Inspection on 04/08/06 for Cleveland House

This inspection was carried out on 4th August 2006.

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

The inspector found 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cleveland House 16/08/07

Cleveland House 12/01/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Cleveland House 1 Cleveland Road South Woodford London E18 2AN Lead Inspector Jackie Date Key Unannounced Inspection 4th August to 8th August 2006 10:30 DS0000066298.V307035.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 DS0000066298.V307035.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. DS0000066298.V307035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleveland House Address 1 Cleveland Road South Woodford London E18 2AN 020 8530 3591 020 8252 2283 info@cmg-corporate.com www.caremanagementgroup.com Care Management Group Limited 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) Mrs Pamela Hamilton Care Home 10 Category(ies) of Learning disability (10) registration, with number of places DS0000066298.V307035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Cleveland House is a ten-bedded home for adults with learning disabilities and challenging behaviour. The building does not have any adaptations for people with physical disabilities and would not be accessible to wheelchair users. It is in a residential area of South Woodford close to local shops and amenities and to transport networks. At the time of the inspection there were eight residents, four males and four females, living at the home. Most of the residents have limited communication. Some residents access day services, others are supported in community based activities by the staff team. The scale of charges per week for each resident range from £1,200 to £2,000 per week. This information was provided in the pre inspection questionnaire. Information about the service provided is contained in the service users guide. DS0000066298.V307035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about nine hours and took place from 10.30am on the first day. The manager, staff and all of the residents were spoken to. All of the communal areas and some of the bedrooms were seen. Staff, care and other records were checked. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector also attended a staff meeting. Due to the level of their disability most of the residents were not able to give any direct feedback about the care that they receive and relatives and other professionals were contacted and asked for their opinions of the service. Feedback was received from five relatives and one professional. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? A lot of work has been done to make the house better. It has got new windows, a new lounge and a new kitchen has been fitted. Some of the bedrooms have been decorated and have had new carpets and furniture. All of this looks very nice and comfortable. The residents like to use the new lounge. A lot more work is going to be done and when it is all finished the house will be a more comfortable and homely place for the residents to live. The staff have had a lot of training to help them to do their job better and to meet residents needs. Most of the residents have had reviews and are starting to go out more and there is now a seven-seater people carrier for people to go out in. DS0000066298.V307035.R01.S.doc Version 5.2 Page 6 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. DS0000066298.V307035.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 DS0000066298.V307035.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service. The required information was not available about the newest resident and therefore staff do not have sufficient information to fully meet this persons needs. Prospective residents and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. Residents do not have fully costed contract/statement of terms and conditions and therefore do not have detailed information about the service that they are entitled to. EVIDENCE: A resident had moved into the home just over a week before the inspection visit. The paperwork with regard to this individual was examined. This person was at a residential school and therefore was only able to visit a few days before he moved into the home. The manager went to visit the person with the assessment team from the organisation. A copy of the organisations assessment was not on the individuals’ file. There was information from the school but this was dated November 2004. Therefore insufficient and up-todate information was not available on the newest resident to enable the staff team to fully identify his needs. Comprehensive and up-to-date assessments DS0000066298.V307035.R01.S.doc Version 5.2 Page 9 must be carried out on all residents prior to their admission to the home. This information must be available at the home to ensure that staff are fully aware of an individuals needs and how to meet them. Information was also available about a prospective resident. The organisations assessment was available and he had also visited the home. However the manager had identified discrepancies in the information provided by his current placement and therefore delayed his admission to the home until these were clarified and she was able to establish clearly that the service would be able to meet his needs. In the interim staff are going to his current placement to work with him and to get to know him better as he has complex needs. Some of the residents have contracts/terms and conditions with the previous proprietor. Although there were some examples of blank contracts with the new organisation none of these had been completed. Therefore it was not possible to confirm that residents have detailed information about the service that they are entitled to. Residents must have fully costed contract/statement of terms and conditions so that they have detailed information about the service that they are entitled to. DS0000066298.V307035.