain personal relationships with people they have met since coming to the home - and those who were friends before moving into 101 Cheam Road. Family and friends are always welcome to visit when they wish. The visiting policy is expressed in symbols as well as words. The service user may see visitors in the privacy of their 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 protection. Four service user’s friends or relatives responded to the Commissions comment card survey – all stating that they felt the home provided satisfactory care overall, that they were made welcome when they visited, and were generally involved and kept informed about their relative / friend’s progress. One respondent commented on the progress their loved-one had made – stating: “her general happiness and health is due to the manager and staff”. The home offers a choice of at least three menu options most evenings. Service users again confirmed that staff members encourage them to choose the menus, to go food shopping [usually without staff supervision], and they take it in turns to prepare the evening meal for the entire group. Alternatives are offered, and a record of this is maintained. Individual care plans also identify service users food preferences. Food is also made available to relatives or visitors - either eating with the other service users at regular mealtimes, or having the table separately to share with their friends / relatives. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. 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: Each individual service user is respected and supported in a positive way to ‘be themselves’ as much as possible. There is little in the routine of the house that is not to a large extent flexible - though of course, some service users rely on a presence of domestic routine to enable them to in-build their own activities. The idiosyncrasies of each service user are certainly acknowledged and respected. Interestingly, service users mainly avail themselves of a professional hairdresser who visits the home and undertakes styling on the premises. This provision is suited to the individual service user’s needs. Charges are reasonable, and more than competitive with outside services. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 16 Two service users avail themselves of a professional chiropodist; a charge of £28 per person is made in this regard. GP and other medical / health professional contacts are made as needed; records of these appointments / visits are appropriately maintained. A single GP practice cares for all service users - principally as all are out of area from their placing authority / original health care practitioner. Specialist practitioners monitor service user’s mental health on both an ‘as-required’ and regular 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. Records of medication administration were well maintained; all medicines received, administered and disposed of [via the Chemist], being auditable. Medication profiles were also available, and clearly identified service user’s current and discontinued medication regimes. The home’s procedures for administering ‘as required ’ (PRN) medication were well detailed to minimise any risks associated with its misuse. Assessments of service user’s willingness and capacity to self-administer their medication are actively undertaken; none currently do so. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. 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 home’s complaints procedure is included in the Service User Guide, which is available to all the home’s service users in a suitable language / format (e.g. symbols), and includes information about how to contact the Area Office of the Commission for Social Care Inspection should the complainant wish to do so. Two complaints were recorded as being investigated within the past twelve months – one relating to a service user’s behaviour towards another, and one relating to an issue of verbal abuse towards a member of staff. Both had been satisfactorily determined – at first level, local resolution. Finances are managed by the home in respect of all service users; suitable records are maintained for all transactions. Two small safes are now fitted in the office to ensure that valuables and monies are kept by the home securely in safekeeping. Service users stated in the questionnaire returned to the Commission that they felt safe at the house. Staff members who have attended the registered provider’s ‘Dignified Management of Conflict’ training – the home’s policy is to only use physical intervention as a ‘last resort’. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 18 Procedures for responding to suspicion or evidence of abuse, including Whistleblowing were available. Sutton Council’s Vulnerable Adult Procedures were available in the office; the inspector continues to recommend that it would be appropriate for the CMG policy to relate and refer directly to the LB Sutton Guidelines. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 – 30. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once the steps to cover exposed radiator surfaces in high-risk areas are undertaken, the home will be a safe environment in which to 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). The home is ‘ordinary’ in external appearance, in keeping with the local ambience; service users can feel as if they are living ‘at home’. The house is well maintained and kept clean and tidy. Furnishings are of good quality and care is taken with the décor throughout. 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 ‘pride’ in the house and the living environment’s standards. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 20 The premises has recently been inspected by a Fire Safety Officer of the London Fire & emergency Planning authority – and has been given a ‘clean bill of health’ with regard to fire precautionary measures. The home has a spacious entrance hallway, a large dining room and open-plan kitchen attached, and a pleasant lounge with TV and music centre etc, leading out into a comfortable conservatory, which is identified as the ‘smoking zone’ for service users and staff. Even though this is the smoking area, the ventilation provides enough that the ambience was clean enough for nonsmokers to use it when smokers were not around. The conservatory is often used for meetings / reviews. Both the kitchen and conservatory have been provided with new flooring surfaces. 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 stated that they were very happy with their room’s facilities and furnishings. All bedrooms viewed were decorated to a high standard; they were well furnished, and personalised to reflect the service user’s individual tastes. One of the bedrooms has recently been provided with new furniture and flooring. The downstairs bathroom has been transformed into a splendid shower room – enhancing the facilities available to service users. The inspector was told the new facility was being used well. One issue noted from this transformation of this particular room was the fact that the radiator in the shower room was not protected. Bearing in mind the developing age and potential frailty of some service users at the home, these areas must be covered to avoid the risk of burns from the hot surfaces. The home was certainly clean and free from any offensive odours at the time of the inspection. The home’s laundry facilities are located in a small room with a door off the kitchen area, and an additional entrance into the garden. 