Inspection on 14/12/06 for Denmark Hill, 164

This inspection was carried out on 14th December 2006.

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

The inspector found 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denmark Hill, 164 04/03/09

Denmark Hill, 164 05/03/08

Denmark Hill, 164 20/09/05

Denmark Hill, 164 21/10/04

Denmark Hill, 164 02/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Denmark Hill, 164 164 Denmark Hill Camberwell London SE5 8EE Lead Inspector Sonia McKay Unannounced Inspection 14th December 2006 08:45 Denmark Hill, 164 DS0000022724.V324571.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 Denmark Hill, 164 DS0000022724.V324571.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. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denmark Hill, 164 Address 164 Denmark Hill Camberwell London SE5 8EE 020 7733 4979 0207 733 4979 h4060@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Ms Elizabeth Anne Bowles Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: 164 Denmark Hill is a registered care home providing care and accommodation for seven service users with learning disabilities. The Royal Mencap Society is the Registered Provider. The property is a large detached house in a residential street. is adapted to make it accessible to wheelchair users or those with mobility problems. Accommodation is provided over two floors with all bedrooms for single occupancy. The home is close to local amenities and public transport connections. Prospective service users are given a copy of the Service Users guide that gives information about the home and the services provided. A copy of the most recent CSCI inspection report is available, on request, from the staff office. Fees range from £963.97 to £1849.00 per week and depend on the individual care needs of each service user. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out in nine hours over one day. The purpose of this inspection was to examine key areas of service. Three service users and one visitor/relative completed CSCI comment cards prior to the inspection. One relative was also contacted by telephone. The inspection involved discussion with the newly appointed home manager and four people living in the home, examining the care arrangements in place for three service users, talking with staff on duty, looking at records, observation of activities and a partial tour of the premises. Management arrangements changed in January 2007 when the new home manager resigned. The home is currently managed by the deputy home manager, whilst recruitment for a new manager continues. What the service does well: What has improved since the last inspection? Written plans detailing the goals and needs of each service user are in place and are reviewed both by staff and service users on a regular basis. This ensures that staff have up to date information about the type of care and support that each person needs and ensures that the views and aspirations of each service user are included. The previous home manager contacted local authority social work teams to request placement reviews for any service user whose placement had not been reviewed within the last year. Placement reviews have now been scheduled Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 6 with the local authorities. These reviews are an opportunity to review whether a placement is still suitable and to identify any additional services that may be required. An automated chair left has been fitted to the main stairway. This improves accessibility of the first floor bedrooms for a service users with an increasing mobility need. 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. Denmark Hill, 164 DS0000022724.V324571.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 Denmark Hill, 164 DS0000022724.V324571.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): 1, 2 & 4. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individual aspirations and needs are thoroughly assessed during a resettlement process that provides an opportunity to visit and to’ test drive’ the home before making a decision to move in. The service users guide to the home must be revised to include more information about services and fees, in accordance with recent changes in legislation. EVIDENCE: Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. (See requirement 1) Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 9 Prospective service users have an opportunity to visit the service before making a decision to move in and the registered provider obtains a detailed community care assessment of need from the placing authority before completing their own assessment, records of which are held on file. Initial care plans are developed with each new service user and are based on information contained in the care management assessment, the homes own needs assessment and discussion with the service user. One new service user has moved into the home since the last inspection visit. Records of visits to the home are in place and it is evident that the admissions process was slow and well thought out, with good communication between the old and new staff teams. The service user was given many opportunities to visit the home before making a decision to move in. There was also a local authority placement review early on in the trial placement. Denmark Hill, 164 DS0000022724.V324571.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): 6, 7 & 9. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users know their assessed and changing needs and personal goals are reflected in their individual care plans and they are consulted about decisions in the home and their own lives wherever possible. Some service users may benefit from the assistance of an advocate. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Two individual case files were examined. The home is introducing a more person centred method of care planning. The new plans are produced in an accessible format using symbols and photographs to illustrate the wishes and likes and dislikes of the individual. Individual profile information details the level and nature of support required in the areas of communication, community access, personal care, behaviour management and personal care. There is also information about important Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 11 relationships, spirituality and culture, weekly and daily routines and leisure activity choices. Each service user has an up to date plan for future care, as required in the previous inspection report. The previous home manager had addressed a requirement for local authority placement reviews by writing to the local authority who were overdue in arranging review meetings. The deputy home manager advised that placement review meetings have now been scheduled for all but one service user. The local authority should be reminded of the need to conduct a statutory review for the remaining service user. The care plans in place specify the goals to be achieved for each service user. The home manager explained the process for monitoring progress with each goal. Each service user has a keyworker from with the team who is responsible for developing plans and goals with each service user. These plans are discussed during supervision meetings between the line manager and each keyworker and during staff team meetings. Weekly activity plans for each service user provide evidence that goals are also translated into specific plans for each day. There are three distinct care-planning elements within the homes systems. Care management care plans, in house care plans and plans that are more person centred and accessible to each service user. A wide variety of methods and visual aids are in place to enable service users to make choices in their day-to-day lives. Each service user has a named keyworker, a member of the staff team with special responsibility to assist a service user with planning and associated administration. Breakfasts and lunches are prepared either by the service user themselves or with staff assistance. Menu files and recipe books are available to assist staff and service users to communicate and offer choices using photographs and pictures. Several service users use a symbol based wall planner to chart daily activities and plan ahead. Service users spoke of their preferred activities both at home and in the community. Planned activities schedules, and activities enjoyed on the day of the inspection, reflected these personal choices. Creative work is in progress to develop a personalised calendar planner for one service user with a keen interest in reggae music. All service users require support from staff to manage their finances and to access the community. The reason for and nature of this support is documented in individual support profiles. The home manager is the state Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 12 benefit appointee for six of the seven residents and a solicitor is the appointee of another. The financial records for each service user are kept safety locked away in the staff office, along with cash balances, bank account books and other valuable documents, such as passports. Receipts for financial expenditures made by or on behalf of a service user are maintained. The financial records and cash held in safekeeping for each service user is checked every day by staff, during the period of handover time between the morning and afternoon shifts. A spot check of records, receipts and cash balances during the inspection provided evidence of accurate accounting and record keeping. As the service users have a learning disability, when complex decisions about health issues and checks arise there is multi disciplinary discussion and decision making in a persons ‘best interest’ if necessary. The home manager said that although advocacy services are not available to individual service users at this stage, consideration is being given to purchasing an advocacy service to facilitate the regularly held service user house meetings. This would be beneficial to the service users, but does not negate the need to obtain individual advocates for each service user. (See recommendation 1). Detailed risk assessments are in place for each service user and are reviewed regularly. These risk assessments detail the action taken to minimise identified risks and hazards. General missing persons procedures are in place, along with individual guidance about each service user (suggested search areas) and a colour photograph. Staff are trained in how to assess risk and are proactive in ensuring that service users are able to take risks as part of developing an independent lifestyle. A careful risk assessment has enabled one service user with epilepsy to have the degree of privacy in the bathroom that he wishes to have. Confidential written information is stored securely in the staff office. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are able to take part in age, peer and culturally appropriate activities and are part of their local community. They are supported to maintain relationships with friends and family. Meals are varied and enjoyed. A healthy diet is provided and mealtimes are relaxed and flexibly timed to fit in with individual activity plans. EVIDENCE: Service users attend a variety of daytime and evening activities including college classes in music, art and keep-fit, and day services involving horticulture, social groups and woodwork. Each service user has an individual weekly activities programme that also includes household chores and responsibilities. Television, radio, videos, musical instruments, art materials and an exercise bike are also available. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 14 There is a large back garden with patio and seating area. One service user grew vegetables this summer and enjoyed using the produce in home cooked meals. Service users have the use of a house mini-bus and designated drivers from within the team. There are also trips to local pubs, cafes, restaurants, discos, cinemas and sports centres. Two service users went to the West Country for a week’s holiday with three members of staff. Two of the service users attend religious services on a regular basis, with staff or family members. Some service users speak with their family on the telephone and visit them with or without staff support. Training materials are available for staff on the issues of sex education for adults with a learning disability should this type of information or support be required and the home manager demonstrated an understanding of the rights of people to have an intimate relationship and the role of staff in supporting and assessing vulnerability. Service users are able to choose what to have for breakfast and lunch and can either prepare a packed lunch or have lunch at the daycentre. Each service user makes a choice for one evening meal each week using menu cards. One service user has particular anxieties around meal preparation times and staff were observed to follow the guidelines in place to alleviate these anxieties when discussing meal arrangements with the service user, thereby reducing his anxiety. Comments received from three service users indicate that they are satisfied with the meals served are provided. Food stocks were good and included fresh fruit and vegetables. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users receive support in the way they prefer and require and their physical and emotional health needs are met. Although there is adequate policy and procedure in place about the handling of medicines, current practice around medication does not provide service users with a safe service and must improve. EVIDENCE: Care files contain information for staff on the preferred personal care routines of each person and details of any assistance needed with each personal care task. Service users appearances suggest that staff are giving them the help that they need, including tactful verbal prompting to ensure that they dress in an appropriate manner for the weather. One service user has a particular preference for clothing of one colour and staff support this person to make purchase choices of his preference. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 16 A designated keyworker system is in operation, with each service user having a member of staff from within the team to co-ordinate their support and care planning. The home currently provides a service to two women and five men and there are both men and women in the staff team. Technical aids and equipment are in use to maximise independence. Health action plans are in place for all but the newest resident. A health action plan is being developed with the newest resident. These plans have been especially designed for adults with a learning disability by the local community team of specialists. The record of health appointments attended indicates that staff support each service user to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. Health appointments include psychology, psychiatry, chiropody, optometry, dentistry, audiology and neurology. There is also support around continence needs. Information about routine health screenings is available in formats accessible to service users with a learning disability. Each service user has an individually designed daily written record. Staff complete records in regard to mood, general health, continence issues, whether any additional medication has been administered (for example, after an epileptic seizure), any behaviours that are being monitored and whether any health appointments have been attended. Weight is monitored closely and professional advice from dieticians incorporated where necessary. Staff noticed that one service user was loosing weight and made appointment for investigations via the GP. A family member commented that the staff team are liaising effectively with concerned family members. Nutritional supplements are now available and further health investigations are underway. Detailed records are also kept of any epileptic seizure. Service users are assisted with taking their medication, which is stored securely in a locked medication cabinet in the staff office. A measured dose system is in place, provided by the local pharmacy. Staff induction includes training in the safe use of medication and the medication administration procedures in place in the home. The home manager described how the staff team prompted a review of the medication prescribed to one service user, recently admitted to the home. As a result, a staged reduction in the amount of medication prescribed to this individual is underway. A sample staff signature list is available and the pharmacist has supplied a tablet identification key to assist staff to identify tablets and capsules supplied in a pre-filled measured dose container. Medication information leaflets are retained for information. Consent to be administered medication by staff has Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 17 been obtained from each service user by use of a form with symbols to aide understanding. During the previous inspection an immediate requirement was issued as medication disposal routes had not been identified and medication received into the home had not been recorded on all occasions. The home manager took immediate action and the requirement was met. However, during examination of medication administration records, medication stock and the recorded outcomes of stock and record checks, it became apparent that there are ongoing issues: • Staff have failed to sign medication administration records on numerous occasions (including 05/12/06) • There is no record of some ‘As required’ medication (rectal stesolid) although stock is available. • Out of date medication is available (rectal stesolid) • Protocols for administering rectal stesolids for serious epileptic seizures are in place for one service user, however current staff are not trained in the administration technique and no ‘in-date ‘ stock is available • Crucial ‘As required’ medication for the management of aggressive and challenging behaviours was short of stock (one tablet remaining) and had not been re-ordered. • Administration instructions on MAR charts did not correspond with administration instruction information on sticky pharmacy labels in some cases • Issues identified in regular routine stocks checks have not been acted on in some cases (staff not signing records and failure to monitor stock levels of ‘As Required’ medications) (See requirement 2) Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: Service users have opportunity to discuss concerns during regular house meetings. Although a hard backed log of complaints could not be located during the inspection the deputy manager subsequently advised that the log is available in the staff office. Individual records are also maintained of action taken to address any complaints received. These records are checked regularly by the area manager on behalf of the registered provider. The handling of the one complaint received since the last inspection was examined and records show that the complaint was investigated and the complainant was given feedback within the required timescale. The complaint was unsubstantiated. The complaints procedure is available in the service users guide and is also posted in a communal area. Discussion with the home manager indicates that when service users make verbal complaints appropriate action is taken. For example, one service user Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 19 had complained about the behaviour of another. The home manager discussed this issue with each service user and a satisfactory outcome was achieved. However, this