Inspection on 26/07/05 for Coombe Road (82)

This inspection was carried out on 26th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Coombe Road (82) 02/08/07

Coombe Road (82) 12/05/06

Coombe Road (82) 24/11/05

Coombe Road (82) 01/09/04

Coombe Road (82) 20/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Coombe Road (82) 82 Coombe Road Croydon Surrey CR0 5RA Lead Inspector Lee Willis Unannounced 26 July 2005 09:45 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 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 Stationary 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. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Coombe Road (82) Address 82 Coombe Road, Croydon, Surrey, CR0 5RA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01543 416106 Milbury Care Services Limited Michael Luganda Care Home 8 Category(ies) of LD Learning Disability (8) registration, with number of places G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 September 2004 Brief Description of the Service: 82 Coombe Road is a residential care home that is owned, managed and staffed by Milbury Care Services, a public limited company that specialises in providing accommodation and personal care for adults with learning disabilities. The home is registered with the CSCI to provide care for up to eight service users. There are currently five female and one male service user residng at the home who are all aged between their late thirties and fifties. Michael Luganda continues to be the registered manager of the home, a post he has held since November 2003. This detached Victorian property is set back from a main road and overlooks a beautiful park in South East Croydon. Located only a few miles from the centre of town centre, the service users are able to make good use of local amenities, including shops, resturants and pubs. The home is also within walking distance of a variety of good public transport links, including trams, which stop directly outside the home and numerious bus stops. The home also has its own vehcile. There have been no significant changes made to the homes physical environment since the last inspection. This three-storey building still comprises of eight single occupancy bedrooms located on both the ground and first floors, a main lounge, dinning area with a conservatory attached, a large kitchen, laundry room, top floor office, and a sleeping-in room for night staff. There is a well maintained garden at the rear of the property, which has a large flat lawn, various trees and shrubs, and a swing that seems to be very popular with one service user in particular. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 9.45am. It took place over three and three quarter hours on Tuesday 26th July 2005. Four service users were at home during this inspection and two were spoken to at length. Both the service users met were willing to share their experiences about life at the home, and their help with this inspection is very much appreciated. The Commission also received two comment cards, which had both been completed by the relatives of service users. The majority of this inspection was spent talking to the homes manager, although a considerable amount of time was also spent interviewing a visiting aroma-therapist, sampling records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: What has improved since the last inspection? In each of the homes three previous inspections the number of new and on going concerns the Commission has had about service has been steadily falling. The vast majority of requirements identified in the homes last report have been addressed and there has been a more than 50 reduction in the number of new requirements highlighted for urgent action in the main body of this report. Areas of practice that have improved in the past twelve months include the homes in-house activities programme. The aromatherapist said the variety of opportunities the service users now had to pursue their leisure interests appears to have been steadily improving over the last couple of years, G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 6 especially now the home has an activities coordinator. Furthermore, it was evident throughout the course of this inspection that the new conservatory is used primarily for activities. A wide variety of art and craft resources were observed to be stored in this area and a member of staff was seen helping a service user with their embroidery. The rolling programme to redecorate and replace all the homes soft furnishings, although on going, is now largely complete. Consequently, the service users now live in a much more comfortable and aesthetically pleasing environment. There has also been a significant improvement in the time it is now taking the service providers own maintenance team to respond to both routine and urgent repair jobs at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 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 standard(s) 1,2 & 5 Improvements have been made to the homes Statement of purpose to ensure prospective service users and their representatives are provided with sufficient information to make an informed choice about the service. The document needs to be reviewed at regular intervals to ensure it remains current and accurately reflects any changes in the home. All the service users have been supplied with written and signed contracts setting out the terms and conditions of occupancy, ensuring that all the interested parties, including the service users, their representatives and the service providers, are aware of their rights and responsibilities. EVIDENCE: As required in the homes previous inspection report its Statement of purpose has been amended and now contains all the information any prospective service user and their representatives would need to have, including what services and facilities the home offers and what its primary aims and objectives are. The manager stated that both the homes Statement of purpose and service users guide would be kept under regular review and updated accordingly