Inspection on 11/01/07 for Colin Care Home

This inspection was carried out on 11th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colin Care Home 16/05/08

Colin Care Home 14/06/07

Colin Care Home 03/08/06

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 Colin Care Home 19 Garlies Road Forest Hill London SE23 2RU Lead Inspector Ornella Cavuoto Unannounced Inspection 11 &15 January 2007 10:00 th th DS0000066922.V326126.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 DS0000066922.V326126.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. DS0000066922.V326126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colin Care Home Address 19 Garlies Road Forest Hill London SE23 2RU 020 7275 0440 020 7275 0442 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) Colin Limited Ms Vernett Brown Care Home 4 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (4) of places DS0000066922.V326126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: Colin Care is a care home that provides long, medium and short term residential care to four men and women who have incurred a brain injury aged between 18-65. The home is situated in a residential road close to good transport links to nearby Catford, Lewisham and Forest Hill areas. The home aims to work with service users to improve their overall quality of life and promote independence. The home is a large period property and has four large bedrooms two of which are en-suite and one bedroom is situated on the ground floor and three upstairs. There is no passenger lift within the home and so there is limited access for wheelchair users. Potential service users are given information about the service at the point when they have an initial visit to the home as part of the assessment process. Service users will be given a copy of reports issued by CSCI. Weekly fees vary from £875 - £1000. There are no additional charges. This information was provided to CSCI in August 2006. DS0000066922.V326126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. Since the last inspection took place in August 2006 the registered manager has resigned. The ‘acting’ manager has been in post since end of September 2006 and was present for the inspection. As part of the inspection process three of the support workers working at the home and three of the service users and a relative were spoken to. Other methods used included inspection of records and a full tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that information regarding fees payable and what is included in the charges made by the home for individual service users is included in the service user guide. DS0000066922.V326126.R01.S.doc Version 5.2 Page 6 The copy of the needs assessments obtained for individual service users prior to referral should be kept on service users’ personal files. The statement of terms and conditions needs to be signed by all service users and a copy kept on their personal files. All service users need to sign their care plan to indicate their agreement and understanding of its content and where, due to reviews or re-assessment of service users needs, changes in the support to be provided to individual service users are made this needs to be reflected in their care plan. All staff require training around risk assessment and management and the home needs to ensure that all risks presented by service users are assessed at the point of referral using information contained in the needs assessments obtained by the home and measures to reduce the risks specified. Staff need to be clear about their responsibilities in respect to confidentiality and that the personal information of service users is handled appropriately. The home needs to ensure it has the necessary information and resources to support service users with accessing opportunities around training and education. Staff need to provide service users with more support to enable them to participate in the local community to make use of facilities and resources available. Service users need to be given more opportunities to partake in structured leisure activities both on a group and individual basis. Service users need to be provided with a consistent level of support by staff with key workers being made fully aware of their role and responsibilities. Improvements still need to be made by the home in the handling and administration of medication. The home needs to ensure that all complaints minor and more formal ones are recorded and any details of investigation and outcome logged. All staff need to receive formal accredited training around adult abuse and adult protection procedures to ensure service users are fully protected from abuse and harm. Those service users that have difficulties with mobility the home needs to ensure an occupational therapy assessment is carried out with them individually and any equipment or adaptations recommended are obtained and carried out by the home. The home needs to ensure that an up to date and accurate rota that reflects the staff on duty and any cover arrangements are noted. There needs to be improvements made in the home’s vetting procedures when recruiting new staff. The training needs of staff need to be identified to ensure all staff undertake both mandatory training and specific training and this is outlined in a training plan so that the individual and collective needs of service users are effectively met. All staff need to be provided with regular supervision. The manager needs to be given more effective support with supervision provided and training where required. Comprehensive quality assurance systems in which service users’ views are regularly obtained as part of self-monitoring need to be developed. All aspects of health and safety must be addressed by the home. DS0000066922.V326126.R01.S.doc Version 5.2 Page 7 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. DS0000066922.V326126.R01.S.doc Version 5.2 Page 8 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 DS0000066922.V326126.R01.S.doc Version 5.2 Page 9 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 & 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide generally includes all the information required by regulation but further information regarding fees needs to be added and information regarding staff changes needs to be updated. A copy of the needs assessments to be obtained prior to admission was not available for all service users. The statement of terms and conditions issued to service users had been amended to include all the necessary information but had not been signed by all service users. EVIDENCE: The home has a statement of purpose and service user guide in place that generally includes all the information required by regulation and the standards. It was identified at the last inspection that all service users had been issued with a service user guide. No further admissions have been made to the home since this time. However, in respect to the statement of purpose the information regarding staffing needs to be updated to reflect the change in management that has occurred. Also, it was noted within the service user guide that certain information such as the complaints policy has been used from another service and still bears that service’s name. This needs to be changed. Finally, following the introduction of a new regulation in September 2006 all care homes must now provide within the service user guide DS0000066922.V326126.R01.S.doc Version 5.2 Page 10 personalised information about the fees and terms and conditions under which service users specifically are provided accommodation including the provision of food and personal care and any other additional charges. The information must also include method of payment of the fees and the person(s) by whom the fees are payable. This needs to be addressed. Also, it is advised the registered provider becomes familiar with all other aspects of this