Inspection on 03/08/06 for Colin Care Home

This inspection was carried out on 3rd August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 17 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 11/01/07

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 3rd August 2006 10:00a Colin Care Home DS0000066922.V306721.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 Colin Care Home DS0000066922.V306721.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. Colin Care Home DS0000066922.V306721.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 Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A 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. Colin Care Home DS0000066922.V306721.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 one day. The registered manager was present for the inspection as was the registered owner. The inspection involved speaking to three of the service users and two staff members. Other inspection methods included a full tour of the premises and inspection of care records. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that prior to service users being admitted to the home that a full needs assessment is obtained from the relevant local authority to ensure that the needs of service users moving into the home can be fully met. All service users living at the home need to sign the statement of terms and conditions that are included in the service user guide. The fees charged must also be clearly stated. A comprehensive care plan needs to be drawn up with all service users living at the home which needs to be done in consultation with the service user, their relative or a representative where appropriate. Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 6 Where restrictions and limitations are imposed on service users that are assessed as being in their best interests these must be clearly outlined within their individual care plans or a risk assessment. Comprehensive risk assessments must be drawn up for all service users. The home needs to ensure that all personal information regarding service users is handled appropriately and their confidentiality maintained. Staff need to support all service users to participate in the local community and make use of its facilities and resources. An activities programme that meets the social interest and leisure needs of service users on both a group and individual level needs to be developed. The home needs to provide a suitable designated smoking area for service users. Service users need to be encouraged by staff to eat more varied meals to ensure they have a balanced and nutritious diet. Improvements need to be made in the handling, administration and recording of medication and staff need to be provided with training in this area. For those service users that have mobility problems the home need to ensure that an occupational therapy assessment is carried out with them and where recommended appropriate equipment obtained or adaptations carried out. There needs to be sufficient staff working at the home at all times and a working rota needs to be put in place with any changes in cover accurately recorded. The home needs to make improvements in its recruitment practice to ensure that service users are being fully protected. The training needs of staff need to be identified to ensure that staff undertakes both mandatory training and specific training and this is outlined in an annual training plan so that the individual and collective needs of service users are effectively met. 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. 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. Colin Care Home DS0000066922.V306721.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 Colin Care Home DS0000066922.V306721.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): 1,2,3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Current & prospective service users have the information they need to make a choice about where they live. Service users’ needs have not been assessed prior to them moving into the home. The home has areas where improvements need to be made to ensure that it can fully meet the needs of prospective service users and those presently living at the home. Service users have not been issued with a statement of terms and conditions with the home. EVIDENCE: The home has a statement of purpose and service user guide in place that both meets with regulation and the standards. All service users have been issued with a service user guide evidence of this was seen in their rooms. All the service users presently living at the home had been moved from a supported housing project managed by the registered manager of the home who reported this is now in the process of being closed down. As the service users have been moved into residential care signifying that they are in need of a higher level of support a re-assessment of their needs should have been carried out by the relevant local authority prior to them moving into the home Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 9 to ensure the placement would be suitable to meet their needs. However, there was evidence that only one of the four service users had had a re -assessment carried out with them prior to moving into the home. The other assessments had been carried out after the service users had moved into the home with one service user still not having had their needs assessed at the time the inspection was held although there was evidence that a date had been arranged with the local authority for this to be carried out. This is not acceptable practice. The home must ensure that prior to service users moving into the home that a full needs assessment is obtained to ensure that the home is fully able to meet their needs (See Requirements). Staff spoken to did demonstrate that they have an understanding and knowledge of service users needs and staff have achieved or are working towards qualifications to ensure they have skills to deliver the services and care which the home offers to provide although there are gaps in their training that need to be addressed. Furthermore, improvements need to be made in areas of care planning, risk assessments and around helping to support service users to lead more fulfilling and structured lifestyles for the home to be able to fully demonstrate that they have the capacity to meet the assessed needs including the specialist needs of individuals admitted to the home (See Requirements in relation to standards 6,9,13,14 & 35 that encompass this outcome area). Although there was evidence that a statement of terms and conditions had been drawn up a copy of which had been included in the service user guide none of the service users had as yet signed this. Furthermore, although generally the statement of terms and conditions did include all required information as specified within the standard it does not clearly state the fees that are charged or period of notice that may issued should a service user be asked to leave the home (See Requirements). Colin Care Home DS0000066922.V306721.