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 available to evidence all 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. All appeared to be in order, with just one noticed minor rectifiable omission. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 & 35. 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: Twelve staff members provide the ongoing service to the house; the staff team is a stable and consistent group of women; only the manager – Clara Deacon – has moved on, being promoted within the company, making way for a previously worker to return to the home to take over the role of manager. Staff job descriptions are comprehensive and linked to achieving service users goals as identified in their care plans. The 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 consistently with an absolute minimum of two care staff currently being available at all times, day and night. Two service users are also identified as requiring a certain number of hours of ‘1:1’ attention. Senior staff are ‘on call’ when not in the building. The pre-inspection questionnaire Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 22 confirmed that no agency staff had been used in the home in the past eights weeks; vacant shifts are covered by ‘bank’ workers, who work exclusively to this home, thus ensuring the all-important continuity for the service users. It is standard practice for CMG not to permit new members of staff to start work, until the company has obtained two satisfactory references from their previous employer, and a Criminal Records Bureau and PoVA check has been undertaken. Staff files hold signed acknowledgment letters from CMG’s Regional Director as proof that staffs CRB checks have been carried out and are held at CMG’s Head Office. The inspector can confirm that these have recently been fully verified by him at the CMG headquarters. The inspector was provided with documentary evidence, in the form of staff profiles - a full record of training - as proof of staff competency. Training in the ‘statutory elements’ (Basic Food Hygiene, First Aid and working with people with mental health issues) are being addressed; eight staff now currently hold a First Aid certificate – almost certainly, therefore, providing for First Aid cover to the home 24/7. All existing staff have undertaken the TOPSS induction / foundation course and new members of staff receive a structured induction within the first six weeks of their appointment and suitable signed and dated records are kept, to evidence they have read and understood the wide variety of policy and practice contents. It is compulsory for all new members of staff to attend the organisation’s ‘Dignified Management of Conflict’ training - and no members of staff would be allowed to practice any form of physical intervention with a service user unless they had first been trained to do so. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 40, 41 & 42. The home operates a set of management systems that ensures that service users benefit from a well-run and well-lead organisation. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures and the day-to-day conduct of the home. Service users can be assured that their welfare, health and safety is generally safeguarded through the home’s rigorous adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: The Acting Manager Mrs Margaret Mohamed has previously worked at the home before returning in the full management role. She has worked for CMG for six years. She is currently completing her NVQ in Management and Care at Level 4, leading to the Registered Manager’s Award. Team Leaders and senior Support Workers also support the management role within the house. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 24 The home has a role to play within the CMG Quality audits each year - and service user representatives and staff members are invited to attend a meeting where the quality of input at the homes is discussed. The registered provider also regularly interviews service users and their relatives on paper to elicit feedback about the quality of the service provision. It can again be confirmed that reports compiled by the home’s Regional Operations Manager following monthly, unannounced visits to the home, are regularly being forwarded to the Commission, in accordance 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. The previous requirement that a policy on ‘Pressure Relief’ be included in the Service and Care Delivery section has been met. Records seen at the home were generally well kept, accurate and up-to-date. 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. The home’s records were, in the main, up to date and well ordered. Health & Safety issues were generally satisfactorily dealt with at the home, however concerns were raised with regard to hazardous substances; some containers were found in a service user’s ensuite toilet (when they should have been returned to safekeeping), and others were stored (ironically) on top of the COSHH cupboard itself. There may well be a need to review storage capacity at the home – perhaps an overflow cupboard is needed. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cheam Road (101) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 x DS0000007154.V251122.R01.S.doc Version 5.0 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 YA7 Regulation 13(4) Requirement Risk assessments for service users must be kept up to date and certainly be put in place immediately a service user moves into the home. Protective covers must be provided for radiators located in bathrooms and toilets throughout the house – and in any other location where there is a risk of exposure of skin to hot surfaces. Timescale for action 07/09/05 2 YA29 13(4) 15/11/05 3 YA42 13(4) All hazardous chemicals must be 05/09/05 kept safely stored in a locked cupboard – in line with best practice and COSHH Regulations. Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 27 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 YA1 Good Practice Recommendations Details of all staff members’ qualifications and experience should be shown more comprehensively in the Service User Guide. It is understood action in regard to this is now ‘in process’ – though not available yet at the home. Half of the respondents to the Commissions Comment cards stated that they would like to be more involved in decision-making at the home; perhaps this is an area the home should revisit? It is strongly recommended that the provider’s policy with regard to adult abuse is amended to accurately tie in the approach required locally under the jointly-agreed London Borough of Sutton Vulnerable Adults Procedure Guidelines. The current April 2002 policy is not explicit enough about the agreed procedural routes for reporting an abuse issue. This remains an issue from previous reports. Policies and procedures identified as absent from the home in the pre-inspection questionnaire (Racial harassment incidents & record keeping) should be evolved and put in place within the home. 2 YA11 3 YA23 4 YA40 Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cheam Road (101) DS0000007154.V251122.R01.S.doc Version 5.0 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!