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Residents’ plans contain detailed information so that staff can meet their needs. However residents’ plans and risk assessments have not all been reviewed recently and therefore may not contain up to date information about their needs. EVIDENCE: DS0000066298.V307035.R01.S.doc Version 5.2 Page 11 All of the residents have plans which give details of how they need/like to be supported. At the time of previous inspection the manager said that they would be introducing the care planning process that was used by the organisation and that all residents would have a review before this happened. It was anticipated that all of the reviews would be completed by the end of March 2006. Some of the residents have had reviews and their care plans have been updated but not all of them. Information was available in the file of one of the residents that has not yet had a review. This was in the process of being updated and had an action plan and some photos to assist her to understand it. It is important that reviews take place regularly and that care plans are updated to ensure that staff have up to date information about residents’ needs and how they should be met. One of the plans seen also clarified the resident’s cultural needs and confirmed that they did not practise their religion, had no specific food requirements but that their family would wish them to have a Jewish funeral. In view of the fact that progress has been made towards meeting this requirement the date for completion has been extended. However continued failure to meet outstanding requirements may result in the Commission taking enforcement action. The degree to which most of the residents can be involved in the development of their care plans is very limited due to their profound learning and communication difficulties. There was evidence that families had been invited to reviews and one of the residents was able to confirm that she was involved in decisions affecting her. Daily recordings are made about what each person has done and support that they have been given. However these recordings are not always very detailed and tend to cover things like personal care, medication and meals. For example one entry seen said that the person had personal care, gave details of what she had eaten and said that she had spent time folding papers in her bag. Recordings need to be more specific and detailed and linked to individual plans. This will ensure that there is detailed information about each resident, which can be used as part of the review process and to identify ongoing and changing needs. There are risk assessments in place. These identify risks for the residents’ and staff and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Some of the risk assessments have been reviewed and were up to date but not all. In one file risk assessments were dated November 2004. Risk assessments must be up to date and reviewed regularly to ensure that staff have up-to-date information about risks to residents and how to minimise them. This will help to keep residents safe. DS0000066298.V307035.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The residents are encouraged to take part in activities and to be part of the local community but this needs to be developed further to ensure that they have as fulfilling a lifestyle as possible. Residents are supported to keep in contact with their relatives and relatives are welcomed at the home. Residents are given meals that meet their needs and individual preferences. EVIDENCE: Residents are encouraged and supported to do as much as they are able for themselves. For example one residents care plan says “encourage him to take his dirty clothes to the laundry”. Another resident enjoys helping in the kitchen and in particular making cakes. Two of the residents attend day services for all or part of the week. Residents are supported to take part in a variety of activities both in the home and in the community. For example DS0000066298.V307035.R01.S.doc Version 5.2 Page 13 going to the cinema, pubs, shopping, the park, out for lunch and bowling. Female residents went on holiday earlier this year and the male residents will be going on holiday in the near future. On the day of the inspection a new seven-seater lease vehicle was delivered to the home and this will be used to take residents out. Photographs were seen of one of the residents on a trip to London. They included pictures of him on the tube, at various museums and in Trafalgar Square. He looked very happy in all of the photographs. Overall there has been an increase in the amount of activities that residents take part in. However feedback from some of the relatives and some of the staff that this was still insufficient and needed to be developed further. The requirement from the previous inspection has therefore not been fully met. However due to the improvements that have taken place the timescale for this to be fully met has been extended to allow for more activities to be developed. Work is underway to develop and improve communication with the residents and to assist residents to make choices and express how they feel. Key rings have been made that can be taken out with residents. They contain small pictures to assist people to show what they want. E.g. I want to go to the toilet. Also feelings boards are being developed with pictures of different emotions and feelings. For those residents that it is appropriate for pictures have been used to develop a flow of the day to show them what is going to happen. All of this is very good work and the development of these communication ideas needs to continue, as this will assist residents to make their needs and feelings known. All of the residents have contact with their families and many of their relatives visit the home regularly. One resident went on holiday to Spain with her family and another is due to go on holiday with her family in the near future. One relative said, “the staff are always welcoming. My sister settled in really quickly and I think that it is all down to the jolly feeling you get there”. Another relative said that he was very pleased with the service. Some of the residents are able to say what they want to eat and are able to contribute to the menu planning. Staff use their knowledge of others likes and dislikes when planning the menu. The manager has made menu cards to assist residents to make choices about what they eat. There are pictures of various different foods and residents can choose from these and then they can be stuck onto a menu board. None of the residents have any special dietary requirements but some residents are being encouraged to have healthier options to assist with weight control. Records are kept of what each person has to eat. DS0000066298.V307035.