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): 6,7,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service The assessed needs of service users have not all been fully reflected in an individual plan. Although service users are provided with information to support them to take control of their own lives and restrictions are only placed on service users where it is identified to be in their best interests this has not always clearly been addressed within a care plan or a risk assessment. Risk assessments had not been completed for all service users living at the home. The home does not always handle information about service users appropriately. EVIDENCE: The personal files for all four service users were inspected. The home has only recently introduced a key worker system. Two files contained a document that addressed ‘functional issues’ of the individual service users and included brief details of their needs in respect to personal care, physical and emotional needs, daily living and personal safety needs amongst others. It was evident Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 11 from the document that this was a preliminary needs assessment to identify the issues that would need to be more comprehensively addressed within a care plan. However, a care plan had not been drawn up for either of the service users. Only one service user had a care plan in place but it was not clear when this had been completed or by whom as it was not signed or dated by a staff member or the service user. There was evidence of daily recording and these demonstrated that the specialist needs of service users were being met with interventions provided from specialist services for some of the service users. It was reported by the registered manager that the intention was to hold multi disciplinary meetings prior to drawing up detailed care plans for the service users. Yet, there was no evidence that any action had been taken to organise these meetings. In addition, the fact that the service users were known to the manager prior to their admission from living at the supported housing project this was not deemed to be an acceptable explanation for why care plans were not in place for service users after they had been living at the home for a period of two months. This needs to be urgently addressed (See Requirements). Service users were observed being able to exercise choice in relation to how they spent their time within the home. There was also evidence within the service user guide that information had been provided on local independent advocacy groups to enable service users to seek advice or guidance if required. However, it was identified that service users were subject to a number of restrictions for example not being allowed to go out unaccompanied. In addition, restrictions had been placed on two of the service users around how many cigarettes they could smoke and also for three service users around their intake of alcohol. It became evident through discussions with the registered manager that these limitations had been imposed to minimise harm and the majority of the service users spoken to understood why they were in place. Yet, apart from one service user where the reasons for why they should not go out unaccompanied had been outlined in a risk assessment decisions made around restrictions for other service users had not been clearly addressed within either a risk assessment or a care plan in which the service user, their relatives or a representative where appropriate should be involved and which should also be reviewed on a regular basis (See Requirements). Risk assessments had been completed for two of the service users. These generally contained good detail on the risks presented by the service users and included an action plan specifying measures to be taken to reduce the identified risks. Also, for one service user presenting with challenging behaviour a detailed risk assessment with recommended interventions to be used by staff was in place that had been drawn up by behavioural support services from the local community team for adults with learning disabilities. However, two of the service users did not have completed risk assessments in place. Given that the service users living at the home present with complex and challenging needs it is important that comprehensive risk assessments are drawn up as soon after admission as possible (See Requirements). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 12 The home has a confidentiality statement that meets with standards and support staff spoken to had a good understanding of confidentiality in that they demonstrated that they were aware when information should be shared with their manager or others. Yet, it was noted that information regarding the medical appointments for one service user had been inappropriately placed on the notice board in the dining room (See Requirements). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 the service Service users are being supported to look at education and training although this is an area that still needs further development. Not all service users are presently being supported to participate in the local community. Service users do not presently have adequate opportunities to engage in appropriate leisure activities. Service users are supported to maintain appropriate family and personal relationships. Generally the daily routines and the house rules promote independence and individual choice but service users do not presently have unrestricted access to the home in that they are not allowed to smoke on the premises. Service users are receiving meals of their choice but these need to be more varied to ensure a balanced and nutritious diet is being provided. EVIDENCE: Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 14 At present all the service users attend a day centre once weekly that specialises in working with individuals with brain injuries. The centre aims to offer a range of activities such as cookery, board games and to support service users with memory improvement. Also, one service user who is interested in gardening is also presently being supported to look at getting involved in a voluntary gardening project. Another service user also expressed that they were interested in going to college but had yet to take any action on this. It is evident that measures are being taken to support service users where appropriate to look at training / education opportunities and so this standard is assessed as met but this is an area that still requires further development. There was some evidence that service users do make use of some of the local facilities such as shops, the local parks and one service user had attended the local library. Service users have access to dial-a-ride. However, it was evident in speaking to service users that they are not all presently being supported to participate in the local community as they could be, for example one service user stated that apart from attending the day centre once a week and attending hospital and G.P appointments they had not been out anywhere. This needs to be addressed with the staff at the home ensuring that service users can make use of services, facilities and activities in the local community where appropriate (See Requirements). At present the home does not have an activities programme in place for service users in or outside the home. This was confirmed by service users with one service user stating, “There’s nothing to do here. A bit more activities would be nice.” Although one service user who has recently purchased a laptop stated that the home has agreed to organise for them to be able to access the internet so they can develop their interest and skills in computers and another has been supported to do some drawing by staff it is evident that this is an area that needs to be developed by the home and the key worker system which has recently been established used effectively to ensure service users have access to and choose from a range of appropriate leisure activities (See Requirements). There was evidence from daily records that service users are supported to maintain appropriate family and personal relationships with family members being able to visit them at the home. Also, one service user regularly spends weekends at home with their family. Generally routines and house rules do promote independence, individual choice and freedom of movement with service users being observed as being able to choose to spend time in their rooms alone or in the company of others. Service users spoken to had keys to their rooms and confirmed that staff always knock before entering their rooms ensuring their privacy is maintained. However, service users do not have unrestricted access to all parts of the home, as the home is completely non- smoking despite the fact that three of the four service users are smokers. It was reported by service users that if Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 15 they want to smoke they have to go outside despite the weather. Although, restrictions on smoking have been addressed within the service user guide it is also important that service users’ individual choices are respected. Therefore, either an area in the home should be identified where service users are able to smoke or a sheltered area outside is put in place (See Requirements). Each service user has a nutrition chart on their personal files where meals provided are recorded. It was reported that at present service users choose what they want individually and they either cook it themselves with support from staff or staff prepare meals. There was a menu in place but it was reported this was not a menu plan but was only used for suggestions of meals that could be cooked. Service users spoken to stated they were happy with the meals they were being provided with. The nutrition charts demonstrated that where service users have specific cultural needs these are being met but that some service users needed to be encouraged to include more of a variety of meals to ensure they are having a balanced and nutritious diet as it was identified that there was some repetition of meals (See Recommendations). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive personal care in the way they prefer and require. Service users physical and emotional needs are well met. The home presently takes responsibility for the medication of all service users living at the home but they are not being presently protected by the home’s policies and procedures. EVIDENCE: Three of the four service users are able to carry out their own personal care with staff providing support and encouragement where required. Service users spoken to confirmed that staff are flexible in the way they provide support and that they receive personal care in the way they prefer and are encouraged to do as much as possible for themselves. As mentioned the home has now introduced a key worker system which should further ensure consistency of support is offered to service users. There was evidence within service user files that the emotional and physical needs are well met with liaison with a range of health care professionals such as G.P’s, opticians, audiologists, neurologists, behavioural specialists, community mental health teams and learning disability teams. Service users Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 17 have been