Inspection on 05/03/08 for Denmark Hill, 164

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Adequate service.

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 7 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 14/12/06

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 Key Unannounced Inspection 5th March 2008 10.15 Denmark Hill, 164 DS0000022724.V347665.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.V347665.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.V347665.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.V347665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2006 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. It 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.V347665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out over seven hours by one inspector. The methods used to assess the quality of service being provided include: • • • • • • • • • • • Talking with the home manager Looking at the Annual Quality Assurance Audit document completed by the home manager (this document is sometimes called an AQAA and it provides the Commission with information about the home) Talking to four of seven people currently living in the home Observation of the care and support they receive Talking to staff on duty during the inspection A tour of the premises with a resident Looking at records about the care provided to two of the residents Looking at records relating to staff recruitment and training Looking at the way medicines are handled by staff in the home Sending surveys to residents, relatives and health professionals Completed surveys were received from three residents, two relatives and two health professionals The Commission would like to thank all who kindly contributed their time, views and experiences to this inspection process. What the service does well: People who are thinking about moving into the home are given ample opportunity to experience life in the home before making a decision as to whether they want to live there. A relative is impressed and pleased that staff have supported a resident through a reduction in medication and are supporting him to learn new skills, express his feelings and communicate better. A health professional said, “ The staff are friendly and polite and I have always been impressed by the high standard of care provided. Its as though the staff are caring for a member of their own family, especially with regards to advocacy. They are able to show that they have the clients best interests at heart”. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 6 Emphasis is placed on communication and residents are assisted to communicate and make choices by regular discussion, using visual planners, picture boards and photographs as necessary. A resident said “ I do my communication board on Sundays to plan my week and I clean my room. Sometimes I like to do my washing. It’s a very nice house”. Feedback from surveys sent to residents shows that they know who to talk to if they have any concerns or complaints. What has improved since the last inspection? What they could do better: There should be better information about the current cost of placements in the home. Some of the bedrooms have an unpleasant smell and need to be better furnished. The written plans for how people could be supported must be reviewed more often to ensure that they accurately describe current support needs and risk management. The home has not had a registered manager for over a year. A manager is I post but has failed to submit an application to the Commission. This means that he has not been assessed as a fit person to manage the home. There is high staff turnover and this affects team development and staff consistency. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 7 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.V347665.R01.S.doc Version 5.2 Page 8 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.V347665.R01.S.doc Version 5.2 Page 9 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. 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. 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. 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. The Statement and Purpose and Service Users Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 10 Guide booklet have been revised and the guide now contains more information about the financial contributions that residents will be expected to pay from their state benefits. However, there is no information about placement fees. A previous requirement to this effect therefore remains unmet. (See requirement 1) Prospective residents 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 resident and are based on information contained in the care management assessment, the homes own needs assessment and discussion with the resident. There have been no admissions since the last key inspection. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. There are good plans for how residents should be cared for and supported and there is consultation with residents about their plans and life goals. However, the written plans and assessments of risk are not routinely re-viewed and amended when a persons needs change. This may place people in danger or curtail their skills development. 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.V347665.R01.S.doc Version 5.2 Page 12 relationships, spirituality and culture, weekly and daily routines and leisure activity choices. One resident has identified clear goals for the future and another, more recent admission is still in the process of settling in to the home and identifying future plans and goals. Some of the written plans for the other resident are out of date and do no reflect his current needs accurately. The persons nutritional needs have changed and the plans have not been amended to reflect this. This must be done to ensure that his needs are clearly identified and met. (See requirement 2) A wide variety of methods and visual aids are in place to enable residents to make choices in their day-to-day lives. Each person has a named key worker, a member of the staff team with special responsibility to assist with planning and associated administrative tasks. Breakfasts and lunches are prepared either by the resident themselves or with staff assistance. Menu files and recipe books are available to assist staff and residents to communicate and offer choices using photographs and pictures. Several residents use a symbol based wall planner to chart daily activities and plan ahead. One resident was keen to talk about his activities and used the planner to help explain what he was going to be doing. All of the current residents require support from staff to manage their finances and to access the community safely. The reason for and nature of this support is documented in individual support profiles. The home manager is the state benefit appointee for six of the seven residents and a solicitor is the appointee of another. The financial records for each resident are kept safety locked away, along with cash balances, bank account books and other valuable documents, such as passports. Receipts for financial expenditures made by or on behalf of anyone are carefully maintained. The financial records and cash held in safekeeping for each person 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 residents have a learning disability they sometimes need support to make bigger decisions. For example, when complex decisions about healthcare arise there is multi disciplinary discussion to consider what course of action is in the persons ‘best interest’. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 13 Staff are trained in how to assess risk and are proactive in ensuring that people are able to take risks as part of developing an independent lifestyle. Detailed written risk assessments are in place for each resident, although assessments in one of the files looked at are overdue for review and do not reflect current needs accurately. Risk assessments detail the action taken to minimise identified risks and hazards, and must be re-considered often to ensure that they provide staff with up to date information about levels of independence and assistance required by staff. (See requirement 3) Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 14 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. Residents 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: Residents 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 resident has an individual weekly activities programme that includes household chores and responsibilities. Television, radio, videos, musical instruments, art materials and an exercise bike are also available. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 15 There is a large rear garden with a pleasant patio and seating area. Residents 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. Mencap fund staff costs for each resident to have an annual holiday. Two of the residents attend religious services on a regular basis, with staff or family members. Some residents speak with their family on the telephone and visit them with or without staff support. The local community is culturally diverse, as is the group of residents and the staff team. This means that peoples cultural needs are better understood and catered for. 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. The home manager demonstrates an understanding of the rights of people to have an intimate relationship and the role of staff in supporting and assessing vulnerability. Residents are able to choose what to have for breakfast and lunch and they can either prepare a packed lunch or have lunch at the daycentre. Each person makes a choice for one evening meal each week using menu cards. Food stocks are adequate and correctly stored. Staff and residents eat together in a large dining room or at the kitchen table. Food stocks were good and included fresh fruit and vegetables. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their physical and emotional health needs are met. Residents are protected by the homes procedures in regards to taking medication and there is good joint working with health professionals. 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. Residents’ 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. Although one relative thinks that the staff could provide better assistance sometimes. The home currently provides a service to two women and five men and there are both men and women in the staff team. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 17 Technical aids and equipment are in use to maximise independence. Health action plans are in place for all but 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 by two of the residents was looked at. One set of records is incomplete. The home manager said that the resident likes to read his files and sometimes removes documents and rips them up. Information about routine health screening is available in formats accessible to residents with a learning disability. The home makes appropriate referrals to a specialist psychology team for support with behaviour that can be challenging at times. A local GP completed a survey for the Commission and commented that the staff generally provide good care and usually seek GP services when appropriate. A specialist nurse who has regular contact with the home said “ Ive always been impressed by the high standard of care provided by the staff. Its as though the staff are caring for member of their own family, especially with regards to advocacy and attention to detail. They always show that they have the clients best interests at heart”. The nurse confirmed the staff always respect each persons privacy and dignity. “ I have never had any concerns with this regards”. In regards to how the home manages medication the nurse said,” The staff get in touch promptly if they are concerned about an individuals epileptic seizure frequency. They show initiative and participate in agreeing the epilepsy management plan. There is excellent reporting of a persons progress and response to changes in medication and treatment”. Staff maintain good daily records for each person. Mood, general health, continence, additional medication required, behaviour and healthcare appointments are well documented. Weight is monitored closely and professional advice from dieticians incorporated where necessary. Detailed records are also kept of any epileptic seizure. Current residents are assisted with taking their medication, which is stored securely in a locked medication cabinet. 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. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 18 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 been obtained from each resident by use of a form with symbols to aid understanding. A spot check of medication administration for two residents indicates improved recording. There are no gaps in recording (in records where staff sign that they have administered a medication), there are no ‘out of date’ items in stock, medication that is used occasionally rather than regularly are recorded appropriately, including a description of when it is to be administered. Staff have also been trained to use a newer type of medication for people with epilepsy, and medication administered internally (via the rectum) is no longer used. This is more dignified, especially in public when careful screening with a blanket can be difficult to achieve. A relative is impressed and pleased that staff have supported a resident through a reduction in medication and are supporting him to learn new skills, express his feelings and communicate better. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 19 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 adequate 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: Residents have opportunity to raise concerns during regular house meetings and meetings with their key worker. Resident surveys receive indicate that residents know what to do if they want to complain and are able to name people who they would want to talk to (the home manager and area manager). There is a log of all complaints made. The log provides details of the complaint but does not provide sufficient detail about the outcome. The home manager assessed the complaints during the inspection and considered that of the nine complaints made since the last the inspection, which was over a year ago, one complaint is substantiated, four complaints are partially substantiated, two complaints are unsubstantiated and he could not recall the outcome of two verbal complaints made by resident. This is unsatisfactory. (See requirement 4) There is ongoing staff training in adult protection and POVA (Protection of Vulnerable Adults). Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 20 There are adult protection procedures in place, and as recommended in the previous inspection report, a copy of the revised local authority (Lambeth) adult protection procedures are now available for staff reference. Specific guidelines are in place for residents who may have any self-injurious behaviours and advice is sought from the local authority behaviour support team as and when necessary. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 21 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, 27, 28 & 30. Quality in this outcome area is adequate 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 current residents. 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 and levels of property damage in some bedrooms affect overall homeliness of these rooms. EVIDENCE: The home is comfortable, homely, cheery and bright. A domestic assistant is employed to help the staff and residents to keep the large home clean. Although generally free from unpleasant odours, one bedroom has a bad smell of urine. (See requirement 5) 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 Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 22 are provided to enable people 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 in preparation for the decreasing mobility of one first floor resident. All bedrooms are single occupancy, and one ground floor bedroom used by a resident 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. Two of the residents have damaged a significant amount of fixtures, fittings and furniture in their bedrooms and their rooms look sparse. Moe should be done to provide more robust fittings so that people can maintain a pleasant bedroom environment. (See recommendation 1) There are two bathrooms, one with a Jacuzzi facility, and one with a level access shower. All 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. Water noted to be too hot previously, is now checked regularly and is within safe limits. This prevents scalding injuries. 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. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 23 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): 32, 33, 34 & 35. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. High staff turnover in the last twelve months has decreased the number of qualified staff available. There is good training available via Mencap although a team training and development plan for the coming year is not available. This must be done to ensure that staff are suitably trained to meet the general and specific needs of the current resident population. EVIDENCE: Seven members of the care staff have left the service in the last twelve months. This represents high turnover in a small home. Only four of the current twelve strong staff team have attained a 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.V347665.R01.S.doc Version 5.2 Page 24 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. A training and development schedule for 2008/9 is yet to be developed. (See requirement 5) Recruitment records for two of the newer staff were examined and were in accordance with Regulation. This means that satisfactory checks had been made before they commenced work in the home. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 25 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. Mencap manage and monitor the service well, but the home manager has failed to register with the Commission. This means his fitness has not been examined despite managing the service for over a year. Systems and checks provide residents with a safe home environment. EVIDENCE: A home manager has been in post for almost a year but has yet to complete his registration with the Commission. This must be done to ensure that he is a fit person to manage the home. (See requirement 7) Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 26 Team meetings and residents house meetings are 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 residents and sampling of records. There are also annual service audits. An area manager was conducting a quality audit of the service at the time of this inspection. Records were noted to be generally well kept and systems and checks are in place to ensure environmental health and safety. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 27 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 1 X 3 X X 3 X Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 28 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. Previous timescale of 31/03/07 is not met. 2. YA6 15(2) The registered person must ensure that the written plans for how care is to be delivered are reviewed regularly and revised when a persons needs change. The registered person must ensure that written assessments of risk are reviewed regularly (at least twice each year) and when support needs, skills and risks change. The registered person must maintain a record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home about the operation of the care home, DS0000022724.V347665.R01.S.doc Timescale for action 31/10/08 11/07/08 3. YA9 15(2) 13(4) 11/07/08 4. YA22 17 22 11/07/08 Denmark Hill, 164 Version 5.2 Page 29 5. YA30 16(2)(k) and the action taken by the registered person in respect of any such complaint. And the registered person must, within 28 days after the date on which the complaint is made, or such shorter period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) that is to be taken. The registered person must 11/07/08 ensure that the home is free from offensive odours (one first floor bedroom has an unpleasant odour of urine). Previous timescale of 31/01/07 is not met. 6. YA32 18 7. YA37 9 The registered person must 31/08/08 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 11/07/08 ensure that the home manager submits an application to register as the home manager for the home. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA26 Good Practice Recommendations The registered person should consider providing more suitable furniture and fittings in bedrooms of people whose behaviour includes property damage. Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 31 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 Denmark Hill, 164 DS0000022724.V347665.R01.S.doc Version 5.2 Page 32 - 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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