Inspection on 02/11/07 for Christ The King

This inspection was carried out on 2nd November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Christ The King 08/05/08

Christ The King 15/11/06

Christ The King 05/12/05

Christ The King 10/08/05

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 Christ The King 68 Tankerville Road Streatham London SW16 5LP Lead Inspector Lynne Field Unannounced Inspection 2nd & 5th November 2007 10:00 Christ The King DS0000055922.V343251.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 Christ The King DS0000055922.V343251.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. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Christ The King Address 68 Tankerville Road Streatham London SW16 5LP 020 8480 5028 020 8480 5031 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) The Healthcare Professionals Services Ltd Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2006 Brief Description of the Service: Christ the King is a small residential care home that aims to provide 24-hour care and support in an independent living setting in the community. It can take up to six residents, men or women aged 18 -65, who are experiencing mental health difficulties and need continual rehabilitation in the community following their discharge from hospitals or from other care institutions. There are six single bedrooms, four with en suite facilities. The registered provider said the current fees payable for each resident range from £750-00 to £1200-00 according to the assessment of needs of the resident. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on 2nd November 2007 and a return visit to check records on 5th November 2007. Both days of the inspection were well facilitated by the registered provider and the manager. The previous manager left before the last inspection in November 2006. The present manager, who at first was the acting manager and is now the manager, filled the post. She has been working at the home since it opened and knows the residents well, needs to apply to become the registered manager. There were six residents living at the home. The inspector spoke to all six residents and two staff during the inspection. Residents said they liked living at the home and had settled into the community well. The manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CSCI. This was taken into consideration. The inspection also involved the case tracking of four residents care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. What the service does well: What has improved since the last inspection? Care plans and risk assessments have improved to include more information and are being reviewed regularly. Statement of purpose and service user guide have been reviewed to include all the information residents would need to help them decide if they wanted to live in the home. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 6 Staffing levels continue to be more flexible to take in to consideration the social needs of the residents. 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. Christ The King DS0000055922.V343251.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 Christ The King DS0000055922.V343251.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): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information in the Statement of Purpose and Resident Guide has been revised to include details of the changes in the management of the home. Resident’s needs are assessed by senior staff before they move to the home and know that staff have decided that the home can meet their needs before they move there. Prospective residents and their relatives can come and look around the home and meet staff and have over night stays before they decide to move there. EVIDENCE: On the day of the inspection a prospective resident was being shown around the home with their carer. The manager said a trained nurse always went to see the resident to do an assessment where the resident was living and gather information about the resident then the prospective resident would be invited to come to spend time in the home and meet all the residents living there. If they liked it they would come for a day with any friends or family. If this is successful there would be a discharge meeting when the whole care package is put together. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 9 One resident has been admitted to the home since the previous inspection in November 2006. The inspector was shown the statement of purpose and resident guide and noted these had been reviewed and updated to include all the information relating to the changes in the management of the home. The inspector saw each resident had a copy of the statement of purpose and resident guide in their bedroom. At this inspection four residents files were case tracked. All contained a community care assessment and the relevant assessments and summary of needs that were completed by the home before the resident came to live there were seen on file. The inspector noted the care plans gave a thorough description of resident behaviours, reactions and preferences and how the resident was to be treated. There were immediate, medium term and longterm goals and these are reviewed monthly and recorded. Risks were identified and how these would be minimised, with actions agreed and recorded. The inspector spoke to the resident who had moved in most recently and they said they had visited the home before moving in to see if they liked it. Christ The King DS0000055922.V343251.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Families and other professionals are involved when reviews are held. Residents are consulted and supported to make decisions about their lives by staff and appropriate independent professionals. Care plans are thorough and reflect residents’ needs and goals. These are reviewed every six months or when the need arises. EVIDENCE: The inspector checked four residents’ files. One was the new residents file. The inspector noted the care plans gave a thorough description of resident’s behaviours, reactions and preferences and how the residents were to be treated. The manager told the inspector care plans are developed from the pre admission assessments and in consultation with the resident, their family, care co-ordinator and other professionals involved in the residents development. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 11 All residents have a primary nurse and an associate nurse working with them who are their key workers. The primary nurse (qualified nurse) is responsible for reviewing the care plans every six weeks or earlier following an incident or if there is concern about a resident. Risk assessments are reviewed at the same time as the care plans or when the need arises. For example one resident was not maintaining good oral hygiene and a very detailed care plan was developed to address this issue. All care plans seen had been reviewed and have been signed by the key worker or manager and the resident. The manager said the risk assessments from the previous placement would be checked and then the home would develop their own risk assessments to suit the residents changing needs. The inspector was shown copies of the resident’s reviews that had been held with all relevant professionals. One residents relative had a particular concern about them and this was discussed at the review and an appointment to see her GP was made to see what could be done about the concern. At the previous inspection, the inspector was told that one of the homes placing authority’s had intended to move three residents to another placement. The residents told the inspector they “liked it at the home and had come to know the area” and did not want to move. Croydon Advocacy Service supported the residents in the consultation process and it has been agreed the residents can continue to live in the home. The inspector met and spoke to all the residents during the course of the inspection. The residents were welcoming and relaxed and the inspector observed interaction between staff and residents as well as interaction and noted they were respectful of each others views and opinions. Two residents were due to visit their GP on the morning of the inspection but one was reluctant to go. The manager discussed the reasons why they needed to go with the resident and an agreement was reached. The home has monthly home meetings and residents views are expressed and acted on where possible. Families are encouraged to participate in social events and birthday parties of their relatives. Christ The King DS0000055922.V343251.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): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to develop independent skills and interests as well as access the community with the support of staff when required. Families and friends are encouraged to keep in touch with the residents and participate in social activities. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents’ rights and responsibilities are respected. A healthy diet is provided, which the residents enjoy. EVIDENCE: Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 13 The inspector saw copies of residents meetings and staff meetings where staff and residents have discussed the choice of activities. These happen every two months. Residents said they felt free to say what type of activity they wanted to take part in. One member of staff has taken the lead in identifying and facilitating appropriate activities in the community and another has taken on the role of facilitating home activities. Each resident has a copy of their individual weeks activities in their bedroom. The activities programme is designed to meet each resident’s individual needs. The inspector noted that some of the weekly activities were related to independent living skills, such as cooking, laundry and keeping their room clean. Residents are also encouraged to take part in activities commissioned by outside specialists such as reflexology, aromatherapy and healthy eating. In this way resident’s are supported and encouraged to take part in activities that are enjoyable, beneficial to their mental and physical health and which give them the opportunity to develop skills within their abilities. Residents said if they need to or want to change an activity they would discuss this with a member of staff. The home celebrates all faiths of the residents and all residents want to join in each other’s celebration. At the last inspection the inspector attended a resident / staff meeting where they were planning how to celebrate Christmas in the home. The inspector asked how this affected residents who are of other faiths in the home. The residents said although they are of different faiths and cultures, one from India, one from Mauritius, one from Sri Lanka and two from Britain they all wanted to celebrate Christmas. One resident is hoping to move on soon. They have become more independent since moving to the home and have expressed a wish to move on. The home is working with the resident and other professionals to facilitate this. The inspector was told they went out every day to various activities that they have arranged to take part in. These are such things as Marshal Arts, Judo and goes to the Hare Krishna temple. He has a bus pass, which he uses to travel all over London and when he lost it he was able to go to the police to report it lost. One resident said they spoke to their family every week. Another resident goes to visit their family and their relatives are always visiting and keeping in touch. Relatives are encouraged to visit the home and keep in contact with the resident. Relatives said “the home keeps them informed about what is going on in the home and the only way they knew about a review meeting was by the home telling them it was to take place”. A member of staff spoke to the inspector about an outing that had taken lace the previous weekend. She said she had taken three residents out at the same time. One resident was going to visit a relative and while they were on their visit she took the opportunity to take two other residents out shopping in a local market which they enjoy doing. The inspector was invited to join the residents for their midday meal, which looked tasty and well cooked. As at the previous inspection, residents told the Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 14 inspector they enjoyed the meals served at the home. One resident takes pride in cooking their ethnic meals on a regular basis and another continues to do so once in a while. The resident told the inspector they went out with a member of staff to shop for the type of food she wanted to eat and cook. The manager said they always have a choice of rice or potatoes with the meal because one resident only likes potatoes and another only likes rice. The residents and staff have a number of favourite restaurants they visit locally in the community. The inspector was told everyone goes out for a meal once every two weeks to promote social inclusion in to the community. Residents showed the inspector photos from the holiday they had in Bournemouth in the summer and said how much they had enjoyed it. Christ The King DS0000055922.V343251.