Inspection on 18/11/04 for Cranmer Scheme

Care Homes For Adults (18 ­ 65)Cranmer SchemeLynda Cohen House 1 Cranmer Road Leeds West Yorkshire LS17 5PXAnnounced Inspection18th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Cranmer Scheme Address Lynda Cohen House, 1 Cranmer Road, Leeds, West Yorkshire, LS17 5PX Email address Tel No: 0113 237 1052 Fax No: 0113 2687470Name of registered provider(s)/company (if applicable) Leeds Jewish Welfare Board Name of registered manager (if applicable) Mr Keith Robinson Type of registration Care Home No. of places registered (if applicable) 16Category(ies) of registration, with (number of places) Learning disability (16), Learning disability over 65 years of age (16) Registration number B080000127 Date first registered 24th June 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 Yes NO 11.04.04 If Yes refer to Part CCranmer SchemePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 318th November 2004 10.00 am Sue DunnID Code071355Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionKeith Robinson ­ Registered ManagerCranmer SchemePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementCranmer SchemePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Cranmer Scheme. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Cranmer SchemePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Cranmer Scheme is part of the Leeds Jewish Welfare boards `Rainbow Project. It incorporates two houses, domestic in style, each with a small garden. Both houses are purpose built to provide a residential setting for Jewish people with a learning disability. The houses are situated on either side of a narrow access road into a housing estate. They are within easy travelling distance for the wider Jewish community and the city centre. Eight people are accommodated in each house. Both houses have ground floor accommodation suitable for people with mobility problems. Lynda Cohen House also has lift access to the first floor and a sensory activities room. The scheme is managed by Mr Keith Robinson supported by a deputy manager and operates in accordance with Jewish Cultural requirements. The service aims to provide residents with opportunities to participate in activities of normal daily living inside the home and in the wider community. The manager and staff perform this task to a high standard. Admission to the home is subject to the homes ability to meet an individuals assessed needs and follows a process of introduction and consultation with prospective and existing residents. Twenty four hour staff cover is provided, with a member of staff sleeping on the premises in each of the houses at night. The home has a comprehensive induction training for all staff leading on to the NVQ award programme. The inspector was informed that the people who live in the house prefer to be called `residents and this term has been used for the purpose of the report.Cranmer SchemePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This report is based on the second inspection to be undertaken during this inspection year. The inspection was carried out by one inspector during the course of a day and was by prior arrangement with the manager. The purpose of the inspection was to ensure that the home was operating and being managed in accordance with the National Minimum Standards for a Care Home for Younger Adults. Of the three requirements made during the last inspection two have been met. The third has been carried forward and will be met when the manager completes the care component of the NVQ 4 which he is aiming to do by March 2005. There were no recommendations carried forward. This inspection took place in Lynda Cohen House with a selection of records examined from both houses and a brief visit made to the service users at Lily Thompson House who are generally more able. Only the communal area of Lily Thompson House was seen during this inspection with an overview of Lynda Cohen House showing the house maintained to its usual clean comfortable standard. The two house continue to operate and be managed with the interests and well being of the residents as a priority. Residents are well cared for and valued as individuals. Action is taken as required to ensure the home continues to meet its stated purpose as a `home for life. Choice of Home 1-5 Four standards were assessed. All were met with standard 5 exceeded. A recommendation has been made regarding the draft pre admission assessment form which has been reviewed since the last inspection. The draft document, if used as intended, will provide an excellent picture of the each individuals needs and the resources required to meet those needs. This will provide a basis for the initial care plan. The licensing agreement is in a format which is sympathetic to the needs of the resident group for whom it is intended. Individual Needs and Choices 6-10 Four standards were assessed. Two, standards 7 and 8 were exceeded. The home does excellent work in the way residents are consulted and offered choices. Staff respond flexibly to the range of needs and activities and aim to balance the needs of the more independent people in the group against those of the less articulate. Risk management plans aim to support rather than restrict activities.Cranmer SchemePage 6 Lifestyle 11-17 Five standards were assessed. Standards 11 and 14 were exceeded. The home supports a good range of opportunities for people on and individual level and based on interests and ability. There was evidence in care files to show that residents are actively involved in reviewing their care plans and their views noted Personal and Healthcare Support 18-21 Four standards were assessed. Standard 21 was exceeded. A recommendation has been made as more work should be done to show that residents are encouraged and supported to administer and control their own medication within a risk management plan in accordance with the minimum standards. Health care services are used appropriately and proactively with staff described by a GP as helpful and well informed. The home has done excellent work in ensuring spiritual needs are met and people supported through the process of illness, ageing and death. Concerns Complaints and Protection 22-23 One standard was assessed and met. Satisfactory systems are in place and followed to ensure the well being of residents is safeguarded. The inspector was not clear how recently staff had received adult protection training and would like to see more evidence of this at the next inspection. Environment 24-30 Seven standards were assessed. All were met. Both houses are domestic in style and discretely located in the local community. The properties are well maintained and comfortably furnished. Cleaning