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. The administration and recording of medication needs to be improved to ensure that the residents are given prescribed medication as safely as possible. EVIDENCE: The residents require differing amounts of support with their personal care, but most are dependent on staff to meet their personal care needs. Details of the help that they need and how they prefer to be supported are in their individual plans. For example “will wash face when verbal prompt given.” “Give him the choice of a bath or shower”. Female staff support the female residents with their personal care. There is a risk assessment for bathing for one of the residents that has severe epilepsy. Therefore residents receive appropriate personal care. All of the residents go to the local doctor and specialist help is received from the community learning disabilities team. Staff take residents to all of their medical appointments. Residents’ files contain details of health care issues DS0000066298.V307035.R01.S.doc Version 5.2 Page 15 and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and, when needed, the chiropodist and community nurse. Feedback from a relative was that the residents are well cared for. Feedback from one social worker was “ the home is of a high standard, has given my client a positive and stabilising experience. I would have no hesitation in recommending this provision for clients with to be administered in the event of a seizure. Training has been arranged for staff to enable them to administer this. In the interim staff have been instructed to telephone an ambulance if this person should have a seizure. Therefore residents’ healthcare needs are being met. None of the residents are able to self medicate and medication is administered by two staff who both sign the record sheet. One of these is usually the senior member of staff on duty. Staff cannot administer medication until they have been deemed competent. They are required to complete a series of questions, which are marked by the manager. The pharmacist provides this question booklet and staff get a certificate when they have completed this satisfactorily. Assessments of staff are on file. Medication is stored in a locked trolley, which is fastened to the wall in the main office. The home also has a controlled drugs cabinet but none of the residents are prescribed any controlled drugs. Examination of the MAR (Medication Administration Record) found that there were several handwritten entries. For accountability any handwritten amendments or additions to Medication Administration Records (MAR) sheets must be signed and dated by the person making the entry. Examination of the medication trolley found that the requirements with regard to medication from the previous inspection had been addressed. Some residents receive PRN (as required) medication and protocols/guidelines are needed for all of these to ensure that all staff know when to give this medication and for what purpose. There are not any detailed guidelines in place on the action to be taken in the event of a medication error occurring and these are needed to ensure that staff are quite clear on the action that must be taken. Specific advice on this was given to the manager at the time of the visit. This will ensure that medication is administered as safely as possible and any problems that might arise are appropriately dealt with. The file of one of the residents indicates the familys wishes in the event of his death and clearly states that they wish him to have a Jewish funeral. DS0000066298.V307035.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. There is a complaints procedure, available in a user-friendly format that would be followed in the event of any complaints being made. Most staff have now received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. EVIDENCE: The complaints procedure is in a pictorial format to help residents understand how to complain. This contains photographs of the manager, service manager and the Inspector. However due to the degree of their disability is unlikely that most of the residents would be able to make a complaint without support. There was one recorded complaint made by a day service on the behalf of one of the residents. The manager dealt with this appropriately. The organisation has a protection of vulnerable adults procedure and the manager was aware of the action that needs to be taken in the event of an allegation or suspicion of abuse. The majority of the staff team have received protection of vulnerable adults training and the rest will be receiving this in the near future. There have not been any recorded incidents of restraint being used for some time. However this may be necessary if the prospective resident moves into the home. If this is the case a protocol will be developed. In addition to this staff are in the process of doing “Digman” training, which focuses on the dignified management of challenging and aggressive behaviour. DS0000066298.V307035.R01.S.doc Version 5.2 Page 17 A random selection of residents’ finances was checked and cash amounts held agreed with records. Receipts were on file. Residents’ monies are securely stored and checks are made at each handover. DS0000066298.V307035.