regulation (See Requirements & Recommendations). All the service users presently living at the home came from a supported living project. Concerns were raised at the last inspection about the fact that apart from one service user who had a re-assessment of their needs carried out with them by the local authority prior to moving into the home, assessments for two of the other service users had been completed post- admission to the home. For the remaining service user an assessment was still to be completed although there was evidence that a date for this to be carried out had been arranged. At this inspection there had been no new admissions to assess a previous requirement that the home must ensure an assessment of need is always obtained prior to the admission of a service user to ensure the home is able to fully meet their individual needs. However, for two of the service users it was noted that the copy of the assessment of need was not included in their personal files and neither could they be found amongst information from the personal files that had been archived. The home needs to ensure that a copy of the assessment is held on service users’ personal files and on admission should be used as the basis for the care plan that is drawn up (See Requirements). At the last inspection although it was found that a statement of terms and conditions had been included in the service user guide that had been issued to service users it did not state the fees charged or period of notice to be given should a service user be asked to leave. At this inspection there was evidence that a new statement of terms and conditions had been drawn up although signed copies of the document were only included on two of the service users’ files. It was reported that for the other two service users the document had been given to their relatives to look at and sign on their behalf. However, evidence to confirm this was only available for one of them (See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 11 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 &10 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. A care plan had been drawn up for each service user although they had not all been updated to reflect changes in the individual needs of service users. Service users do make decisions about their lives and although there have been some improvements in the restrictions placed on service users being included in care plans and risks assessments, not all individual risks presented by service users had been addressed in a risk assessment and neither had presenting risks been managed appropriately by staff. The home is still not ensuring that confidential information about service users is handled appropriately. EVIDENCE: At the last inspection it was identified that none of the service users’ personal files contained evidence of an up to date care plan that had been drawn up with them that was based on the needs assessments provided by the referrer. At this inspection an improvement in this area had been made. A care plan was in place for each service user that looked at areas relating to personal and DS0000066922.V326126.R01.S.doc Version 5.2 Page 12 social support and areas relating to health care needs. In addition, there was evidence within the care plans that addressed aggressive and self -harming behaviour and also how specialist requirements were to be met, for example for two of the service users who experience problems with drinking measures taken by the home to access support for them to look at their drinking and to help them to reduce their alcohol intake had been specified. Care plans had been reviewed on a two monthly basis. Yet, for one service user it was noted that the care plan had not been updated to include a change in their needs. These were outlined within a report carried out by the Speech and Language team (SALT) that made recommendations for measures to be taken by staff to support the service user to increase their level of social interaction and also ways to improve their communication skills. Although the manager reported action had been taken to begin to address some of these issues, it is important that the home ensures that when care plans are reviewed any changes in the individual needs of service users are reflected so that progress in these areas can be monitored and evaluated. In relation to service users, their relatives or a representative being involved in the drawing up of care plans, evidence was available that the care plan of one service user had been given to a family member to look at and sign to indicate their agreement and understanding of its content whilst another care plan had been signed by the service user. In respect to the other two service users one care plan had not been signed. The manager reported that the other service user had refused to sign their care plan as they disagreed with some of its content but measures to address this further with the service user had not been taken. Finally, the home has a key worker system in place and support staff spoken to did demonstrate they had awareness of individual service users’ needs as outlined within their care plans. However, the manager reported that at present key workers are not taking responsibility for the drawing up and reviewing of care plans. Instead, the manager is taking sole responsibility for this. There was evidence within the minutes of a staff meeting that the role of workers in respect to care planning had been discussed with them but it is advised this is looked at further to ensure that key workers have an input into the care planning process (See Requirements and Recommendations). There was evidence that service users’ rights to make decisions are respected in that two of the service users manage their own finances. Information regarding external advocacy services has also been included in the service user guide that has been issued to service users. A previous requirement that restrictions placed on service users’ choices or rights should be clearly documented, for example in respect to not going out unaccompanied or having their use of cigarettes or alcohol limited, this has been met. Individual service users had signed an agreement that outlined these restrictions. There was also evidence within care plans and risk assessments of where restrictions and limitations had been put in place for service users. However, it was acknowledged by the manager that resident meetings as an opportunity to allow service users to make decisions about different aspects of living in the home that affect them have not been held (See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 13 At the last inspection risk assessments that identified risks presented by the needs of individual service users and included details of control measures to be taken by staff to try to minimise these had only been drawn up in respect to two of the four service users living at the home. This was despite evidence presented in reports and assessments within the personal files of individual service users that demonstrated that high- risk behaviours could arise. At this inspection there was evidence included within individual care plans where risks had been identified and action to address these had been specified. There were also separate risk assessments that addressed risks although one had not been fully completed, they were not signed by the service users and one had not been dated nor signed by a staff member. In addition, although as mentioned there was an agreement signed by some of the service users agreeing to restrictions that they should not go out unaccompanied risk assessments with action to be taken by staff if these service users did go out alone or go missing could not be identified. Furthermore, it was evident that for one service user a risk assessment in respect to risks that were made known to the home was only drawn up following the occurrence of a serious incident that resulted in an adult protection investigation. Furthermore, it was reported by a relative of the service user that action to immediately reduce the level of risk was delayed after the incident happened. This is clearly not acceptable practice. This was discussed with the manager who did not demonstrate a clear understanding of risk assessment and management. This is therefore an area that requires training to be undertaken by all staff (See Requirements and for details Standard 35). In relation to confidentiality it was noted at the last inspection that personal information regarding service users’ medical appointments had been placed on a notice board in the dining room. At this inspection it was found this had been removed. However, concerns were raised that the personal files of service users were not kept in a locked cabinet but on an open shelf in the office. This needs to be addressed. In addition, although support workers spoken to demonstrated some understanding of confidentiality they were not all clear about circumstances when confidentiality should be breached (See Requirements) DS0000066922.V326126.