Inspection on 12/06/07 for Croydon Road,78

This inspection was carried out on 12th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croydon Road,78 09/05/06

Croydon Road,78 08/11/05

Croydon Road,78 04/05/05

Croydon Road,78 01/11/04

Croydon Road,78 25/05/04

Croydon Road,78 02/10/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Herbert Street

Stacey Street Nursing Home

Haven (The)

Delrose House Ltd

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

CARE HOME ADULTS 18-65 Croydon Road,78 78 Croydon Road Penge London SE20 7AB Lead Inspector Miss Rosemary Blenkinsopp Unannounced Key Inspection 12 th June 2007 09:00 Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croydon Road,78 Address 78 Croydon Road Penge London SE20 7AB 020 8676 9965 020 8676 9965 claire.fakhet@community-options.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Community Options Limited Post vacant. Care Home 7 Category(ies) of Past or present alcohol dependence (7), Past or registration, with number present drug dependence (7), Mental disorder, of places excluding learning disability or dementia (7) Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2007. Brief Description of the Service: This home is part of the Community Options group. Community Options has a number of facilities in the Bromley area. The home has its own dedicated Manager and staff team, whilst senior management and personal support are provided centrally. The home is a detached house in a residential area of Penge. It is located close to the High Street and is well served by public transport. The building itself is located over three floors accessed by stairs. There are no adaptations in this home as all residents are primarily younger, physically able adults. The purpose of the home is rehabilitation to enable residents to live more independently. Residents in this home have mental health disorder and are subject to the Care Programme Approach (CPA). This is a system of multi-disciplinary monitoring and review to keep abreast of the individuals mental health. Staff are provided throughout the 24-hour period, including waking staff. All other health care support is provided through the community including the GP. The weekly fee is £313.59. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced over a one day period by one inspector. In preparation for the inspection the Deputy Manager had completed and returned the AQAA assessment form, this was well completed. The inspector did not have sufficient time to send out questionnaires to residents so these were given out during the site visit. At the time of the inspection the Manager was on duty with two support staff. The home accommodates up to seven residents and at the time of the inspection the home had full occupancy. All resident in this home are subject to Enhanced Care Programme Approach after care systems. Following the site visit the inspector contacted members of the multi disciplinary team who were involved with residents in the home and their next of kin. The inspector case tracked two residents, viewing their records, including care plans and risk assessments. The residents themselves met with the inspector as did staff on duty. A selection of records were inspected including those relating to quality assurance measures, health and safety certificates. Staff discussions revolved around their training support and working life. The recruitment files are retained off site therefore these were not included as part of the site visit. What the service does well: The service deals with those residents who suffer from long term enduring mental health problems. The service provides support in terms of rehabilitation enabling residents to live more independently. This can be a difficult task as unpopular activities such as household chores, maintaining bedrooms etc can be difficult areas to motivate residents to address. Staff do work closely with residents in a consistent manner encouraging and supporting them with all activities of daily living. Staff in this home work with members of the multi disciplinary team to ensure objectives, as set out in care plans, are achieved. Community Options are an experienced organisation in the field of mental health. They work actively to promote the rights of residents and mental health issues generally. They provide opportunities for residents to input into operational issues and to become involved in developments of the service. They do seek to engage with residents and as far as possible and act upon suggestions. One good example of user involvement is the newsletter, which is well received throughout the organisation. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are subject to assessment procedures by staff in the home. Supporting reports from members of the multidisciplinary team is received which provides staff with information on which to base an initial plan of care. All assessment procedures must be conducted, even for those residents who are transferring internally, as the resident group in homes varies as does the skills, knowledge, and expertise of staff. EVIDENCE: At the time of the inspection there were seven residents in the home. All of these residents are on the enhanced level of Care Programme Approach. This is a system of after care whereby monitoring and reviews are undertaken by their care coordinator and with involvement by the multi disciplinary team, resident and staff in the home. The inspector selected two residents to case track that of a fairly recent admission and that of a resident who had transferred within Community Options from another facility. It was evident that significant work had gone into organisation of the files and the reviewing of the information retained within them. In the first file there was a referral form regarding placement dated August 2006. In addition information received under the Care Programme Approach, Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 9 including the care plan and the risk assessment were on file. There was evidence of the assessment visit undertaken by staff at Community Options. The company’s own care package was partially completed. Personal information was recorded and contacts for the resident in place. In the