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, but 29 and 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The residents live in a clean home that is suitable for their needs. Ongoing improvements are making it more homely and have given residents a choice of communal spaces. EVIDENCE: The house is in South Woodford and is near to the local shops, bus routes and a train station. The communal areas comprise of a combined lounge diner, a quiet room with TV, a garden area, kitchen and laundry. Each resident has a single bedroom with an ensuite toilet and hand basin. There are enough baths, showers and toilets to meet the residents’ needs and none of the current residents need any special adaptations. Since the current organisation took over the home a great deal of work has been carried out to improve the environment. New windows have been fitted, the new lounge has been developed, a new kitchen has been fitted and several of the bedrooms have been redecorated, re-carpeted and new furniture purchased. In addition a new laundry has been created and an industrial DS0000066298.V307035.R01.S.doc Version 5.2 Page 19 washing machine and dryer installed. The areas that have been redecorated and refurbished have been done so to the good standard. They are extremely comfortable and homely. One of the residents said that she chose the colours for her bedroom. Another resident’s bedroom is about to be decorated and a flag from Ghana has been purchased to mount on the wall to reflect his own culture. Staff spoken to the said that the additional lounge space had been very beneficial and the residents appear to enjoy spending time in there. The rest of the work needed in the home, which includes a refurbishment of the bath and shower rooms and some further redecoration, is planned and will be completed as soon as is practicable. Therefore no requirements have been made with regard to this. If the remainder of the work needed at the home is carried out to the same standard the minimum standards for the environment will be exceeded. The home appeared to be clean and there were not any unpleasant odours. DS0000066298.V307035.R01.S.doc Version 5.2 Page 20 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): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Staff are receiving the necessary training to give them the skills to meet residents’ current needs and provide an appropriate service for them. Staffing levels are sufficient to allow for this. Sufficient evidence was not available to confirm that the necessary checks are carried out on staff prior to employment. This is needed to establish whether systems are in place to protect residents. Staff need to receive more regular formal supervision to ensure that they have the opportunity individually to discuss their own development and any problems and developments within the service. EVIDENCE: There are a minimum of four staff, including a senior, on duty during the day and two waking night staff. Staffing levels are adjusted, if needed, to cover appointments and activities. The manager stated that when visits were taking place to the prospective resident an additional member of staff would be on duty. The shift pattern has changed recently and staff now no longer routinely work long days. The daytime shifts are now 8 a.m. to 3 p.m., 2 p.m. to 9 DS0000066298.V307035.R01.S.doc Version 5.2 Page 21 p.m., with an additional 10 a.m. to 7:30 p.m. shift to cover the day activities. This shift pattern is in line with good practice. Feedback from relatives was that they felt that there were adequate staff on duty. Feedback from staff was that this staffing ratio was adequate but there had been times when there had been some staff shortages. However there is now a good list of bank staff and recruitment has been taking place. The manager is supernumerary. At the time of the inspection the deputys post was vacant. At the time of the previous inspection it was recommended that a programme of team building and team development be implemented. Since the last inspection there have been several staff changes and recruitment is still ongoing. It is therefore recommended that once recruitment has been completed this recommendation be implemented to assist the new staff team to work together to meet the needs of the residents. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. Staff records are held centrally at the organisations head office in line with an agreement made with the Commission. However there was insufficient information held at the home to confirm that all of the necessary checks had been carried out and that all of the necessary information had been gathered. Therefore it was not possible to confirm that all of necessary staff records are held or that the recruitment procedure is robustly followed. Evidence must be available at the home that all of the necessary staff checks have been carried out and that all of the necessary staff records are held by the organisation. The Commission has developed a written pro forma that should be completed and signed by a representative of the organisation and kept at the home. From discussions with staff and looking records it was apparent that the organisation had been providing a lot of training to staff. New staff have had a formal induction and other training has included protection of vulnerable adults, first aid, makaton, autism and report writing. Two staff are doing NVQ level 3 and the manager is doing the assessors course to enable her to assess staff for the NVQ. Four of the new staff are registered to do NVQ in September. Therefore the staff team are being provided with the training and skills that they need to meet the needs of the residents. Staff spoken to confirmed that they have been receiving supervision but due to the fact that the deputy has left the manager has been doing all of the supervision. Therefore it has not been as frequent as it should be. The manager said that the senior staff are due to receive supervision training and when they have had this they will be taking over some of the supervision. Staff spoken to said that they feel able to talk to the manager and to the service manager about any concerns they might have. The previous inspection required that arrangements must be made so that staff receive regular, recorded supervision at least six times per year, to give an opportunity for monitoring of work and professional guidance. Also for staff to discuss DS0000066298.V307035.R01.S.doc Version 5.2 Page 22 concerns individually. In view of the progress towards meeting this requirement the timescale for completion has been extended. DS0000066298.V307035.