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users have been supported to look at training and education opportunities but the home needs to ensure it has adequate resources and information to adequately support service users in this area. Service users are still not being fully supported to participate in the local community. There are still not adequate opportunities for service users to engage in appropriate leisure activities. Service users are supported to maintain appropriate family and personal relationships. There are restrictions in place for individual service users but overall service users’ rights are respected. Generally service users are receiving meals of their choice. EVIDENCE: DS0000066922.V326126.R01.S.doc Version 5.2 Page 15 In terms of service users being supported to access training or education opportunities the majority of them attend a day centre, Headways once weekly that specialises in working with individuals with a brain injury and aims to offer a range of activities such as cookery, board games and to support service users with memory improvement. Furthermore, there was evidence that individual service users were involved in education and training, for example one service user who is interested in gardening had enrolled with a voluntary gardening project although had not carried out any work with them recently. Another service user attends a computer class every Friday and was looking at undertaking a cookery class but this was full. Also, with input from the community occupational therapist the service user was being supported to look at developing their budgeting skills and to have a ‘no prompting’ day in order to encourage them to be more independent and improve their daily living skills. There was also evidence that one of the service users had appointments arranged to see a Disability Employment Adviser to support them to look at training or employment opportunities. However, it was noted that this was only initiated after a six monthly review was held with the placing authority on the advice of the social worker after the service user complained about a lack of structure living at the home. Given that the home states in its statement of purpose that it aims to support service users to “promote their independence” and where appropriate “rehabilitate individuals back into the community” the home needs to ensure there is sufficient information available in the home about appropriate resources and facilities to meet service users needs in this area (See Requirements) At the last inspection it was identified that not all service users were being supported to participate in the local community as they could be with one service user stating that apart from attending the day centre once weekly and hospital and G.P appointments they had not been out anywhere. At this inspection one service user stated they had attended church occasionally, had been to a hairdresser nearby and had been to the pub a couple of times since living at the home whilst another service user spoke of attending a local gym. Both had used the shops locally. However, there was still limited evidence that service users had been supported to use other local facilities such as the cinema, restaurants, cafes, the library and other places of local interest such as museums, gardens/parks. This is still an area that needs to be addressed by the home (See Requirements). There were weekly activity schedules in place for individual service users that outlined their daily routines including leisure activities although these were limited. Inside the home these mainly consisted of playing board games with staff, listening to music and watching movies. Outside the home, activities provided included shopping and going for a walk. However, one of service users spoken to expressed that they would like to do more walking/exercise whilst another said they would like to go for walks in the local park. One of the service users attends a local gym as mentioned previously. Two of the service users had records in their personal files that were aimed at providing details DS0000066922.V326126.R01.S.doc Version 5.2 Page 16 about the time spent with them by staff. However, these were not being used effectively in that generally they did not specify how much time was spent with them, what was discussed or what activity was carried out with them. Instead, they duplicated information that would be contained in the daily records including comments such as “Had a good day” or “Says he is feeling better.” Another service user had a record of hourly checks being carried out by staff. It was reported that the checks were put in place as the service user spends a lot of time isolated in their room and also suffers from seizures and so were aimed at ensuring they had some social contact with staff. Yet, neither these checks nor any other records could be identified that indicated any structured time in which activities had been undertaken with them had taken place. This is despite social needs having been addressed in the service user’s care plan and as mentioned in respect to Standard 6 a report had been completed by the Speech and Language Team (SALT) to look at ways of encouraging social interaction and participation with the service user and made recommendations amongst others that art and literacy work should be carried out with them. The service users’ key worker did report that time had been spent with them doing painting and spelling using alphabet cards. Due to communication issues this could not be confirmed with the service user. In addition, it was noted in the report completed by SALT that a shopping day with the service user was not being utilised by the staff at the home. The acting manager reported that the service user did not want to go but again there was no evidence to indicate any action had been taken by staff to encourage the service user to do this. Overall, it was evident that service users are still not being given opportunities or provided with adequate support to engage in a range of leisure activities inside or outside the home to socially interact either on an individual or group basis and more effort to address this needs to be made and records of this maintained for all service users (See Requirements). There was evidence from daily records that service users are supported to maintain family and personal relationships. It is positive that one of the service users was supported to attend a party over the Christmas period where they met up with old friends. Family members are able to visit service users regularly at the home. A relative who visits the home regularly was spoken to and they said, “Staff are always friendly”. Although service users