file there was a hospital discharge letter, which included mental health information. There was an assessment from the occupational therapist outlining activities of daily living, needs and risks. There was confirmation of the assessment and subsequently a placement offer. There was no evidence of a trial visit although when the inspector met the resident, he stated that he had not wanted to visit the home as he had grown up on the area and had enough information about the place he was going to. The contract from the Local Authority was a not available; the inspector was advised there was a dispute about the level of fees. There was a signed licence agreement in place. Community Options contract was limited in content, perhaps due to the funding issues, this was signed. Residents are provided with admission information that included the Statement of Purpose and Service User Guide. In the second file there was less assessment information, although there were terms and conditions, and a licence agreement, all signed by the resident and staff. There was no information to advise the inspector of what information had been provided, prior to admission, or if trail visits had taken place. There was no documentation to relate if the next of kin had been provided with an opportunity to visit the home. In all cases, residents must be fully assessed to determine their suitability in prospective accomadation, and demonstrate the home’s ability to meet their needs. Once assessed all residents must have written confirmation of the homes ability to meet their needs. Please see requirement 1. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were in place; reflective of needs and consistent with those areas set out in CPA care plans. Supporting risk assessments were in place to promote greater independence with activities of daily living. Residents are involved with the setting up of care plans to encourage collaborative working in achieving objectives. EVIDENCE: The care plan of the most recently admitted resident was inspected; it reflected physical health needs as well as mental health and alcohol issues as detailed in the CPA assessment information. The care plans had detailed interventions recorded, which would provide staff with a good guide when providing support. There was the resident’s signature as well as the staff’s signature on the care plan. The care plan had monthly reviews in place and summaries recorded in relation to the progress or otherwise made on the identified issues for the resident. This resident had dietary issues, which were outlined, and weight checks were been undertaken. A visit by the dietician had been requested. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 11 Risk assessments covering mental and physical health issues were in place and reflective of those in the CPA information. The content of these was good and reviews were recorded. There was an individual missing persons risk assessment, although this was without a photograph, but did have a description of the resident included and he was able to identify himself. There was a full summary in respect of the case review conducted 13 April 2007. This included those areas identified on the care plan and further action detailed on areas, which were problematic, namely the resident’s finances. The company have made a division between care plans and support plans, the inspector was unable to identify the difference between these two. Staff advised the inspector that the support plan was that which the resident had input to, whilst the care plan was staff led, due to resident’s lack of insight or other restrictions. This was confusing to the inspector. The home must ensure that all problems are represented with a specific plan of action, which is fully reflective of identified needs and risks, with appropriate interventions detailed, which is not duplicated. A second care plan contained similar information, which was reflective of needs – physical, and mental health issues. The resident’s signature was in place as was the staff member’s and review dates stated. Reviews conducted under CPA procedures were documented the last one having been 21 May 2007. There was a contingency plan included in the CPA information. A list of CPA review dates was recorded. Risk assessments were in place with appropriate actions detailed to address issues. The Community Options package was mainly incomplete the inspector was unsure if this was still an operational document. The care plan had an individual missing persons statement and a crisis plan, which the resident themselves had identified and helped develop. There was information from the transferring home which included her care plan. Residents confirmed that they are involved in the development of care plans and are invited to attend CPA reviews. The daily events referenced the issues identified on the care plans and provided information on developments. On some of the documentation there was first names of staff used. On all documentation, full signatures and dates must be included. Overall it was noted that the care plans were more comprehensive in content and reflective of needs, including those to promote rehabilitation and more independent living. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was evidence that residents have choice in their days, but that these are sufficiently structured to achieve rehabilitation objectives, including those relating to work, education and leisure. EVIDENCE: The inspector met with several of the residents during the site visit. Residents themselves were positive about their stay and the changes made. The two residents who were part of the case tracking met with the inspector although one had little to say. The other resident was enthusiastic about the home, he felt staff supported him and was engaging in the chores and tasks needed as part of rehabilitation. He confirmed that he had his own bedroom and front door key and was free to come and go. He had little in the way of visitors but was aware that they were welcomed in to the home. The inspector was also invited to attend the residents group meeting during the lunch time period. Five residents attended and a hot lunch was provided. This was a very