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and although some checks are needed on window restrictors, provides a safe environment for the residents. The registered provider monitors the service appropriately to check the quality of the service provided to residents. EVIDENCE: The manager has a lot of experience of working with people with learning disabilities and of managing residential services. The Commission registered her earlier this year. Feedback from one relative was “she is doing a brilliant job and things have improved leaps and bounds”. Staff said that they could talk to the manager and that she was approachable. The home is well managed. DS0000066298.V307035.R01.S.doc Version 5.2 Page 24 The quality of the service provided to the residents is monitored by the home manager and by the organisation. A representative of the organisation has been carrying out monthly monitoring visits as required by the previous inspection and a member of staff said that she was able to talk this person about any issues. One of the recent reports gave information about discussions with one of the residents and therefore it is apparent that residents’ views are sought as far as possible. All of the necessary health and safety checks are carried out and the home received a satisfactory report following a visit by the fire service in February 2006. There is a fire procedure but this does not cover the action that should be taken in the event of a fire during the night. A fire procedure must be developed to ensure to all staff are aware of the correct action to be taken in the event of a fire at night when all the residents are in bed and less staff are on duty. A new call system has been installed in the home and staff and residents, that are able, can summon assistance when needed. As stated previously new windows have been installed as part of the physical improvements to the home. Window restrictors have been fitted to prevent windows from opening too far. However during the first visit the restrictor had been undone on an upstairs landing window, and during the second on a window in resident’s bedroom upstairs. This was discussed with the manager and addressed immediately on both occasions. Window restrictors must be used at all times to protect residents. If residents are able to easily undo the restrictors then the type of restrictor will need to be changed to ensure that not only do they meet fire requirements but also that residents are kept safe. DS0000066298.V307035.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 X 2 2 3 X 4 3 5 2 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 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 X X 2 X DS0000066298.V307035.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 YA2 Regulation 14 Requirement Comprehensive and up-to-date assessments must be carried out on all residents prior to their admission to the home. This information must be available at the home The organisation must provide each resident with a fully costed contract/statement of terms and conditions as detailed in standard 5.2. Care plans must be reviewed with the resident and significant others at least every six months and updated to reflect changing needs. (Previous timescales of 31/07/05 & 31/03/06 not met). Timescale for action 31/10/06 2. YA5 4,5 31/10/06 3. YA6 15 31/10/06 4. 5. 6. YA6 YA9 YA14 15 13 16 Daily recordings need to be more 31/10/06 specific and detailed and linked to individual plans. Risk assessments must be up to 30/09/06 date and reviewed regularly Residents must be supported 31/10/06 and enabled to take part in appropriate activities both in the home and in the community (Previous timescales of 30/04/06/ not met). DS0000066298.V307035.R01.S.doc Version 5.2 Page 27 7. YA20 13 8. YA20 13 9 YA20 13 10. YA34 17,19 11. YA36 18 Any handwritten amendments or additions to Medication Administration Records (MAR) sheets must be signed and dated by the person making the entry. Individual protocol/guidelines must be in place for the administration of PRN (as required) medication. Detailed guidelines must be in place on the action to be taken in the event of a medication error occurring. Evidence must be available at the home that all of the necessary staff checks have been carried out and that all of the necessary staff records are held by the organisation. Arrangements must be made so that staff receive regular, recorded supervision at least six times per year. (Previous timescale of 30/ 04/06 not met). A night time fire procedure must be developed. Window restrictors must be used at all times to protect residents. If residents are able to easily undo the restrictors then the type of restrictor will need to be changed. 31/08/06 31/08/06 31/08/06 31/10/06 31/10/06 12. 13. YA42 YA42 23 13 15/09/06 30/09/06 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 YA33 Good Practice Recommendations It is recommended that a program of team building and team development be implemented. DS0000066298.V307035.R01.S.doc Version 5.2 Page 28 DS0000066298.V307035.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000066298.V307035.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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