supported to regularly attend hospital appointments and where service users suffer from epilepsy, staff closely monitor seizures with monitoring charts being in place to record their frequency and duration. The home has a medication policy in place that meets with standards. At present none of the service users living at the home take responsibility for their own medication. A sample of Medication Administration Record (MAR) sheets were checked and it was identified that the staff working at the home had not signed the sheets when they had administered medication but had simply ticked them instead. The registered manager provided a copy of team minutes to demonstrate that staff had been instructed that they must ensure they sign the MAR sheets. However, this is clearly not acceptable practice and needs to be addressed. Although staff had received some instruction around medication as part of their induction it was evident from this that they were in need of medication training that meets with National Minimum Standards specifications and this was in need of being arranged as soon as possible. Also, in future staff should not be allowed to administer medication until they have completed training. In addition, the MAR sheets contained a number of gaps. The registered manager reported that this could be possibly be attributed to service users going on social leave but in these circumstances the appropriate code should be used to indicate this. It is also advised that when service users go on social leave a photocopy of the MARS sheets be given to the service user and their relative for them to sign as a record that the medication has been administered. Other areas of concern identified included medication not being signed in when received and quantities not recorded on the MARS sheets, medication returned to the pharmacy not being recorded and where changes to the administration of medication had occurred the instructions on the MARS sheets had not been altered for example for one service user the GP had agreed that instead of a service user receiving a particular medication at night they could receive it in the morning. It is advised that service users’ MAR sheets are taken to the G.P so they can write in any changes decided upon. Finally, so staff can familiarise themselves with the medication received by service users it is recommended that a medication guide such as a British National Formulary (BNF) is purchased by the home (See Requirements and Recommendations). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 18 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 judgement has been made using available evidence including a visit to the service. Service users spoken to did not have any complaints but would approach staff if they had concerns. Service users are protected from abuse. EVIDENCE: The home has a complaints policy and procedure that meets with standards. A copy of the complaints policy is included in the service user guide, which has been issued to all service users. Included in the complaints policy is information about local advocacy services where service users can seek independent advice and representation if required. Service users spoken to stated they did not have any complaints about the home but they would speak to staff if they did have any issues that they felt unhappy about. No complaints had been received by the home. The home’s adult protection policy that outlines the different types of abuse, action to take if abuse is suspected and prevention of abuse meets with standards. However, it is also advised that the registered manager obtain a copy of the Lewisham’s Interagency Guidelines around the management of adult abuse for staffs’ information. Although staff have not received any training as yet on adult protection staff spoken to had a good working knowledge of adult abuse, different kinds of abuse and action to take if abuse was identified (See Recommendations). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. 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 the service. The home, which has only recently been opened, has been completely refurbished and is well decorated but it still needs to be made more homely and more comfortable for service users. Service users’ bedrooms generally meet their needs. There are adequate communal spaces that supplement service users’ individual rooms. The home needs to ensure that all service users have the specialist equipment they need to maximise their independence. The home is kept clean and hygienic. EVIDENCE: The home is a large spacious period property that has been refurbished throughout in neutral colours and there is laminate flooring in all four of the bedrooms, the corridors and communal spaces. Two of the bedrooms have en suite facilities that include a shower and toilet. The home is located in a quiet residential road and is close to bus routes and has a mainline railway station nearby. Although, the home has been decorated to a good standard the home in parts was quite bare, for example the lounge although there were Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 20 comfortable chairs there was very little other furniture or furnishings. It was evident that the home still needs to be made more homely and comfortable by purchasing additional furnishings such as pictures and rugs decisions on which service users could be involved (See Recommendations). Service users’ bedrooms were all large and spacious and contained all the required furniture. Service user bedrooms had been suitably personalised. In relation to communal spaces the home has a spacious lounge, which is bright and airy. There are french doors leading to the garden at the rear that is very well maintained. There is also a separate dining room and a kitchen, which is domestic in nature and from which there is a door where again the garden can be accessed. The home has two service users that have problems in fully mobilising. Yet, there was little evidence that the home had any specialist equipment or that adaptations had been made to help maximise their independence and ensure their safety. The home needs to ensure that both service users have an occupational therapy assessment carried out with them to ensure the physical environment of the home fully meets their individual needs (See Requirements). The home was clean and hygienic on the day of the inspection. The home does not have a separate laundry room; the machine and dryer are stored in a cupboard on the landing away from the areas where food is prepared. Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34& 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Support staff working at the home are qualified or in the process of obtaining a relevant qualification. Although there was a sufficient number of staff on duty on the day of the inspection, the rota in place did not clearly demonstrate that there would be always be an adequate number of staff working at the home. The home’s recruitment practice does not presently protect service users. Although there was evidence that staff have received an induction this does not meet with Sector Skills Council specifications and a training plan is yet to be drawn up to ensure that the collective and individual needs of service users are able top be effectively met by staff. EVIDENCE: There are currently four permanent support staff working at the home who it was reported have only been in post for approximately a month. Prior to this those who worked at the supported housing project were temporarily staffing the home. It was reported that two of the new staff have a National Vocational Qualification (NVQ) Level 2, one has a NVQ Level 3 and is in the process of completing a NVQ Level 4 in Health and Social care whilst another staff member is due to start a NVQ Level 4 in Health and Social care. Staff spoken to confirmed they had achieved or were in the process of completing NVQ. Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 22 There was sufficient staff working at the home on the day of the inspection. Two staff members were on duty during the day. It was reported that two staff are also on duty in the afternoon/evening and one staff member does a sleep in. However, the rota in place indicated that there would not always be an adequate number of staff on duty. There has been a loss of two permanent staff members since the home opened and as a result 2.5 staff now need to be recruited to ensure that the home is fully staffed. The home does not have any bank staff in place at present and the registered manager and the registered owner have reportedly provided cover along with the other staff working at the home. However, this was not clearly reflected on the rota. The same rota has been used on an ongoing basis with no changes made apart from gaps being noted where staff have left. This is not appropriate practice. The home must, for health and safety reasons and to evidence that appropriate staffing levels are being maintained at all times within the home, ensure there is an up to date and accurate weekly rota in place and any changes that have to be made due to sickness or annual leave or staff having left that these are clearly recorded with staff cover arrangements being specified. A copy of past rotas must also be kept for reference (See Requirements). The staff files of all the permanent staff working at the home were checked. Only one file contained evidence of a Criminal Record Bureau (CRB) check. This was a photocopy and had been carried out by a previous employer, which is not acceptable. The registered manager reported that although CRB checks were not included in the other staff files these had been checked albeit that they were also from previous employers. POVA First checks that enable staff names to be checked against the Protection of Vulnerable Adults (POVA) list had not been carried out. Furthermore only one reference instead of the required two had been obtained for all staff. An immediate requirement was issued at the time of the inspection that new CRB application forms must be completed for all staff and in the interim POVA First checks be obtained and evidence that this has been carried out sent to CSCI. In addition, the registered manager must ensure all documentation required by regulation is obtained prior to allowing staff to commence working in the home (See Requirements). There was some evidence that staff have undertaken relevant training prior to their employment with the home but only one member of staff had completed mandatory training that was up to date in respect to food hygiene, first aid and infection control. Subsequently, all staff working at the home need to undergo training in all required mandatory topics including manual handling as soon as possible. In addition, given that the service users present with a range of specialist needs it is important that specific training is provided to ensure that staff can individually and collectively meet the needs of service users and this is outlined in an annual training plan. In addition, there was evidence that staff had received an induction although this does not meet with Sector Skills specifications, which needs to be addressed (See Requirements). Colin Care Home DS0000066922.V306721.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The register manager has both the experience and qualifications to ensure the home is well run. The home has not as yet put in place effective quality assurance mechanisms to ensure service users views are obtained as part of self-monitoring. Not all aspects of the health, safety and welfare of service users are protected EVIDENCE: The registered manager is very experienced having been a registered provider /manager of care homes since 1988. She is a qualified nurse and has also completed a NVQ Level 4 in management. The home as yet has not put in place any effective quality assurance mechanisms to ensure that service users’ views are obtained as part of self monitoring as well as the views of family, friends and other professionals involved in the service. Service user meetings are also yet to be arranged to Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 24 give service users an opportunity to discuss aspects of living in the home (See Requirements). The home has health and safety policies in place. The home has in place up to date certificates for the testing of electrical appliances, electrical wiring and for the gas system. In respect to fire maintenance there was evidence that fire alarm call points have been tested weekly and testing of emergency lighting has been carried out but there were no fire drills recorded as having been carried out and this needs to be addressed. In addition, the home did not have a building risk assessment in place. Also, when incidents occur in the home an incident report must be sent to CSCI as soon as possible. Finally, as mentioned previously staff need to have all mandatory training updated including manual handling, food hygiene and infection control amongst others (See Requirements). Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 1 3 2 4 X 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 2 25 X 26 3 27 X 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 2 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 1 X X 2 X Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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(1) Requirement The registered person 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 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. The registered person must ensure that all service users sign the statement of terms and conditions included in the service user guide and a copy kept on their personal files. Also, that the statement of terms and conditions must clearly state the fees charged and also the period of notice that may be issued to service users should they are asked to DS0000066922.V306721.R01.S.doc Timescale for action 30/03/07 2. YA5 5 (1) (b) 31/01/07 Colin Care Home Version 5.2 Page 27 leave. 3. YA6 15 The registered person 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. The registered person must ensure that service users’ rights to make their own decisions is respected but where limitations or restrictions need to be imposed this should be done in consultation with service users, their relatives or a representative where appropriate and clearly recorded as part of their individual care plan or risk assessment which should be reviewed on a regular basis. 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. The registered person must ensure that the confidentiality of service users is maintained and that personal information kept on service users is 31/01/07 4. YA7 12(1) &(2) 31/01/07 5. YA9 13 (4) (a) &(b) 31/01/07 6. YA10 12(4) (a) 31/01/07 Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 28 7. YA13 12 (1)(a) 8. YA14 16(2)(n) 9. YA16 12(3) 10. YA20 13(2) 11. YA20 13(2) handled appropriately specifically that personal information on service users should not be placed on the home’s notice board. 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 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. The registered person must ensure that in respecting those service users whose decision it is to smoke that a designated smoking area is identified either within the home or outside the home but that a sheltered area is provided outside that is comfortable for them to use. The registered person must ensure that all staff receive 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. The registered person DS0000066922.V306721.R01.S.doc 31/03/07 31/03/07 31/03/07 31/03/07 31/01/07 Page 29 Colin Care Home Version 5.2 12. YA29 23 (2)(n) 13. YA33 18(1) (a) 14. YA34 19 & Sched 2 must ensure consistency in the handling, administration and recording of medication specifically that: - All staff sign the Medication Administration Record (MAR) sheets rather than tick them and where medication cannot be administered an appropriate code is used. - That new medication is checked and signed in on the (MAR) sheets with the quantity of each medication recorded. - That all medication returned to the pharmacy are recorded. The registered person 31/03/07 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. The registered person 31/01/07 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 are recorded on the rota. Rotas should be kept for a period of time before being disposed of. The registered person 31/08/06 must ensure that staff are not allowed to commence DS0000066922.V306721.R01.S.doc Version 5.2 Page 30 Colin Care Home 15. YA35 16. YA39 17. YA42 working in the home until all required documents are obtained including a new Criminal Bureau Record check and two references. (Immediate Requirement issued 03/08/07) 18(1) The registered person 31/05/07 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. 24 The registered person 31/05/07 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. 31/03/07 13(4)(a)&(c)&23(4) The registered person (c) 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. - A building risk assessment is completed. - Fire drills are carried out DS0000066922.V306721.R01.S.doc Version 5.2 Page 31 Colin Care Home on a regular basis at least four times a year. 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 YA20 Good Practice Recommendations The registered person should consider giving a photocopy of the Medication Administration Record (MAR) sheets to service users or their relatives when service users go on social leave so that the administration of their medication can be recorded. The registered person should try to encourage staff/service users to take MAR sheets with them when attending GP appointments so that any changes to medication can be recorded on the MAR sheets and signed off by the G.P. The registered person should consider purchasing a medication guide such as the British National Formulary (BNF) for staff’s information and enable them to become familiar with the medication being administered to 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 purchase more furnishings to make the home more homely and comfortable for service users. 2. YA20 3. YA20 4. 5. YA23 YA24 Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Colin Care Home DS0000066922.V306721.R01.S.doc Version 5.2 Page 33 - 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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