to reflect changes. Both these documents need to be dated as evidence of the reviewing process. There have been no new permanent admissions to the home in the past twelve months, although one emergency placement was recently accepted on a temporary basis. The individual placed as an emergency was relocated after G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 9 just three weeks when it became apparent that their needs were incompatible with the existing service users. The home continues to have two vacancies, although the manager is now adamant that in accordance with its Statement of purpose the service will no longer be catering for emergency or temporary respite admissions. Each service user now has an up to date, written and signed contract setting out their terms and conditions of occupancy. Two contracts sampled at random specified all the information required by the National Minimum Standards and the associated Care Homes Regulations (2001); including fees charged, what they cover, and more importantly what they did not; periods of notice to be given in the event of a placement being terminated; and the rights and responsibilities of both the service providers and service users. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 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 standard(s) 6, 8, 9 & 10 Care plans accurately reflect service users current needs and immediate/longterm goals, but further amendments are required to ensure care plans set out in far greater detail the actual support each service user needs to achieve their these goals. This lack of detailed guidance for staff means there is no assurance that service users needs are being met. EVIDENCE: Care plans sampled at random were all clearly based on service users individual assessments and covered every aspect of their personal, social and health care needs, setting out in detail each service users immediate\and longterm goals. However, the manager concedes that plans could be improved and the service providers have already responded by setting up a working group to develop a far more person centred approach to care planning, which will set out in greater detail what specialist support each service user requires to achieve their identified goals. A good example of a specialist need is communication. It is hoped that the introduction of a new care plan format will enable staff to set out in detail what each service users preferred mode/method of communication is, and more importantly how they intend to meet it. It is hoped that a more uniformed and person centred approach to care planning will address the aforementioned shortfalls. The manager believes G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 11 the new format will be in place by the end of the year (2005). It was positively noted that care plans continue to be reviewed at regular intervals and up dated accordingly to reflect changing needs. Since the last inspection the number of service users who have independent advocates to speak on their behalves has doubled to two. The manager stated that the new advocate has visited the home on two separate occasions and will be invited to attend the service users next care plan review meeting. Records indicate that four service users meetings have been held since September 2004. The last took place in May’05 and topics covered included, menu planning, activities and Birthdays. These meetings are generally well attended by the service users and two individuals in particular seem to take a very active part in the proceedings. One service user met said they enjoyed attending these meetings. A comprehensive set of risk assessments are included in the care plans, specifying what action needs to be taken by staff to ensure identified risks and/or hazards are, so far as ‘reasonably’ practicable, minimised. Risks covered every aspect of service users lives, including personal care, relationships, and epilepsy, accessing the wider community, climbing the stairs, and using sharps. Information held about service users is still being stored on ‘open’ shelving in the top floor office. As required in the homes previous report the manager has reminded staff that this room must remain locked at all times when it is not in use. A notice to this effect is pinned to the office door and the manager stated that visitors are never left unaccompanied in the office. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 16 & 17 Some progress has been made on improving arrangements to identify service users social, leisure and recreational interests, and provide them with far greater opportunities to engage in ‘age’ appropriate activities within the home. However, more work is needed to ensure service users and their representative’s expectations regarding activities are realised, particular with regard community based ones. Overall, meals appear to be nutritionally well balanced, nicely presented, and provide daily variation and interest for the people living in the home. EVIDENCE: G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 13 Having sampled 50 of the service users daily diary notes, along with more specific leisure/recreational records, it was noted that they generally matched the homes weekly activities schedule. One service users activity record for the month of July revealed that they had joined in music, drama and aromatherapy sessions at the home, been painting in the activities room, spent time on social leave with their family, and been out on trips to the park, shops and a local music festival. A visiting aromatherapist spoken to a length said “in the eighteen months she had been visiting the home she had seen a definite improvement in the number of the social activities being offered to service users”. Furthermore, since the homes last inspection it was positively noted that as recommended in the previous report the manager had recruited a fulltime activities coordinator. This has clearly strengthened the homes activity base. Nevertheless, the aforementioned comments notwithstanding, the general consensus