are subject to some restrictions as mentioned with regards to Standard 7, generally service users’ rights are respected in that they had keys to their rooms and service users spoken to confirmed that staff always knock before entering their rooms ensuring their privacy is maintained. In respect to the daily routines of the house promoting independence two of the service users reported that they do their own shopping and cooking with supervision from staff and tidy their rooms. Finally, subject to a previous requirement in respect to service users’ rights that a designated smoking should be identified rather than service users being compelled to stand outside unsheltered to smoke, this has been met. It was reported that service users are now allowed to smoke in their bedrooms. Risks with regards to smoking DS0000066922.V326126.R01.S.doc Version 5.2 Page 17 had been addressed either within their individual care plans or a separate risk assessment. Service users spoken to were happy with this arrangement. Each service user had a nutrition chart in their personal files where meals eaten by service users had been recorded and also additional snacks. All service users choose what they would like to eat on an individual basis and they either cook it themselves under the supervision of staff or staff prepare the meals. There was a menu in place although this was only used to give staff suggestions for meals to cook for service users. Although feedback from service users varied generally those spoken to were happy with the food and the way meals were organised. Nutrition charts indicated that repetition of meals was kept to a minimum. There was also evidence for one service user who has culturally specific needs that these were being met. DS0000066922.V326126.R01.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. Not all service users were satisfied with the personal support received from staff. Physical and emotional needs of service users are being met by the home. The home’s medication policies and procedures for dealing with medication are not presently fully protecting service users. EVIDENCE: Service users generally are able to carry out their own personal care and only require minimal support or prompting from staff. Service users were observed as generally well dressed and groomed. In terms of general day –to- day support although the home operates a key worker system to try to ensure consistency feedback from service users about the support received from staff varied. One of the service users stated that they received support from staff the way they prefer, knew who their key worker was and stated that they did have contact with their key worker who would come to their room to chat. However, the other service users spoken to expressed dissatisfaction with the support received from staff. One stated they did not know who their key worker was whilst the other stated regarding staff generally, “ Some days you DS0000066922.V326126.R01.S.doc Version 5.2 Page 19 do see them other days I could be lying on my bed and you don’t see them at all”. This is not acceptable. It is important that all service users living at the home receive a consistent level of support and that all staff are made clear about their role as a key worker and the responsibilities involved. Furthermore, it was noted in a report included in the personal file of one of the service users that they respond more positively towards male workers and yet all staff presently working at the home are female. This was discussed with the manager who reported that when the service recently recruited staff none of the male applicants were found to be suitable. However, it is recommended that in future the home look at ways of balancing the staff team to provide a choice to service users of staff who work with them (See Requirements & Recommendations). Individual medical appointment sheets were included in service users’ files but had not been kept up to date. The manager reported that these were no longer being used but it is advised that an individual record of appointments should be kept to help monitor contact with health professionals. Despite this there was evidence included in personal files within daily notes, through copies of letters and reports, individual care plans and within the service’s daily diary that the physical and emotional needs of service users have been met by the home and that there has been liaison with a range of health care professionals including G.P’s, neuropsychiatrists and neurologists, speech and language, behavioural specialists, counsellors and specialist alcohol services. Service users have attended hospital appointments as required and where service users have been supported to maintain a reduction in their alcohol use and also for those who suffer from epilepsy monitoring charts have been put in place that have been regularly completed by staff (See Recommendations). The home has a medication policy that meets with standards. At present none of the service users take responsibility for their own medication. At the last inspection in checking a sample of Medication Administration Record (MAR) sheets it was identified that the staff had ticked them when medication had been administered rather than signing them. There was evidence that staff had received some instruction around medication as part of their induction but formal training from a pharmacist had not been received. A requirement was made that the home needed to ensure this was organised for staff and that in future staff should not be allowed to administer medication until they had completed formal training on medication. At this inspection the manager reported that this training had still not been set up for staff. A sample of MAR sheets that were looked at demonstrated an improvement in the recording of the administration of medication in that staff were now signing and only a couple of gaps were identified where service users were applying creams themselves. However, although the manager has introduced weekly stock checks a number of discrepancies were found in that stocks of tablets did not correspond with medication that had been signed as having been administered and this needs to be monitored more closely. In respect to other concerns identified at the last inspection involving medication not being signed in with DS0000066922.V326126.R01.S.doc Version 5.2 Page 20 quantities not recorded on the MAR sheets and medication returns also not being noted down, it was found at this inspection that the manager had introduced a stock control book in which all medication received and returned had been logged. (See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. Not all service users consider their views have been listened to and acted on and complaints have not all been appropriately recorded. The home has not always followed appropriate reporting procedures in relation to adult protection to ensure that service users are completely safeguarded from abuse and self- harm. EVIDENCE: The home has a complaints policy and procedure that meets with standards and sets out the stages and timescales for the process. A copy of the complaints policy that had been written more simply was also included in the service user guide and provided information about local advocacy services where service users could seek independent advice and representation if required. The home needs to ensure that the new address and contact number for the Commission of Social Care Inspection’s (CSCI) local office of Southwark is altered on the all policies used by the home. Not all service users spoken to felt their views had been listened to and although the home had a complaints log in place minor low level complaints had not been recorded, for example it was identified in the daily recording that one of the service users had made a complaint about the food but details of the complaint