complaint had not been recorded. (See recommendation 2) There is ongoing staff training in adult protection and POVA (Protection of Vulnerable Adults). There are adult protection procedures in place, although the revised local authority (Lambeth) adult protection procedures are not available. Staff should be familiar with these revised procedures to ensure that they take correct action. (See recommendation 3) A service user made a disclosure to a family member. The home manager took appropriate action by contacting the placing authority to advise of a potential adult protection issue. On investigation the disclosure was assessed as being about a historical event. Specific guidelines are in place for service users who may have any selfinjurious behaviours and advice is sought from the local authority behaviour support team as and when necessary. At the time of this inspection an investigation is being conducted into the use of physical intervention by a member of staff. The outcome of which is not yet decided. Arrangements for the investigation indicate that senior managers respond swiftly to any issue with adult protection implications. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and suitable to meet the needs of the service users accommodated, although hot water temperatures must be reduced in some areas to ensure that service users are safe from scalding injuries. The ground floor communal areas and bedrooms are accessible to people with mobility needs. Steps must be taken to ensure that one bedroom is free from offensive odours. EVIDENCE: The home is comfortable, homely, cheery and bright. A domestic assistant is employed to help the staff and service users to keep the large home clean. Although generally free from unpleasant odours, one bedroom has a bad smell of urine. (See requirement 4) Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 21 The home is situated in an area that affords good access to local amenities and public transport. Level access, adequate doorway widths and ramped access are provided to enable service users who use wheelchairs, and other mobility aids, easy access to the ground floor communal areas and garden. The home is in keeping with other homes in the local area and both interior and exterior decoration are of a high quality. A stair lift has been fitted since the last inspection visit in preparation for the decreasing mobility needs of one first floor resident. All bedrooms are single occupancy, and one ground floor bedroom used by a service user with a mobility need has ceiling hoist facilities and an adapted ensuite bathroom. Bedrooms are personalised and reflect the taste and interests of the person accommodated. Service users said that they were happy with their bedrooms. There are two bathrooms, one with a Jacuzzi facility, and one level access shower room, all of which have toilets. There is also a separate toilet. The bathrooms and toilets are bright and airy and are located close to bedrooms and communal areas, the doors are fitted with locks with an appropriate override facility to be used in an emergency. The lock and door handle on one of the toilet doors has been repaired, as required in the previous inspection report. A requirement to reduce hot water temperatures in some areas of the home is unmet. Records of the hot water temperature checks, conducted by home staff, show that some water outlets are still dispensing water that is too hot. Hot water temperatures must be thermostatically controlled to within safe limits to prevent scalding injuries to service users. (See requirement 3). The home has adequate and accessible communal space comprising of a large well-furnished lounge, dining room and kitchen/diner. There is also a large garden with tables and chairs and ramped access. The kitchen has a wheelchair accessible food preparation area. A profiling bed and pressure-relieving mattress are in place for two service users with physical disabilities. One service user has frequent seizures and a physical disability. A baby listening device is positioned the service users bedroom to enable staff to hear if he needs assistance. The use of this equipment should be reviewed, with relevant professional input, to ascertain whether an alternative seizure monitor and call alarm system would be more appropriate to meet his needs and preserve his privacy and dignity. (See recommendation 4). Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33, 34 & 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users benefit from clarity of staff roles and responsibilities and they are supported by a competent and effective staff team which is on course to attain the required level of NVQ qualified staff. There is insufficient evidence of thorough recruitment procedures available and the home manager must familiarise himself with restrictions applied to new staff without full criminal records clearance, to ensure that service users are adequately protected. EVIDENCE: Job descriptions of all staff posts are clearly posted in the staff office. The home is making good progress in attaining the required 50 of staff attaining a national vocational qualification in care (NVQ). There are three members of staff on duty during the day and two members of staff on duty at night. One member of staff stays awake at night and another is asleep, but available for emergencies. A staff sleeping room is available. There is also a manager on-call at all times. There is a team of relief/bank workers available to cover sickness and staff holidays. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 23 Staff duty rotas examined showed that these staffing levels had been maintained. All new staff undergo Mencap induction and foundation training that covers learning disability, health and safety, risk assessment, challenging needs, inclusion, medication, mental health issues, manual handling, first aid and fire safety. Training in valuing, protecting, including and involving residents is also provided. An induction and training programme for the Denmark Hill service is also in place and covers in-house procedures and individual guidelines and training for working with the people living in the home. There are ten members of staff. Four members of staff have obtained a national vocational qualification (NVQ) at level 2 and two members of staff have attained an NVQ level 3. A training and development schedule for 2006/2007 is in place. This schedule details the training that is available from the Mencap organisation. Discussion with the home manager indicates that although he has an