is to a high standard without any loss of `homeliness. Residents all have their own bedrooms, decorated and equipped to personal choice and needs and take part in the general domestic activities of their homes according to ability. Staffing 31-36 Four standards were assessed. Two were met. Two had a minor shortfall. A recommendation has been made. There is a good skill mix of staff within the team and due to the close proximity of the two houses staff are able to adapt to the social, recreational and care needs of people at an individual level. It was pleasing to note that additional funding has been obtained to meet the increasing care needs of one person. The manager recognises that staff need further training in the care of people with dementia and is advised to contact the Bradford dementia development unit for information about suitable training. The organisation continues to make efforts to have 50 of staff with the NVQ award by April 2005, despite some staff turnover. There must be evidence to show that staff receive formal staff supervision at least 6 times a Cranmer Scheme Page 7 year. Conduct and Management of the Home 37-43 Six standards were assessed. Five were met. Standard 37 had a minor shortfall. The manager is aiming to complete the care component of the NVQ4 award within the timescale in order to meet the standard. The home is managed in a way which encourages the participation of residents and staff through formal and informal systems. The policies and procedures have recently been reviewed and are to be amended as appropriate. Health and Safety check procedures are routinely carried out and recorded. Systems are in place to ensure the management committee and the named person for the providers of the service are well informed about the operation of the home.Cranmer SchemePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 9 YA37 The manager must have completed the care component of the management award by the required date There must be evidence to show that all staff working in the home receive supervision at least six times a year By 31.3.05218YA36By 31.3.05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The pre admission assessment should include a pen picture of relevant past history and include the views and comments of the service user and/or their representative. Staff should be mindful that service users should be encouraged and supported to retain administer and control their own medication within a risk management framework wherever possible. The organisation is advised to approach the Bradford dementia development unit regarding dementia training for staff.1YA32YA203YA32Cranmer SchemePage 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Cranmer SchemePage 10 PART BINSPECTION METHODS & FINDINGSYES YES YES YES YES YES YES NO YES YES YES YES NO YES YES NO YES YES NO YES 7 1 0 NO NO YES YES 15 X 18/11/04 10.00 5.45The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)Cranmer SchemePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Cranmer SchemePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 698 X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The Statement of Purpose remains the same but has been updated to include any staff changes. Residents pay for such services as hairdressing, clothing and social outings from their personal allowances according to their wishes and receive appropriate practical support from staff as requiredStandard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Not assessedCranmer SchemePage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The inspector was shown a draft copy of an assessment form which is being developed by the Rainbow Project for people referred to the home. The assessment is divided into sections, each area having a space for comments to enable the assessor to record what resources and support will be required to enable the home to meet the assessed needs. Clearly a lot of thought has gone into this document which, if used as intended, has the potential to provide the home with a clear picture of how they are to form an initial care plan which covers all the assessed needs. It will also identify any needs which cannot be met. It is recommended that a section be included to provide a pen picture of significant people, and events in the life history of the person being assessed. The comments and views of the potential resident and /or their representative should also be incorporated. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The home has a procedure for introductory visits which is adapted to the needs and requirements of each individual.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 4 Key findings/Evidence Standard met? A copy of the licensing agreement was seen in the files examined by the inspector. This is in a format which aims to overcome the communication difficulties of some residents and showed evidence that staff assist people to understand the content of the document.Cranmer SchemePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Four care files were examined, two from each house. All the files contained the information required by the National Minimum Standards and were consistent in layout, making it easy for the inspector to access and cross reference information. In all but one file the style of recording showed clear evidence that service users had been involved in the preparation and reviews of their care. More articulate people in Lily Thompson House knew when their care plan reviews were to take place.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 4 Key findings/Evidence Standard met? The inspector observed several examples of staff offering service users choice and the right to make decisions at various levels throughout the day. The conversations between staff and service users clearly indicated this was the norm. Advice is sought from other professionals as required.Cranmer SchemePage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 4 Key findings/Evidence Standard met? It is apparent that care needs are increasing as the people living in the houses age. This was more noticeable in Lynda Cohen House where people who were previously involved in the day to day running of the home become less active. The staff are mindful to maintain a balance between the more articulate and opinionated members of the group and the needs of the quieter members. Staffing of the scheme enables one to one work and outings to take place with less independent people. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not assessed Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Care files are safely stored and information recorded in accordance with the protection of data. A discussion took place about the arrangements and length of time for storing archived material as the volume of paperwork increases. The inspector confirmed that records must be stored for at least seven years after the death of a service userCranmer SchemePage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? Residents continue to participate in a range of formal and informal activities in the wider community according to interests and abilities. Staff continue to explore new opportunities for people. As a result of this one resident had attended a new service on the day of the inspection which he had enjoyed. There was an element of excited anticipation about the plans for the forthcoming Chanuka party to be held at Lynda Cohen House and the annual party at the Jewish Day Centre. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not assessedStandard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Service users continue to lead an active life with support from staff to enable them to pursue any hobbies and interests. There was evidence in care plans and during discussion with service users which showed that spiritual needs are recognised.Cranmer SchemePage 17 Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 4 Key findings/Evidence Standard met? This standards was assessed and exceeded at the last inspection. Care records and conversation indicated that people have ample opportunity for leisure activities. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not assessedStandard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Care plans are reviewed and recorded in a way which shows people are able to express their views as part of this process. There was evidence that the people who remained at home on the day of the inspection had been able to make choices about how to spend their day. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The inspector joined two of the service users for a light lunch in the dining room. The main meal continues to be served at the end of the day at a time convenient to the service users plans for the evening. All food purchased and served is in strict accordance with Jewish dietry laws.Cranmer SchemePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Whenever possible service users visit the surgery. Staff had no hesitation in requesting a GP visit for one person who was unwell on the morning of the inspection and had chosen to go back to bed. The inspector was able to speak with the visiting GP who described the staff as helpful and well informed about the people in their care and stated that the request for a home visit had been appropriate.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 203 Key findings/Evidence Standard met? The accident recording system complies with data protection. Each form allows ample space for detailed recording of an event with a section for managers comments a risk assessment and action plan. Risk management plans are aimed at supporting people to continue to lead a fulfilling lifestyle rather than restricting their movements in an overprotective way. As accident records are transferred to individual files on completion it is recommended that the manager devise a quick accident reference log in order to maintain an overview of the number of accidents sustained by each individual. This to contain just a name and date to refer the reader to the appropriate file for more detailed information. One person regarded as at risk of developing pressure sores has been referred for skin viability tests.Cranmer SchemePage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? None of the service users manage their own medication. Medication administration systems have been tightened up with two staff now present and signing when medication is given. This is required for controlled medication but a matter of choice for routine medication as long as procedures are followed. It is important for staff to base their policies and procedures and practices on the national minimum standard which states where appropriate service users retain, administer and control their own medication. It was agreed that arrangements be made for the safe storage of one persons medication on the ground floor due to the amount and method of administration at the present time. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 4 Key findings/Evidence Standard met? The inspector has had evidence in the past that the staff maintain a home for life. It was encouraging to note that additional funding has been obtained to provide additional support for one person. Staff have given good emotional and practical assistance for people during periods of hospital admission. Care files showed that service users have had the opportunity to discuss their wishes in the event of their death and this has been clearly recorded.Cranmer SchemePage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not assessed X X X X X X X Standard met? 0Cranmer SchemePage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The operations manager takes the lead on CRB checks and provides the manager of the home with CRB check numbers as confirmation that the checks have been undertaken. The inspector clarified that the frequency of updating CRB checks for existing staff is at the discretion of the organisation. Staff sign a declaration which requires them to inform the organisation if circumstances change. Failure to do so could be grounds for dismissal The manager is aware that all new staff and existing staff must have had a satisfactory CRB check. It was not clear from the pre inspection information how recently staff had received adult protection training.Cranmer SchemePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The houses are well positioned within the local community and within easy reach of synagogues and services for the Jewish community. Both houses are domestic in style and indistinguishable from other houses in the area. Systems are in place to ensure the buildings are safe and well maintained. The sensory room which can be accessed without going into the home is being used temporarily as an office by the operations manager and community worker. This will revert back for use by the home when the new community centre reopens.Cranmer SchemePage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 16 6 0 0 3 16 02 0 0 0Key findings/Evidence Standard met? The home meets the standard for an existing registration.Cranmer SchemePage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms in Lynda Cohen House were inspected during this visit as the last inspection focussed on the rooms in Lily Thompson House. All were furnished to reflect the tastes and needs of each individual and to meet the requirements. There was evidence in the care files to show that service users have chosen their furnishings and fittings. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? Bathrooms were clean warm and appropriately equipped. An adjustable height bath and tracking hoist have been installed in a bathroom shared by two people with physical disabilities. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? All communal areas retain their homely feel and are cleaned and maintained to a high standard. The more able service users were observed to use these areas as their own home. The kitchen units in Lynda Cohen House have been replaced since the last inspection Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Aids and equipment are provided subject to individual assessed needs. A new ceiling track has been fitted in one bedroom to provide more floor space for the occupant. The inspector saw evidence that regular service checks are carried out on lifting equipment.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? An overview of the premises found them to be clean hygienic and free from offensive odours.. Both houses have well equipped domestic style laundries which service users use individually with varying levels of staff assistance.Cranmer SchemePage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Three staff were on duty in Lynda Cohen House where additional funding has been given to meet the increasing needs of one individual. Two staff were working in Lily Thompson House. Due to the close proximity of the two house staff respond flexibly to the needs of residents in each house and ensure that people are supported to access day services and other activities in the community. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The statement of purpose shows a good skill mix within the staff team. Training is ongoing with updates as required. Annual fire safety training has recently taken place. The manager recognises that the team need training in the care of people with dementia but has found nothing specific for people with Downs Syndrome. The inspector is of the view that the principles of caring for a person with dementia are the same and should be person focussed, therefore training needs for staff could be met by any person centred training course.Cranmer SchemePage 26 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 8 8 0 X 6 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X0X2 Key findings/Evidence Standard met? The organisation is making efforts to meet the target of 50 of care staff with the NVQ award. From a total of 15 care staff six staff have the award and one person is currently working towards the award. A member of staff with NVQ has recently left the organisation. The inspector noted an increasing level of physical dependency within the service user group in addition to the level of prompting and emotional support required. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Not assessed Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessedCranmer SchemePage 27 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? The inspector was informed that the manager arranges staff supervision according to the rotas. This system can lead to supervision being missed. One person who has been working in the home for a period of 2 months had not had supervision during that time. There must be evidence to show that each member of staff has supervision at least six times a year.Cranmer SchemePage 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The manager has three units still to complete of the care component part of the NVQ4 award, which he aims to complete in the timescale. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager stated that some staff meetings have been cancelled due to changes to staff rotas. The inspector has observed staff expressing their views and ideas and going about their duties in a relaxed and professional manner. Key workers complete a monthly progress report for the people for whom they act as support workers. Residents are encouraged to express their views and comment on the way the home is managed through key workers, in house reviews, meetings and informal discussions. The inspector has seen the confidence and skills of residents develop during the time they have lived in the home.Cranmer SchemePage 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The inspector was informed that the organisation has had an external consultant to advise them on their policies and procedures and are currently working on a quality assurance policy. A new business plan format has been developed which is to be discussed at the next meeting with staff, residents and the management committee which meets on 14th Dec. The operations manager continues to do a monthly report on the conduct of the home which is presented to the management committee. A house inspection is undertaken periodically on behalf of the housing committee. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The home has policies and procedures for guidance for staff and the welfare and protection of residents. These have recently been reviewed, as stated in standard 39, to ensure they continue to meet the needs of the service. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? All the records requested for inspection were readily available. Care files were consistent in format and contained relevant information which made for ease of cross reference. Records met the requirements of data protection. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Systems are in place for regular health and safety checks to be undertaken. One member of staff takes the main lead in ensuring staff are updated on current legislation regarding health and safety issues. A full Health and Safety audit is carried out six monthly. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not assessedCranmer SchemePage 30 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorSue DunnSignature Signature SignatureRegulation Manager Chris Picking Date Public reports 5th January 2005It should be noted that all CSCI inspection reports are public documents.Cranmer SchemePage 31 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 18th November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCranmer SchemePage 32 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office.Cranmer SchemePage 33 D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Cranmer SchemePage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Sheila Saunders of Cranmer Scheme confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Cranmer SchemePage 35 Cranmer Scheme / 18th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000001476.V160754.R01© This report may only be used in its entirety. 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