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Medication handling and procures are not safe. Residents could be put at risk when the procedure for the administration of medication is not followed. EVIDENCE: The residents files inspected, contained all the information staff need to support the residents in their preferred personal care routines and details of how much help an individual requires with different personal care tasks. The record of health appointments attended indicated that staff supports each resident if this is what the resident requires, to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. This included the outcome of the appointment. The manager said the home does not accept implied consent and they always discuss appointments with Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 16 residents and if a resident initially says they do not want to attend, the reasons why will be discussed and a solution found. As part of the residents daily living development plan, each resident is encouraged to take part in the running of the home and has household chores that they do on a regular basis. These are discussed and agreed at the residents meeting, with residents stating what they want to do. The inspector saw this in practice on the day of the inspection when residents helped cook the midday meal and clear away afterwards. Four of the resident’s medication was checked. There is now a running total system that was discussed at a previous inspection in February 2006. This has made it possible to check more easily if there has been a medication error and to know when this had happened. The inspector checked four residents medication and found many medication errors and overall the handling of medication and procedures were found to be unsafe. This was discussed fully with the registered provider and the manager. The inspector was told staff have had medication training and only the trained nurses dispense medication. The manager must reinforce the seriousness of medication errors particularly by trained staff. The manager was to immediately conduct a full audit of all the medication in the home and to speak to all staff responsible for dispensing medication. The manager told the inspector she does a medication spot check every week and records this on the medication charts. This needs to be much more robust. The inspector was told they were discussing with the pharmacist and GP the possibility of the home having the medication in blister packs. The manager said if a mistake was made, the manager would immediately contact the member of staff involved and dealt with in supervision and through refresher training. Medication issues are discussed at staff meetings and in supervision. Christ The King DS0000055922.V343251.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. Practices and training at the home ensure that residents are protected from abuse. Residents confirmed that they felt their views were listened to and acted upon. EVIDENCE: There is an adult protection policy and procedure in place including whistle blowing. In addition, there is an appropriate restraint policy, stating that restraint should be used only as a last resort. Care staff spoke to the inspector during the inspection and said there were different types of abuse, not just physical abuse, such as verbal abuse and financial abuse. They said if they suspected abuse was happening they would reassure the service user and report what they suspected to the manager. There had been one complaint from a neighbour and this was being dealt with appropriately. The manager told the inspector all complaints are taken seriously and appropriate action had been taken to ensure all complaints were addressed immediately. The inspector had been kept informed about the nature of the complaint and how it was progressing. Residents meetings are held every two months. The inspector was shown minutes of the meetings and noted that residents are encouraged to speak out Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 18 about any concerns they may have. Residents were put in touch with the Croydon Advocacy Service, an independent advocacy service, to help them speak out about how they feel about the proposed move to another unit and this helped residents feel they had more control. The home told the inspector they were aware that because of the mental health issues the residents have, relying on written documents to facilitate complaints can be disempowering and they endeavour to find other ways of empowering them. They said they need to continuously educate the residents about the complaints procedure and their right to complain. The manager said they maintain a reflective log on all complaints received to enable them to proactively deal with situations before they arise, by observing a trend. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,2830 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable with adequate private and shared space, toilets and bathrooms. Residents’ bedrooms promote their independence. The home is well maintained and furnished. EVIDENCE: Two residents showed the inspector around the home. There is a range of communal spaces, including large lounge / dinning room. The garden has a raised patio area that has been extended to include a walkway to the large heated outhouse that is used for some of the homes activities. Residents are encouraged to smoke outside but in the colder weather they use the heated out house when it is not being used for activities. There is a personal computer available in the lounge area for use by the residents. The large kitchen leads off the dinning area and there is a laundry, which is next to the kitchen, has a washing machine and a dryer. The inspector noted the door between the Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 20 kitchen and the living area, which is a fire door, was being propped open. The inspector spoke to the manager who says the residents like to have the door open for easy access. If this is to continue it should be fitted with a fire door guard. Opposite this is a small toilet with a wash hand basin. There is a sink installed for clothes that need to be hand washed. Residents told the inspector they were supported by the staff to do their washing and ironing. The provider told the inspector they had decorated the hall, stairs, landing and kitchen while the residents were on holiday in Bournemouth. The inspector noted some of the kitchen cabinet doors were loose and the provider said the homes maintenance man was in the process of finishing off the kitchen. There are six single bedrooms over three floors. There is one bedroom on the ground floor and all bedrooms are of adequate size with four having en-suite facilities. Both residents who showed the inspector their bedrooms said they were happy with their bedrooms and they had been able to make them homely by bringing personal possessions. The home is clean and well maintained. It is decorated and furnished in a comfortable style. The staff and residents continue to do a good job keeping the house clean. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to be supernumerary to be able to carry out her management role effectively. Staff files need to be audited and any shortfalls needs to be addressed to ensure the residents are protected by the homes recruitment policy and practices. EVIDENCE: The inspector was shown the staff rota and noted that there was always a Registered Mental Nurse on shift as agreed with the relevant care manager who indicated they would not be happy to place a resident in the home unless there was an RMN on every shift, particularly at night when problems when some residents can become more unsettled. The inspector noted the manager is not supernumerary and is counted as one of the two staff on duty. This means she has to fit in her management work around the activities of the residents and the home. During the course of the Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 22 inspection there were constant interruptions on her time by residents who needed her help and support. The other staff member escorted two resident to their GPs appointment, so was not available. If this is what happens during the course of an ordinary working shift, it would make it extremely difficult for her to carry out her management duties effectively. During the inspection the manager phoned to as permission to get an extra member of staff to cover her during the shift and the provider agreed to this. The inspector recommended the manager is supernumerary at all times. The inspector discussed this fully with the provider and manager on the first day of the inspection and the provider said the manager was able to get extra staff should the need arise. The inspector checked back copies of the rota and was unable to find many occasions when this had been done. On the second day of the inspection was told it had been agreed the manager would be supernumerary. The registered provider said she came to the home almost every day and attended staff and resident meetings. Copies of the meetings were seen by the inspector and indicated that the home had a high level of commitment to raising the standards of care the residents were receiving. The manager emphasised the importance of staff training and encouraged staff to come up with new ideas that will improve the quality of the service. The registered provider reinforced the importance of team working and consistency in the delivery of care. There were copies of the certificates of training the staff had received held on their files. This included induction training and mandatory training, diversity and equality training. The inspector spoke to two staff and checked eight staff files during the course of the inspection. Three were new members of staff, one who had started two weeks previously who did not appear to have had a CRB check. The manager said they had applied for one but there was no evidence of this in the file. This needs to be addressed and evidenced on the staff file. On other staff files viewed there were two written references, a signed copy of their contract stating terms and conditions and Criminal Records Bureau checks as required including confirmation of training that has been undertaken. The inspector noted several staff had CRB checks that were more than three years old. It is good practice to up date CRBs every three years. See recommendations. The manager said she was doing teaching sessions/ workshops on Mental Health issues, Medication, How to defuse a situation and stop it escalating. She followed this up with handouts. Staff told the inspector they had regular supervision every six weeks and the inspector noted there were copies for the supervision notes on file, that were signed by the manager and the member of staff. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a home that is well run and managed. This will be endorsed when the acting manager is registered with CSCI. Senior management roles in the organisation promote clarity, accountability and promote the best interests of residents. EVIDENCE: The manager is a trained registered mental health nurse who needs to apply to become the registered manager. A requirement has been given about this. She has worked in the service since the home opened and knows the residents well. As stated above, the manager is not supernumerary and is counted as one of the two staff on duty. This means she has to fit in her management Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 24 work around the activities of the residents and the home. The inspector recommended the manager is supernumerary at all times. Residents are given the opportunity to give their views of the home at residents meetings, which were recorded in the minutes of the meeting that are held every two months. The inspector was shown copies of the minutes of the meetings. The inspector was shown copies of the completed residents surveys and they were all positive. Staff and residents said they have confidence in the manager and there is a relaxed feel about the home. Residents told the inspector they felt that their views were listened to at residents meetings and they felt they could speak to the staff about any concerns they had at any time. The home has policies and procedures in place around health and safety. The inspector was shown the records relating to health and safety measures and servicing of the equipment and these were correct and up to date. Fire safety records evidenced that fire alarm call points are carried out weekly and regular fire drills had taken place at different times to ensure all staff are familiar with the process. Christ The King DS0000055922.V343251.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 2 25 3 26 X 27 3 28 3 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 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 3 3 X X 3 x Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Timescale for action 05/11/07 2 YA24 23(4) 3 YA34 19 (1) (2) (3) (4) 8 (2) (a) 4 YA37 The registered person must ensure that all medication is administered and recorded correctly at all times. The registered person must take 31/12/07 adequate precautions to protect the home from fire by keeping the kitchen door closed or fitting it with a fire door guard. The registered person must 31/12/07 ensure that only staff that are fully vetted before being employed at the home. The registered person must 31/12/07 ensure an application for the registration of a manager of the home is made to the Commission for Social Care Inspection. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 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 2 Refer to Standard YA34 YA37 Good Practice Recommendations It is good practice to up date CRBs every three years. The inspector recommended the manager is supernumerary at all times. supernumerary at all times. Christ The King DS0000055922.V343251.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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