good forum for residents to raise issues concerns and comments. It was apparent that residents felt empowered during this meeting Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 13 and spontaneous interaction between one another, and staff, was evident. Residents were assertive in some of their requests and comments, however these were responded to appropriately by staff. Discussion about daily chores, the holiday and leisure activities were some of those subjects raised. Residents were seen to come and go throughout the day. There are various activities which residents are expected to participate in whist living in the home. Those tasks include the maintaining and cleaning of their own bedrooms and communal areas. This does cause some conflict between residents and staff; it is an uphill struggle to maintain standards throughout the home. Activities outside the home are encouraged, as participation in the local community is part of on going rehabilitation. One resident stated that he attends the gym frequently and was seen to do so the morning of the inspection. He had taught himself to swim and was waiting for further coaching to improve upon this. Another proposed activity was adult literacy classes. He had an external support worker whom accompanied him to his activities. He stated he enjoyed the activities and valued the staff support during this. Each resident has an individual activities programme designed around their needs. In house and external activities are provided. The local MIND centre was one of the centres residents frequented. Another resident stated that she spends periods with her sister, which she usually enjoys. Currently there are three residents who are waiting for more independent living accommodation. This is very positive Residents plan their own menu for the week and staff assist with the shopping for his and preparation of the meal. Once a week residents all dine together to promote a sense of community and engagement within the home. The EHO had visited November 2006, and had found items satisfactory. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All health care is provided though local community provision to encourage community involvement and use of services, which promotes rehabilitation of residents. Health care needs are monitored and appropriate services involved as required. Medications are stored safely, supporting documentation is well completed and staff are trained in medications, all of which reduce the margin for error. EVIDENCE: Within the case notes there was reference to health appointments including those for physical health issues and those relating to mental health issues. Evidence of CPA reviews were in place, which provided information and updates on current areas needing input, and in some cases additional action was implemented. There was a form outlining visits and appointments made by members of the multi disciplinary team. These were further referred to in the daily events section of the resident’s notes with more detail provided. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 15 All residents are expected to access local health provision to encourage independence and integration in to the community. All residents do access health service, such as the GP, and dentist in the community. Mental health follow up, is by way of out patient appointments, visits by the Community Psychiatric Nurse (CPN), and CPA reviews. The inspector contacted members if the multi disciplinary team following the inspection. They related positive information in respect of their dealings with the home. They felt staff were professional in all contacts and that any changes in behaviour of the residents was immediately referred to them. It is essential when dealing with mental health residents, and fluctuating mental health issues that lines of communication are clear and timely to ensure prompt action if required. They felt that the staff worked well with residents and managed their behaviours effectively. The medications were inspected. All staff that administer medications are trained to do so and are subject to regular competency assessments. The competency assessments are conducted by a Manger of another Community Options facility to ensure fairness. One resident is fully self medicating. The resident had been subject to a phased programme of self-medication and was risk assessed before the introduction of this. There is a self medication protocol in place for this. The resident is subject to regular reviews in respect of self medication procedures. Medication charts had photographs in place and there was a list of medications, which the resident was taking, detailing side effects and adverse reactions. Hand transcribed medication had two staff signatures to confirm the accuracy of the information recorded. There was a separate record for those medications received into the home and those disposed of. The pharmacist stamp confirmed receipt of medications for disposal. There were no controlled drugs, as required medications, or eye drops in use on the day of the site visit. The administration of medications was not observed at the site visit. Medication audits are conducted weekly. Medications are safely stored in a lockable cabinet. First aid boxes in the home were well stocked with appropriate items .All staff are first aid trained, except one. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on complaints is available and includes external avenues for the reporting of such. Complaints are taken seriously and are dealt with in a professional manner, which promotes an open culture. Protection of residents is afforded by way of Company procedures, external guidance and the staff’s awareness of such procedures, encouraged by a company ethos of reporting poor practice. EVIDENCE: The residents with whom the inspector met were aware of how to make a complaint. One resident stated that she had the number of the Chief Executive, and had rang her on occasions when she was upset. Other residents referred to staff in the home or members of the multi disciplinary team as other avenues to refer concerns. Residents did not seem to have any hesitation about raising concerns within the home and this was evident during the residents meeting. Information on how to make a complaint is on display, in the hall and included in other documents such as the Statement of Purpose. The company have specific policies with time frames included on the investigation of complaints. The inspector has been involved with previous complaints, which Community Options have investigated, and during such, they have demonstrated an open and transparent manner when dealing with them. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 17 The CSCI has received no complaints about this service .In the complaints log there was the complaint monitoring form. This form should be amended to include if the complainant is satisfied with the outcome of the investigation, as it is not specifically stated. The home has the company policies in respect of adult protection and whistle blowing. In addition there was the local Bromley interagency guidance available. Staff were aware of where to access these documents, and the content of these policies. Staff stated that these topics were covered during induction training and thereafter with updates on POVA and adult protection issues. The staff with whom the inspector met were confident about how to action suspected or actual abuse stating internal avenues as well as external organisation such as Care Management and MIND. Staff demonstrated a good knowledge in relation to whistle blowing and the procedures to follow. Staff felt that they could raise any issue even those, which were contentious, and that they would be listened to and action taken by the company. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Communal areas were well maintained and provided the residents with comfortable surroundings. Bedrooms were to a variable standard and more monitoring of these areas needs to be undertaken by staff to ensure that they are maintained in a reasonable state for residents to live in. EVIDENCE: The home had significantly improved in environmental standards. Communal areas were clean, tidy and odour free, the front of the house had also improved. The dining area and adjoining annex had been improved partially because of the smoking restrictions in this area. The dining table was not being used as an ash tray, which has been noted on previous inspections. A new storage cupboard was located here and items safely stored in it. Plants and a fish tank in the lounge provide a homely feel. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 19 The kitchen was better equipped with crockery and cutlery; these items had been insufficient on previous inspections. Individual fridges have been provided to residents, who now retain food and provisions in their own bedrooms, this had reduced the concern about missing foodstuffs. Fridges are routinely checked by staff to ensure purchases are in date. Individual bedrooms were to a variable standard. One bedroom at the top of the house is due for a complete refurbishment including re plastering of walls redecoration etc. The window in this room is restricted so much that airflow is limited. Whilst the refurbishment is going ahead a new window should be provided to allow airflow, although sufficiently restricted to prevent injury. This room is noticeably hotter than the other areas and uncomfortable in the hot weather. One resident showed the inspector his bedroom; it had improved but was still only to an adequate standard. Cleaning of bedrooms is a potential area of conflict, however staff have a duty of care to ensure all areas are retained in a clean hazard free and hygienic manner. Household chores and maintenance of the environment would be essential skills for any resident moving in to independent accommodation, hence residents must be prompted to do these. Following the inspection the Manager of the home called to say that this bedroom had been redecorated and cleaned with more frequent monitoring implemented. The two ground floor bedrooms were satisfactory; one is well maintained by the resident who proudly shows her room. The carpet in the staff room should be replaced as this is worn and stained. Please see requirement 2. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents needs. Induction and training provide staff with the skills and knowledge they need to work with the client group. EVIDENCE: At the time of the inspection there were three staff on duty including the Manager and two support staff, one of who was a long term bank staff. The home has two full time vacancies that are covered by the use of a full time bank staff and overtime by permanent employees. The use of agency had reduced because of problems in terms of continuity and consistency of care. Community Options have appointed a training coordinator early 2007. This has been beneficial for staff, training has improved and regular updates organised. The inspector met with all staff on duty although spent more time with the Manager and two other staff. The first care staff who was interviewed, had been in post for some time, she was very positive about the changes made to the home. She cited improvements to the environment, more rehabilitation activities for residents and a more confident staff group. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 21 The Deputy Manager had been present at a previous inspection where several areas of poor practice and other issues had been identified. The Deputy Manager now had sufficient insight to identify the shortfalls at that time and why things had deteriorated. She felt far more confident in her management ability and attributed this to the continuous support from the Manager. The completion of the AQAA by her, confirmed a good level of knowledge in relation to the standards. She had just completed the RMA. Other training recently had included management of violence and aggression The Manger was particularly experienced and helpful throughout the inspection and all parties in the home referred to her in a positive manner. Staff confirmed training including NVQ, statutory topics and that related to residents needs. Four staff have NVQ level 2 or above out of a total of nine. Recent training received by the care staff included a four day first aid course May 07. The updates on POVA, management of