understanding of the training needs of the team a specific training plan incorporating mandatory, specialist and vocational training needs for the coming year is not yet developed for the Denmark Hill team. (See requirement 5) Recruitment records examined were incomplete in some cases. Discussion with the home manager indicates that complete recruitment records for newly appointed staff are available at the head office. Complete sets of recruitment records must be available for inspection in the home. (See requirement 6) The home manager and a member of staff confirmed that criminal records checks had been applied for and POVA First checks undertaken as an interim measure. The home manager was not aware that staff with only a POVA First check could not undertake the full range of support duties (for example, prohibited from providing personal care until a satisfactory enhanced criminal records check is available). (See requirement 7) One enhanced criminal record check examined showed that a check with the department of education had not been undertaken, despite the member of staff having worked with children rather than adults prior to employment in the home. (See requirement 8) Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service must appoint a home manager to ensure effective leadership of the home. Record keeping is generally good but must be improved in the area of the administration of medication. Systems are in place to promote and protect the health, safety and welfare of service users, although action must be taken to reduce hot water temperatures to prevent potential injuries. EVIDENCE: The registered home manager has been redeployed to an area manager position with responsibility for Denmark Hill. The home manager who facilitated this inspection has since resigned and the deputy home manager is Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 25 now acting as the home manager whilst recruitment of a home manager continues. (See requirement 9) Team meetings and service user house meetings have been held regularly and extensive minutes of these meetings are maintained. Mencap has a continuous improvement plan and extensive quality monitoring mechanisms in place. These include regular visits on behalf of the registered provider, discussion with service users and sampling of records. There is also annual service audits. Records examined during this inspection provided evidence of: • The record of visitors to the home • The dates and times that staff worked have worked in the home • Regular checks conducted on fire detection and fire-fighting equipment • Regular fire evacuation drills • Regular health and safety checks • Safety checks on small electrical appliances and the homes fixed wiring • Financial records held on behalf of service users in the home. • Professional inspection of fire safety and food hygiene in the home • Records of regular temperature testing of hot water supplies • Professional tests of hoists Medication administration and associated record keeping must be improved to ensure service users are safe. (See requirement 2) Hot water temperatures are too high in some areas of the home. (See requirement 3) The test record of small electrical appliances could not be located. The area manager has since confirmed that all electrical appliances have been safety tested. COSHH materials are stored securely (cleaning materials, clinical waste and household chemicals). Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 2 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 1 X 2 X 3 X X 2 X Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The registered persons must make suitable arrangements for the safe handling of medications in the home. • Records must be kept of all administration • Adequate stocks must be maintained • Out of date medication must be checked and disposed of • Administration directions on MAR charts must correspond with pharmacy generated administration directions • Steps taken to address problems identified by routine stock and records checks must be DS0000022724.V324571.R01.S.doc Timescale for action 31/03/07 2. YA20 13(2) 17 12 12/01/07 Denmark Hill, 164 Version 5.2 Page 28 3. YA42 YA24 23(2)(c) 12(1)(a) 4. YA30 16(2)(k) 5. YA32 YA35 18 6. YA34 12 19 recorded • Staff must be trained to use all medications prescribed as necessary (specialist administration routes) The registered person must ensure that hot water temperatures are thermostatically controlled at the point of an outlet to temperatures that are within safe limits (close to 43 degrees Celsius). The previous timescale of 14/10/05 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by The registered person must ensure that the home is free from offensive odours (one first floor bedroom has an unpleasant odour of urine). The registered person must ensure 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’. This training and development programme must be supplied to the Commission by The registered person must ensure that evidence of a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users is maintained in the home for inspection. DS0000022724.V324571.R01.S.doc 31/01/07 31/01/07 28/02/07 01/01/07 Denmark Hill, 164 Version 5.2 Page 29 7. YA34 19 12 8. YA34 19 12 9. YA37 10 The registered person must ensure that staff with only a POVA First check are adequately supervised and do not undertake duties that require enhanced criminal records check clearance. The registered person must ensure that criminal records checks undertaken include checks with the department of education if a member of staff has previously worked with children rather than adults. The registered person must recruit/appoint a suitably qualified and experienced home manager. 01/01/07 01/01/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA7 YA22 YA23 YA29 Good Practice Recommendations The registered persons should ensure that service users are given access to independent advocates/ self-advocacy group. The registered person should ensure that a record is kept of verbal complaints made by service users. The registered persons should obtain a copy of the local authority adult protection procedures and ensure that all staff are familiar with them. The registered persons should review the suitability and effectiveness of a baby audio monitor in use in the home to monitor epileptic seizures and to aid communication for one service user. Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Denmark Hill, 164 DS0000022724.V324571.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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