were not specified and there was no evidence that any action to address this had been taken. Two formal complaints had been logged since the last inspection. One complaint concerned a service user’s ring going missing, which was later found. Another complaint was made by a relative concerning a staff member but again there were no details of the complaint, action taken or what was the outcome. The DS0000066922.V326126.R01.S.doc Version 5.2 Page 22 manager who stated they were not aware of the details of the complaint reported the owner of the home had been sent the letter and they had dealt with the matter holding a meeting with the relative. However, a detailed record of all complaints, action taken and the outcome needs to be maintained in the log kept at the home and where appropriate CSCI and the relevant local authority informed (See Requirements). In respect to adult protection the home has a policy that meets with standards. Only two staff were identified as having completed any training around adult protection/ abuse although the manager reported that all staff had recently looked at adult abuse as part of an induction programme purchased by the home that meets with Skills for Care specifications. Those staff spoken to did demonstrate some knowledge about different types of abuse and what action they should take if abuse was suspected or identified. Similarly, the manager had some knowledge of adult protection procedures and their responsibilities for example in relation to making referrals to the POVA list where those individuals identified as unsuitable to work with vulnerable adults are named. Yet, there have been several issues that have arisen since the last inspection in which the home has failed to follow reporting procedures as required under adult protection and also regulation by CSCI, for example three complaints were made by two service users about inappropriate behaviour towards them from other service users. These incidents had been recorded by the home and there was evidence that action had been taken to investigate and some appropriate measures taken to address the issues. However, there was a failure by the home to immediately notify the social workers of those service users involved for a judgement to be made as to whether further investigation under adult protection procedures was considered necessary. CSCI was also not informed of these incidents as required under regulation 37 of the Care Standards Act 2000. Following information from the placing authority about these three incidents and another placing authority concerning a serious incident that had occurred in the home involving a service user attempting to self -harm of which they had not received appropriate notification and which again was not reported to CSCI, an immediate requirement was issued prior to the inspection being held that specified all incidents regardless of severity needed to be reported to CSCI until further notice. This was in addition to a previous requirement made at the last inspection due to the home not reporting incidents to CSCI. This was discussed with the manager at the inspection who demonstrated that they did not have a clear understanding of the regulation and when matters needed to be reported. In addition, the home has had one adult protection investigation since the last inspection. Following the incident where the service user attempted to self- harm another incident occurred approximately three weeks later involving the same user who harmed themselves by setting themselves alight. The investigation identified a number of areas of concern including the home’s understanding of adult protection procedures and also in relation to how the matter was managed by the staff working at the home with gaps in training being identified (For details see Standard 9 & 35). As a result of these issues it is evident that all staff DS0000066922.V326126.R01.S.doc Version 5.2 Page 23 including the manager need to have further accredited training on adult abuse and also around adult protection procedures. In addition, a previous recommendation that the home obtain a copy of Lewisham’s Interagency Guidelines on Adult Protection for staff still needs to be addressed (See Requirements and Recommendations). DS0000066922.V326126.R01.S.doc Version 5.2 Page 24 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): 24,26,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to make the home more homely and comfortable for service users. Service users bedrooms meet their needs. There are adequate communal spaces that supplement service users’ individual rooms. An assessment of the home by an occupational therapist for individual service users is still needed to ensure they have the specialist equipment or adaptations are in place to maximise their independence and give them access to all parts of the home. The home was generally clean and hygienic apart from one of the service user’s bedrooms. EVIDENCE: It was advised at the last inspection that the home should consider purchasing more furnishings such as pictures and rugs to try to make the home more homely and comfortable for service users. At this inspection, it was found that DS0000066922.V326126.R01.S.doc Version 5.2 Page 25 there were more pictures although it was reported that following a health and safety inspection of the home by the local borough advice was given that placing a rug in the lounge area may prove a hazard to those service users with mobility difficulties. Overall, the home, which is a large period property has been decorated to a good standard with neutral colours being used throughout and laminate flooring in all four of the bedrooms, the corridors and communal spaces making it bright and airy. However, not all parts of the home are accessible to all service users. It was identified that one of the service users living at the home who has mobility difficulties is unable to access the garden without staff support due to having to walk down some steps which are quite steep from both points of access that are from the lounge and the kitchen (For details see Standard 29). Service users’ bedrooms were all large and spacious and contained all the required items of furniture. Two of the bedrooms have en-suite facilities that include a shower and a toilet. Service user bedrooms had been suitably personalised. In relation to communal spaces the home has a spacious lounge. There are French doors and as mentioned steps leading down to the garden which is well maintained. There is also a separate dining room and a kitchen that is domestic in nature. A previous requirement that two of the service users who have difficulties fully mobilising should have an occupational therapy (OT) assessment carried out with them has not been met. This is to ensure the physical environment of the home is suitable to meet their needs and to determine if any specialist equipment or adaptations are required to help maximise their independence and ensure their safety. At this inspection one of the service users who has a room upstairs stated that they have difficulty managing the stairs and would have preferred a ground floor room but one is not available. There is only one bedroom on the ground floor. Furthermore, as mentioned previously problems were identified with one of the service users accessing the garden. Positively, the risk of falls for both service users had been addressed within their care plans but it is still necessary that an OT assessment is arranged for both service users (See Requirements). Generally the home on the day of the inspection was clean and hygienic. It was noted that one of the service users’ room was particularly untidy with dirty clothes on the floor although there were no malodours. The acting manager reported that support workers offer support to tidy and clean the room on a daily basis but this is generally refused by the service