of opinion expressed by the homes manager, a Care manager representing one service users Placing Authority, and the Commission, was that more could be done to strengthen the number of and variety of activities the service users engage in outside the home. For example, none of the service users are going on holiday this year and to compensate for this the manager should give serous consideration to ensuring all the service users have the opportunity to go on the equivalent number of day trips instead. The manager acknowledges that the range of day trips and outings the service users have been on in recent years has not been particularly inspiring and needs to be improved. The manager stated that based on an assessment of risk none of the service users are permitted to access the wider community without appropriate staff supervision. The front door has been fitted with a coded keypad device to minimise the risks associated with service users leaving the home without appropriate staff support. However, contrary to the requirement identified in the homes previous report this limitation on service users freedom of movement and choice, although agreed, is still not identifiable in care plans or the homes Statement of purpose. These documents must clearly set out the homes rational behind its decision to restrict the service users in this way. The published weekly menus are conspicuously displayed in the kitchen. The meals provided seemed to be nutritionally well balanced and varied. It was positively noted that the home also catered for specific cultural and healthcare needs, with Afro-Caribbean meals, as well as food suitable for diabetics, clearly identified on the published menus. As part of a tour of the premises ample stocks of fresh fruit, potatoes, bread, cereal, biscuits, soft drinks, teas and frozen vegetables, meat, and fish were seen correctly stored in the kitchen, in accordance with basic food hygiene standards. The kitchen remained open throughout he course of this inspection. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 21 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified and met. Significant progress has been made by the home to record the majority of service users wishes regarding death to ensure the event with be handled with respect and as the individual and/or their representatives would wish. EVIDENCE: The homes accident book revealed that none of the service users had been admitted to Accident and Emergency in the past nine months. This record contained seven new entries regarding accidents involving service users. All these accidents pertained largely to cuts and falls and no major injuries were sustained in this time. Documentary evidence was available on request to show that sufficient numbers of the current staff team are suitably qualified to administer basic first aid. Detailed records are kept of all the service users health care appointments with community-based professionals, including GP’s, psychiatric nurses, speech and language therapists, dentists, and opticians. As required in the homes previous inspection report progress has been made to ascertain and record the wishes of service users regarding their deaths. This process is on going and appears to being handled sensitively. Progress on the matter will be assessed at the homes next inspection. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 15 G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Suitable arrangements are in place to ensure complaints are listened too, handled objectively and acted upon. In the main the homes vulnerable adult protection and abuse prevention measures are suitably robust to ensure the service users are so far as reasonable practicable protected from harm, although insufficient numbers of the current staff team have received the necessary training to effectively deal with incidents of aggression. This training shortfall places both the service users and staff at risk of harm and/or abuse. EVIDENCE: No new entries have been entered into the homes complaints log since it was last inspected in September 2005. The home has a detailed complaints procedure, which contains all the information required by the National Minimum Standards and the associated Regulations (2001). A copy of the procedure is included in the service users guide and one service user said that they felt confident that staff would always listen to any concerns she may have. There have been no allegations of abuse made within the home in the past twelve months and therefore no staff have needed to be referred for possible inclusion on the protection of vulnerable adults register. Nevertheless, there have been twenty significant incidents in the home involving service users in the past nine months, three of which resulted in staff physically intervening and restraining a service user. The majority of these incidents concerned a the service user placed as an emergency, who was relocated soon after their arrival because the home was unable to cope with their challenging behaviour. The only other service user who was physically restrained by staff during this time has specific guidelines in for staff to follow in the individuals care plan. The manager stated that it is compulsory for all staff to attend a six-hour Home Office approved Non-violent crisis intervention course, which must be up G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 17 dated annually. Staff records revealed that at least 50 of the current staff team either needed to up date their existing crisis intervention training or attend the course for the first time. This training shortfall needs to be addressed as a matter of urgency. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27 & 28 Improvements made to the interior décor of the home in the past twelve months ensures the service users now have a far more homely, safe and comfortable environment in which to live. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 19 EVIDENCE: It was positively noted that all the outstanding environmental requirements identified in the homes last report have been met in full within the prescribed timescales for action. There have been no major changes to the physical structure of the home since the last inspection although the rolling programmes to redecorate all the service users bedrooms and communal areas is now complete. The manager stated that plans to replace all the homes communal carpets and the leather sofas in the lounge have been agreed and will take place by the end of the year. Plans are also being drawn up to install a new shower facility in the ground floor bathroom. Progress on all these matters will be assessed at the homes next inspection. The uneven piece of carpet located near the kitchen and ground floor toilet doors represents a tripping hazard and immediate action will need to be taken to make it safe. Furthermore, as previously agreed with the manager the rather offensive smelling carpet in one service users bedroom also needs to be replaced with more ‘suitable’ flooring covering. An Environmental Health Officer last visited the home in October 2004 and no requirements were made. Several bedrooms were viewed at random and were found to be very personalised and decorated to a ‘reasonable’ standard. Having tested the temperature of water running from the hot tap attached to the first floor bath it was found to be a safe 41 degrees Celsius at 12.15. The damaged oven that has not been working since it was installed over three months ago. This needs to be repaired/replaced as soon as practicable as this clearly limits the choice of meals the staff can prepare the service users. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 & 35 Progress has been made to ensure the home has a relatively stable staff team, which is in the main ‘suitably’ trained to meet the health and welfare needs of the service users. However, sufficient numbers of staff still need training to ensure they are suitably qualified and competent to meet all the service users specific autistic and communication needs. The employers’ responsibility to undertake appropriate checks on police records for new staff is still inconsistent and this lack of diligence may put residents at risk from employees who are unsuitable to work with vulnerable adults. EVIDENCE: The manager said all the homes new and amended policies and procedures are regularly discussed at team meetings and that a new record had been established which staff must sign and date as evidence that they have read and understood their contents. Having examined this record it was evident that the process of getting staff to sign this record had begun and was on going. Records indicate that only one member of the current staff team has successfully completed a National Vocational Qualification in Care Level 2 or above, although the manager said that four other members of staff have also completed this course, but are awaiting their certificates of attendance to be delivered. Furthermore, the manager is adamant that his entire staff team will G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 21 have either completed or at least stated their National vocation Training by the end of the year (2005). The manager is aware that at least 50 of staff must have achieved an NVQ Level 2 or above in care by the end 2005. The manager stated that Milbury Care have recently reassessed their training provision and are now fully committed to meeting the aforementioned objective. Progress on this matter will be assessed at the homes next inspection. The manager acknowledges that the ethnic mix of the current staff team, the vast majority of whom are of black African and/or Afro-Caribbean origin does not accurately reflect that of the service users, who are mainly white Caucasians. The manager said he would be mindful of this cultural imbalance when he next recruits new members of staff. The duty rosters show that staffing levels remain unchanged. At least three members of staff continue to be on duty thorough the day, on both early and late shifts, while a fourth member is often employed on Fridays to meet service users activity needs. Furthermore, since the homes last inspection and as previously mentioned, it was positively noted that a full-time activities coordinator has now been employed to work Monday to Friday. At night, one waking and one sleep-in member of staff are on duty. The manager believes that current staffing levels remain adequate to meet the service users needs. Since the homes last inspection the manager has employed two new members of staff, both of whom have transferred from other Milbury Care establishments. New staffs’ file contained the majority of information the service providers are legal obliged to obtain in respect of these new recruits. However, one staffs Enhanced Criminal Records check revealed that despite transferring from another Milbury home, the service providers had failed to ensure this individual had applied for a new CRB when they first joined the company. This not only contravenes the Care Homes Regulations (2001), but also means this individual has not been checked against the recently created Protection of Vulnerable Adults register. It was agreed at the time of this inspection that this member of staff must not work unsupervised with service users until the home has obtained a satisfactory criminal records check for them. Sufficient numbers of the existing staff team have either received or are booked to attend suitable courses in a number of core areas of practice, including fire safety, first aid, epilepsy, vulnerable adult protection and abuse training. However, the manager acknowledges that insufficient numbers of his current staff team are not ‘suitably’ trained to meet all the service users unique needs, particularly with regard their specialist communication and autistic needs, e.g. None of the staff have received any Makaton training in recent years. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 22 The manager stated that Milbury care have employed a new training officer and he is confident that all these training shortfalls will be addressed by the end of the year. Staff should also attend a person centred care planning course. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Although the service providers have adopted a professional recognised quality assurance system the results still need to be published as evidence that the views of service users, their relatives and other representatives are being sought and taken into account when judging the homes performance. Overall the homes health and safety arrangement are adequate to protect the service users and staff from avoidable harm, although the water heating still needs to be checked against legionella to minimise the risk of infection. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 24 EVIDENCE: The home has a professionally recognised quality assurance system in place, which is used to seek the views of service users and their representatives, using questionnaires and surveys. However, since the Regional Operations manager who carried out these surveys was recently replaced the results of the surveys remain unpublished. The service providers must make more of a concerted effort to ensure all the relevant parties, including service users their relatives and the Commission can view the results of the homes quality assurance surveys. Overall, the home is well maintained and it was positively noted that the vast majority of the outstanding health and safety issues identified in the homes previous inspection have been met in full within the prescribed timescales for action, including all those relating to fire safety arrangements, electrical wiring and COSHH products. Inspection of the homes fire records indicated that the fire alarm system continues to be tested on a weekly and fire drills carried out regular intervals. Up to date Certificates of worthiness were also in place for the homes fire alarm system and portable electrical appliances as evidence that a suitable qualified professional had checked them in the past twelve months. However, no recorded evidence was available to show that the homes water heating had been checked for legionella, despite this being identified as a major shortfall in the homes previous report. This issue must be addressed as matter of urgency. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 3 2 x x Standard No 11 12 13 14 15 16 17 x 3 3 3 x 1 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 1 x G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6 Timescale for action The homes Statement of purpose 15th August and service users guide must be 2005 dated as proof that they are being reviewed at regular intervals and updated accordingly to reflect changes. Care plans must contain more 1st October specific details regarding each 2005 service users preferred mode of communication and any specialist support they require to communicate their wishes and feelings more effectively. Any agreed limitation regarding 1st October service users freedom of 2005. movement and choice needs to be included in their care plan and the homes Statement of purpose, setting out clearly the homes rational behind the decision to restrict the service users in this way. Previous timescale for action of 1st November 2004 not met All staff who have yet to up date 15th August or attend an accredited training 2005 course in the appropriate use of physical intervention techniques must do so as a matter of urgency. Documentary evidence of this training must for Version 1.40 Page 27 Requirement 2. 6 12((3) & 17(1)(a), Sch 3.3(l) 3. 16 4(1), 5(1) & 17(1)(a) Sch 3.3(q) 4. 23 13(6) & 18(1), Sch 2.4 G53-G53 s28482 Coombe road v198862 260705 .doc inspection on request. 5. 26 16(2)(c) (k) Offensive odour caused by carpet in ground floor bedroom to be replaced with more suitable floor covering. 13(4) & Up turned hallway carpet, which 23(2)(b) currently represents tripping hazard to be evened out. 16(2)(g) Damaged oven to be & 23(2)(c) repaired/replaced. 13(6) & 19, Sch 2.7 New recruit whose Criminal records check is out of date needs to be checked against the protection of vulnerable adults register and apply for a new CRB. Sufficient numbers of the current staff team must be suitably trained to meet the autistic needs of the service users. Sufficient numbers of the current staff team must be suitably trained to meet the specialist communication needs of the service users and be able to communicate effectivley with them in their preferred mode of communication, i.e Makaton. The results of service user and/or their representatives surveys must be published as part of an effective quality assurance system. The homes water heating must be checked against legionella. Previous timescale for action of 1st October 2004 not met. 1st September 2005 15th August 2005 1st September 2005 15TH August 2005 6. 7. 8. 28 28 34 9. 35 12(1) & 18(1) 12(1) & 18(1) 1st November 2005 1st November 2005 10. 35 11. 42 24 1St November 2005 1st September 2005 12. 42 13(4) & 16(2)(j) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 28 1. 6 2. 14 3. 4. 5. 32 33 35 The service providers should introduce a more person centred approach to care planning and ensure the new format sets out in greater detail what support each service user needs to acheive their immediate and long-term goals. The homes community based activity base should be improved and the service users should have far greater opportunities to go on more day trips/outings to places of interest. 50 of care staff to have achieved an NVQ level 2 or above in Care by the end of 2005. The manager should be mindful of the cultural imbalance that exists between the current staff team and the service users when recruiting new members of staff. Sufficient numbers of staff should attend a person centred care planning course. G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 29 Commission for Social Care Inspection Croydon, Kingston & Sutton Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI G53-G53 s28482 Coombe road v198862 260705 .doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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