violence, manual handling and basic food hygiene had all been applied for. Training was said to be provided regularly and encouraged. A second staff member confirmed planned updates on statutory topics and mental heath awareness. Training certificates included those for basic food hygiene, health and safety for seven staff. The Manager is a manual handling trainer and all staff except one, she stated, had received an update. All updates on statutory topics must be provided at required intervals and although staff had sufficient knowledge of these, regular training is essential. Supervision takes place every six weeks or as required by the staff member. A copy of the supervision notes are provided to the employee. Staff meeting were held six weekly wher any issue could be raised. The personnel files are not retained on site; these will be inspected at a separate visit. At previous inspections, the standard of the information retained in the personnel files evidenced that good recruitment procedures are undertaken prior to employment. Please see recommendation 1. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced Manger who has a demonstrated track record of improving services and raising standards. Health and safety checks are in place to ensure that the premises are safe for residents to live in. Quality assurance measures enable staff and residents to input into improving the service. EVIDENCE: The home has had an acting Manager since January 2007. She is a qualified nurse in the field of psychiatry and remains on the NMC register. She has recently completed the Diploma in Dual Diagnosis and the Cognitive Behavioural Therapy course. She is currently doing a Cognitive Analytical Therapy course which she is self funding. She has been a Manager with Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 23 Community Options, in similar types of homes, for many years and has a wealth of experience. The Acting Manager advised the inspector that she is undertaking Regulation 26 visits for other Community Options facilities, which takes approximately two days of her working month. This must be carefully monitored to ensure that this does not detract from the management of the home, that has in the recent past, had significant problems. The Manager on the day of the inspection sought to obtain the application form to become the Registered Manger and complete the CSCI procedures. The registration certificate is incorrect and needs to reflect the new Manager and should be changed once the Manager has concluded the registration procedures under the CSCI. The inspector checked the finances of the two residents whom had been included in the case tracking. Both had financial difficulties and needed considerable input and assistance with money. The home retains some personal money for residents who are prone to spend it inappropriately and without leaving sufficient for essentials such as their rent. Balance sheets were in operation with receipts, wher possible, retained. The monies checked were correct. All residents have their own bank accounts. Financial audits take place twice daily at staff handover; any discrepancy would be fully investigated. Community Options have introduced a new audit tool, which is yet to be a working document. This audit tool was comprehensive and covered many of the current inspection areas. It is scheduled to be applied to every home every a six months. Senior staff in the company will conduct the audit. Residents and staff meetings are in operation these are minuted and actions arising addressed. Monthly house reports were on site. Minutes of Community Options Manager’s meetings were available. Other quality assurance tools included the staff survey, Community Options annual review, the in house objectives and the overall company plan. Other internal audits have been referred to in other sections of this report. Community Options have a newsletter in print and circulated throughout the company. Residents are actively encouraged to attend or be represented at the AGM. Regulation 26 reports were available for the last two months although there was a gap when staff sickness occurred earlier this year. The employer’s liability certificate was on display and valid. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 24 A selection of health and safety certificates and supporting records were inspected including those for gas and electrical, these were satisfactory. Water temperatures were checked monthly. The health and safety statement had been signed by the Chief Executive 2007, and the fire risk assessment was current. The fire authorities had visited the home earlier this year and made several recommendations, these had all been addressed apart from one, which was in hand, and notification was seen regarding this. The home conducts weekly fire alarm tests and fire door checks. The fire alarm installation was serviced May 2007,and is on a callout contract. Fire instruction had been addressed twice since February2007, with staff and residents attending. The Manager is reminded that all staff should have fire training twice a year for day staff and four times a year for night staff. Staff fire training certificates were available. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. YA2 Standard Regulation 14 Requirement The Manager must ensure that all prospective residents are fully assessed and all information available prior to admission. The home must confirm in writing to the residents its ability to meet the identified needs. Previous time frame for action 30/7/06. This is now outstanding. The Manager must ensure that all areas of the home including residents bedrooms are maintained in a hygienic clean and hazard free state with monitoring to confirm this. Timescale for action 30/08/07 2. YA26 16 30/08/07 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 Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 27 1 YA32 The Manger should ensure that all staff have mandatory updates in training at appropriate intervals and this is evidenced. Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Croydon Road,78 DS0000006909.V340262.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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