user. It is advised this is monitored to prevent the situation deteriorating further and to prevent any health and safety issues developing (See Recommendations). DS0000066922.V326126.R01.S.doc Version 5.2 Page 26 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): 32,33,34,35 &36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There was some evidence that some of the staff working at the home are qualified and it was reported others are in the process of obtaining a relevant qualification but evidence of this needs to be obtained. An accurate rota that reflects changes in staff cover is still not being maintained by the home. There was insufficient evidence to demonstrate that proper vetting procedures have taken place in the recruitment of staff. Staff have still not been supported to access training to ensure that the individual and collective needs of service users can be met effectively. There was no evidence available to indicate that staff have received regular supervision. EVIDENCE: There are presently five permanent support staff working at the home, two of which have been recruited since the last inspection. There was evidence within staff files for two of the staff that they have obtained qualifications abroad, one in nursing and the other a Bachelor in Medicine. It was reported that the staff member who had a background in nursing was presently in the process of DS0000066922.V326126.R01.S.doc Version 5.2 Page 27 completing a NVQ Level 4 in Health and Social Care. This staff member was spoken to and confirmed this stating they were due to finish the course in April 2007. In respect to the other support workers it was reported all were in the process of studying for NVQ Level 2 qualifications. Two of these staff were spoken to who confirmed this. All staff are completing these courses independently without support from the home. As a result the home needs to obtain evidence that they are enrolled on these courses and once completed a copy of the certificate needs to be obtained by the home to be kept on their individual staff files (See Requirements). At the last inspection it was found that the same rota was being used on an ongoing basis and this did not always reflect that there was an adequate number of staff on duty due to gaps where staff had left and arrangements made to cover these shifts had not been recorded. At this inspection although a weekly rota covering a six -week period was in place this still did not accurately reflect staff that were on duty, for example on one of the days of the inspection it was identified from the rota that one of the workers was marked down as being on a day off but was actually working a long day covering an early and a late shift and the worker for whom they were covering was on annual leave but this had not been noted down on the rota either. As specified at the last inspection the home must ensure for health and safety reasons to evidence that appropriate staffing levels are being maintained and that staff are working an appropriate number of hours that there is an accurate weekly rota in place. Any changes due to staff sickness or annual leave also should be specified and alternative cover arrangements noted. Furthermore, the home does not have any bank staff. It is recommended that the home consider employing a number of bank staff to alleviate some of the pressure of covering shifts from the permanent staff who it was noted regularly do double shifts (See Requirements and Recommendations). Staff records for all support workers presently working at the home were checked. These were found to include all the necessary documents required by regulation including Enhanced Criminal Record Bureau (ECRB) checks carried out by the home and two references. This is an improvement on the last inspection where it was identified that only one reference had been obtained for all staff and evidence of an ECRB check that was from a previous employer was included in only one of the staffs’ files. Following an immediate requirement being issued to the home evidence was provided to CSCI shortly following the last inspection that a check against the POVA list where the names of those staff deemed unsuitable to work with vulnerable adults are listed, had been carried out for all staff and that new ECRB applications had been completed. In respect to other vetting procedures used by the home in the selection of staff it was found that the home had introduced a new application form that did not clearly request that a full employment history should be provided. Instead, it only gave space to write details of the last three positions held. This needs to be altered so that a full history is obtained to ensure that any identified employment gaps can be addressed with DS0000066922.V326126.R01.S.doc Version 5.2 Page 28 applicants. In addition, although the manager provided evidence of questions reported as being used in the recent interviewing of staff there was no evidence of records of the interview process carried out with the staff members that were recruited or other applicants (See Requirements). In respect to training, apart from the two newly recruited staff where there was some evidence included in their staff files that they had completed some relevant training including some mandatory training prior to being employed by the home generally there was limited evidence that any other training had been completed by staff since the last inspection. A previous requirement in respect to training had not been met. This required that all staff working at the home should have their individual training needs assessed and that a training plan be drawn up that outlines all training completed by staff, identifies gaps where training needs to be undertaken including any mandatory training that needs updating and any specific training to ensure the individual and collective needs of service users are met. A staff training record listing course titles to be completed by staff was found on individual staffs’ files but for three of the staff these were blank. Furthermore the list of course titles were not comprehensive. Not all mandatory topics apart from health and safety and fire safety were listed. Although medication was included other areas, for example importance of locking the store and boiler room, policy on receiving gifts, what to do in an emergency are those that should have been addressed as part of an induction programme rather than a training plan. In terms of induction, as mentioned with regards to Standard 23 the manager did provide evidence of a programme purchased by the home from a recognised organisation that meets with Skills for Care specifications and also of a training package on challenging behaviour where staff watch a DVD and then complete worksheets. The manager reported both had been carried out with staff who were in the process of completing the worksheets. Staff spoken to confirmed this but evidence of the worksheets they were working on was not available for inspection. With regards to specific training those topics listed on the staff training record were limited. They included management of seizures, management of aggression and nutrition but where staff had completed this training it was recorded as consisting of a handout printed from the internet that staff had read. This is not adequate. Staff spoken to did have a general knowledge of service users’ needs but it was evident that they lacked some insight into those service users who presented with more specialist needs for example those service users who have alcohol problems. Concerns were raised with the manager about the lack of specific training staff had received particularly due to the range of specialist and complex needs presented by service users. This issue was also raised at a recent adult protection conference. It was reported that there had been some discussion with staff at Headways the day centre attended by some of the service users regarding training courses related to working with individuals with brain injury and training had been discussed with staff in supervision although there was no available evidence to confirm this. It is important that the home take measures to address this area (See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 29 The acting manager reported that supervision had been held with staff but the sessions had not been recorded. One member of staff confirmed they had received supervision but indicated that this was carried out on a continual basis as opposed to having formal structured supervision. The manager needs to ensure that all staff receive at least six supervision sessions annually and records of these are maintained (See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Support needs to be provided to the acting manager to ensure the home is well run. The home is still to put in place effective quality assurance systems to ensure service users’ views are taken into account as part of self- monitoring and development of the home. The health, safety and welfare of service users are not being presently fully promoted and protected. EVIDENCE: The present acting manager has been in post since the end of September 2006 after the registered manager of the home resigned from the post. They are a qualified Registered General Nurse (RGN) and prior to working at the home had experience of working in nursing and residential care homes mainly with older people with dementia. The manager reported that although they have not DS0000066922.V326126.R01.S.doc Version 5.2 Page 31 had any previous direct experience managing a care home they have taken responsibility for being in charge of the floor when working in nursing homes and as result have had some experience of managing staff. It is positive they had submitted their application to become registered with CSCI and also to commence studying for the Registered Managers Award (RMA)/NVQ Level 4 in Management. The manager has also made improvements in care planning and within the management of medication by introducing weekly stock checks. However, both prior to the inspection and also through the process of completing the inspection it became evident that the manager has gaps in their knowledge for example in relation to practice in the area of risk assessment and management (For details see Standard 9) and also in respect to their responsibilities in terms of regulation such as in the reporting of incidents and also the management of adult protection issues (For details see Standards 22 & 23). The manager reported that there was a period of handover with the registered manager but apart from this the manager has not received any supervision or training since coming into post and apart from the owner who does not have a background in care there do not appear to be any mechanisms in place to support the manager to access advice and information as required to ensure the home is effectively run. This needs to be addressed by the registered owner/responsible individual (See Requirements). The home has still not put in place any effective quality assurance systems to ensure that service users’ views are obtained as part of self monitoring as well as the views of family, friends and professionals involved in the home through completing customer satisfaction questionnaires. As mentioned in respect to Standard 7 service user meetings also have not been held to give service users an opportunity to discuss aspects of living at home to give their views and feedback. Also, since the home opened only one providers report has been sent to CSCI. These should be carried out monthly (See Requirements). In respect to health and safety the home had up to date maintenance certificates in place for gas and electrical wiring and that Portable Appliances (PAT) had been tested. There was also evidence as mentioned previously that the local authority had carried out a health and safety inspection in November 2006. In respect to fire equipment weekly fire alarm tests had been carried out and subject to a previous requirement regular fire drills had been completed although who was involved in the drills and the length of time it took to complete them was not noted down and this needs to be done in future. Checks of the emergency lighting had not been done and although the fire alarm had recently been checked maintenance of other fire equipment had not been carried out since the home had opened. Also, a fire risk assessment had not been completed. Water temperatures had not been monitored since August 2006 and a risk assessment of the building had not been drawn up. Finally, a previous requirement that the home must send a regulation 37 report to CSCI for all incidents that occur in the home has not been met and an immediate requirement was also issued to the home in respect to this which is to remain DS0000066922.V326126.R01.S.doc Version 5.2 Page 32 in place till further notice (Also see details in respect to Standards 22 & 23)(See Requirements). DS0000066922.V326126.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 2 X 2 X 1 X X 1 X DS0000066922.V326126.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4&5 Requirement Timescale for action 31/05/07 2. YA1 2(3) 3. YA2 14(1) The registered person must ensure that the home’s statement of purpose and service user guide are updated to include changes in staffing that have occurred and also that all documents within the service user guide that bear the name of another service are changed to include the name of the home. The registered provider 31/05/07 must ensure that the service user guide includes information about the fees charged by the home and what is included in the total fees payable. The registered person 31/05/07 must ensure that prior to any service user moving into the home that a full needs assessment has been carried out by the relevant local authority and a copy of this is obtained to ensure that DS0000066922.V326126.R01.S.doc Version 5.2 Page 35 4. YA5 5 (1) (b) 5. YA6 15 6. YA6 15(2) the home is fully able to meet the needs of the service user. A copy of the assessment should be kept on the service user’s file. (Previous timescale of 30/03/07 not exceeded. Requirement could not be fully assessed as no new admissions have occurred but copies of assessments were not all on service users’ files –this was not met at time of inspection) The registered person 31/05/07 must ensure that all service users sign the statement of terms and conditions and a copy kept on their personal files. (This is an updated requirement). The registered person 31/07/07 must ensure that a comprehensive care plan is drawn up in consultation with all service users, their relatives or a representative where appropriate and the service user indicating their involvement signs this. (Previous timescale of 31/01/07 not exceeded –partially met at time of inspection) The registered person 31/07/07 must ensure that following reviews or reassessment of service users’ needs that any DS0000066922.V326126.R01.S.doc Version 5.2 Page 36 7. YA7 12(3) 8. YA9 13 (4) (a) &(b) 9. YA9 18(1)(c)(i) 10. YA10 12(4) (a) changes in support are reflected within their individual care plans so that progress can be monitored and evaluated. The registered person must ensure that service user meetings are held on a regular basis to give service users an opportunity to give their views and feedback about different aspects of living in the home and that minutes of these meetings are maintained. The registered person must ensure that all service users have a comprehensive risk assessment in place that addresses all identified risks presented by individual service users and control measure/ action is specified on how risks/hazards are to be reduced. (Previous timescale of 31/01/07 not exceeded –partially met at time of inspection) The registered provider must ensure all staff working at the home receive training around risk assessment and management. The registered person must ensure that all staff are aware of their responsibilities around maintaining confidentiality and also circumstances / situations when confidentiality needs to be breached. Also, that the 31/07/07 31/05/07 31/07/07 31/07/07 DS0000066922.V326126.R01.S.doc Version 5.2 Page 37 11. YA12 12(1) 12. YA13 12 (1)(a) 13. YA14 16(2)(n) 14. YA18 12 personal files of service users should be kept in a locked cabinet when not in use. (This is an updated requirement) The registered person must ensure that there is adequate information and resources available to support service users to access appropriate training and employment opportunities. The registered person must ensure that all service users are given opportunities to participate in the local community and make use of its facilities and resources (Previous timescale of 31/03/07 not exceeded –partially met at time of inspection) The registered person must ensure that service users are provided with an activities programme that involves them partaking in activities both inside and outside the house on an individual and also a group basis and a record of activities that individual service users are involved in is maintained. (This is an updated requirement. Previous timescale of 31/03/07 not exceeded –not met at time of inspection) The registered person must ensure that all staff provides a consistent level DS0000066922.V326126.R01.S.doc 31/07/07 31/07/07 31/07/07 31/07/07 Version 5.2 Page 38 15. YA20 13(2) 16. YA20 13(2) 17. YA22 22 of support to all service users and that they are all clear about their role as a key worker and the responsibilities this involves. The registered person must ensure that all staff receives training around medication that meets with the specifications of standard 20:10 within the national minimum standards and in future all new staff must receive this training prior to being allowed to administer medication. (Previous timescale of 31/03/07 not exceeded-not met at time of inspection). The registered person must ensure consistency in the handling, administration and recording of medication specifically that stocks of tablets correspond with those that have been administered. (This is an updated requirement) The registered person must ensure that all complaints both minor /low level dissatisfactions and formal complaints are recorded/logged, details of any investigation and the outcome are kept on file and where appropriate relevant professionals and CSCI are informed about the complaint. Also, the change of address and contact details for the local office DS0000066922.V326126.R01.S.doc 31/07/07 31/07/07 31/07/07 Version 5.2 Page 39 18. YA23 13(6) 19. YA29 23 (2)(n) 20 YA32 18(1) 21. YA33 18(1) (a) of CSCI Southwark needs to be altered on the complaints policy. The registered provider must ensure all staff working at the home receives formal accredited training on adult abuse and adult protection to ensure they are fully aware of reporting procedures. The registered person must ensure that for those service users who may have mobility problems or are disabled that an occupational therapy assessment is carried out and where recommended suitable equipment is purchased or adaptations to the home carried out. (Previous timescale of 31/03/07 not exceeded-not met at time inspection held) The registered person must ensure that evidence is obtained of all staff who are presently undertaking National Vocational Qualifications (NVQ) and when the courses have been completed a copy of the certificate is obtained and kept on individual staff files. The registered person must ensure that there is a sufficient number of staff working at the home at all times and that this is reflected on a weekly rota. Also, where changes are made in the staffing arrangements that these DS0000066922.V326126.R01.S.doc 31/07/07 31/07/07 31/07/07 31/05/07 Version 5.2 Page 40 22. YA34 19 & Sched 2 23. YA35 18(1) 24. YA36 18 (2) are recorded on the rota. Rotas should be kept for a period of time before being disposed of. (Previous timescale of 31/01/07 not exceeded-not met at time the inspection was held). The registered person 31/07/07 must ensure that adequate vetting procedures are used when recruiting staff to work in the home specifically that a full employment history is obtained and any gaps in employment are explored and accounted for. Also, that a record of the interview process carried out with staff is maintained. 31/05/07 The registered person must ensure that all staff working at the home have their individual training needs assessed and that a training plan is drawn up that outlines all training to be undertaken by staff which must include updating all mandatory training such as manual handling and also specific training to ensure the individual and collective needs of service users can be met effectively. (Previous timescale not exceeded) The registered person 31/07/07 must ensure all individual staff receives at least six supervision sessions annually and records of the sessions are maintained. DS0000066922.V326126.R01.S.doc Version 5.2 Page 41 25. YA37 9(1)&18(1) 26. YA39 27. YA39 28. YA42 The registered provider must ensure that the acting manager receives adequate support in the way of formal supervision and training to ensure the home is effectively run. 24 The registered person must ensure that the quality assurance systems for the home are developed. An effective system where service users ‘ views underpin all selfmonitoring, reviews and development of the home. (Previous timescale of 31/05/07 not exceeded-not met at time of inspection) 26 The registered provider must ensure that monthly provider visits are carried out and copies of the reports sent to CSCI 13(4)(a)&(c)&23(4) The registered person (c)&37 must ensure that all aspects of health and safety are addressed: -That when incidents occur in the home that a Regulation 37 report must be sent to CSCI as soon as possible. (Immediate requirement issued 27/11/06 to remain in place till further notice) - A building risk assessment is completed. - A fire risk assessment is completed and fire equipment is maintained. - Water temperatures are checked and recorded. (This is an updated requirement) DS0000066922.V326126.R01.S.doc 31/05/07 31/07/07 31/07/07 31/07/07 Version 5.2 Page 42 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. 3. 4. 5. 6. Refer to Standard YA1 YA6 YA18 YA19 YA23 YA30 Good Practice Recommendations The registered provider should try to ensure they are fully familiar with the new regulation regarding information about fees being provided to service users. The registered person should try to develop the role of the key worker further to involve them in the drawing up and reviewing of care plans. The registered person should try to look at ways of recruiting male staff to give service users a choice of who works with them. The registered person should try to maintain an individual record of medical appointments and contact with health professionals for all service users. The registered person should consider obtaining a copy of the London Borough of Lewisham’s Interagency Guidelines on adult protection for staffs’ information. The registered person should try to ensure that the situation involving the service user who refuses support to clean and tidy their room is monitored closely to prevent a further deterioration and health and safety issues arising. The registered provider should consider the employment of bank staff to alleviate the pressure from the permanent staff to provide cover for annual leave and sickness. 7. YA33 DS0000066922.V326126.R01.S.doc Version 5.2 Page 43 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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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