Inspection on 27/06/06 for Dunton Road, 71-73

This inspection was carried out on 27th June 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 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunton Road, 71-73 01/12/05

Dunton Road, 71-73 03/08/05

Dunton Road, 71-73 02/03/05

Dunton Road, 71-73 27/07/04

Dunton Road, 71-73 30/03/04

Dunton Road, 71-73 27/01/04

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Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Dunton Road, 71-73 71-73 Dunton Road Bermondsey London SE1 5TW Lead Inspector Lisa Wilde Unannounced Inspection 27 & 30 June & 7th July 2006 10:00 th th Dunton Road, 71-73 DS0000007100.V303551.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 Dunton Road, 71-73 DS0000007100.V303551.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. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunton Road, 71-73 Address 71-73 Dunton Road Bermondsey London SE1 5TW 020 7232 0016 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) Three C`s Miss Daisy May James Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 7 (seven) people male or female with mental disorder other than dementia, some of whom may be over 65 years old. residents with disabilities which restrict their mobility must be accommodated on the ground floor 1st December 2005 Date of last inspection Brief Description of the Service: The home provides care for up to seven people with mental health issues. This home is made up of seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues as it is on the ground floor. There is no lift in the home. The bedrooms meet the space requirements of the standards as does the communal space. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. The home is close to several bus routes into central London and the surrounding area. The Old Kent Road, which offers shopping facilities, pubs, restaurants and a large supermarket is close by. There are a number of smaller shops and a Post Office in Dunton Road. On the day of the inspection there were no vacancies. The fees for a place at this home were not available at the writing of the draft report. The home makes the reports of the Commission’s inspections available in the staff office. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day at the home in June 2006 and then with two conversations with the Business Manager of the organisation to get more information about what was going on with the people who refer people to live at the home. When at the home the inspector spoke with staff and both managers, two service users who were in the home and a relative who was visiting. The inspector also toured the shared areas of the home, looked at documents and checked the service users’ money and valuable kept in the home. The service users and the relative said they had no problems at the home. The inspector found that staff are working very hard to make things better and the home is improving but there is still a lot of work to do to make sure that the home is meeting the National Minimum Standards. There have been problems sorting out the management structure and the current Registered Manager is not able to work full time at the home, which is not acceptable. The inspector would expect the management posts to be recruited to as soon as possible and work done by the next inspection to make sure that the requirements made in this report are met. What the service does well: The standards assessed at this inspection showed that the home makes sure that: • people who want to move to the home have their needs assessed by staff before they move to the home. • people who have been offered a place at the home can visit the home and have trial stays before they finally decide to move there. • service users are supported to make decisions about their lives as far as is possible. • staff at the home support service users to fill their week with different activities both in the home and in the local community. • service users are supported to maintain their relationships with family and friends and to develop new relationships as they choose. • service users’ health and personal care needs are fully met. • complaints and concerns from service users and their families are taken seriously and action is taken to try and make things better. • staff at the home know what to do if there is a suspicion that service users are being abused. • staff are qualified and trained well enough to do their jobs. • the home handles service users’ money safely. Dunton Road, 71-73 DS0000007100.V303551.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. Dunton Road, 71-73 DS0000007100.V303551.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 Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. 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. Information about what service users can expect from staff is given to service users but it is not currently written in a way that they could best understand which means that service users may not be clear about their rights and responsibilities at the home. People who want to move to the home have their needs assessed by staff before they move to the home so service users know that staff believe they can work well with someone before they are offered a place. People who have been offered a place at the home can visit the home and have trial stays so that they can meet staff and service users and get to know what the home is like before they finally decide to move there. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that all service users are issued with the up-to-date service user guide and a copy of the housing association’s tenants’ handbook. The deputy manager and staff stated that this had been done. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 9 The current service user guide is not really useful to service users as it is not in a language that they could fully understand. There is a Vietnamese service user who would not be able to read this document. There is new legislation in place now that will come into force on 01/09/06 and 01/10/06 which will require services to state exactly what fees each service user is paying and how it breaks down into different areas, in the service user guide. (See Requirement 1 & Recommendation 1) There was a previous requirement that the Registered Individuals must ensure that the staff team and potential referral sources are clear about the admission criteria and levels of need the home can work with. The Registered Manager was not certain that this had been done as she was still unclear of exactly what type of issue they were expected to work with at his home. The inspector talked with the organisation’s Business Manager following the inspection who was due to have a meeting with South London and Maudsley team (SLaM) who refer people to this home. Following this meeting it appeared that the organisation and SLaM had reached further understanding around criteria but that this must now be communicated to the manager and to the staff team. (See Requirement 2) A service user has recently moved to the home from the organisation’s other home nearby. This service user had been visited by staff who had started bringing her to this home from their day centre to get to know her and for her to visit the home. The service user had not wanted to visit the hoe for an overnight stay but this would have been possible had they wanted it. The manager and another worker had visited the service user to assess their needs and the staff team had decided together whether they should offer them a place. This assessment had covered mental health and associated needs but had not covered gender, relationships, culture, ethnicity and other social needs. The inspector discussed these issues with the managers and a staff member who felt that they could begin to assess these issues during an assessment before someone moved to the home so they could write better care plans with them once they moved to the home. (See Requirement 3 and Recommendation 2) Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. 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. Staff write care plans with service users that outline what staff will do to support service users and help them develop their skills. These care plans do not always set realistic goals which means that the plans will not be successful. Service users are supported to make decisions about their lives as far as is possible. Staff at the home assess risks with other people involved in service users’ care but the plans they put in place to manage or minimise these risks are not always clear and thorough which means that service users or others may be at risk of harm. EVIDENCE: The inspector looked at the care plans for all service users and found that a lot of work had been done on them since the last inspection. Most areas are now covered by the plans although in some plans the areas of sexuality, religion and other social needs are all included in the same section of the plan when Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 11 they should be looked at as separate issues with different plans in place to respond to any issues. Some areas of the plans were not as clear as they should be and one area was inappropriate in that it made statements about staff supporting a service user to undertake illegal activity. The language of some care plans showed that although they may have been signed by service users they are not actually being read to service users in detail as certain parts of the care plans would not be things that staff would want to say to a service user. Some areas of the care plans were unrealistic but this issue has been addressed under Standard 18. (See Requirements 4, 5 & 6) The Registered Manager discussed how staff support servoice users to make decisions. She felt that the staff work in an entirely enabling and empowering manner which allows service users to be given information and make informed choices while being fully aware of any consequences of their decisions. Conversations with staff showed this to be the case. Risk assessments had been drawn up since the last inspection which the Registered Manager said were aimed at providing interim guidance for staff to keep service user safe. The plans were brief and did provide some guidance in some areas but were not full risk assessments and management and included some information that should not be included in a risk action plan. The deputy manager had drawn up thee plans with the care co-ordinator for the home (Community Psychiatric Nurse) but it appeared from the plans that further training in this area is necessary for risk to be fully assessed and managed. (See Requirements 7 & 8) Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. 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. Staff at the home support service users to fill their week with different activities both in the home and in the local community. Service users are supported to maintain their relationships with family and friends and to develop new relationships as they choose. Staff try and make sure that service users get the food that they want to eat but sometimes service users ask for things and do not get them. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that all service users have an individual programme of appropriate and stimulating activities within and outside of the home. Work has been done in this area and weekly programmes have improved. Service users are encouraged to attend local centres for activities and in-house there is a music Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 13 group and an art group. The Vietnamese service user attends two different Vietnamese centres and another attends and African-Caribbean day centre. There is going to be a week’s holiday in Devon later in the year and weekend or day trips are also planned. Enough work has been done to meet the previous requirement but these standards will be assessed again at the next inspection to make sure that progress continues. Most service users can come and go from the home as they choose but where they are not able they are supported by staff to go out and be part of the local community. Families are involved in the home as much as possible and can visit when they choose. The inspector spoke with one relative who visited during the inspection who said they had no problems at the home. Menus showed that although service users request different things to eat in the service user meetings, they don’t always get cooked for them and often the food cooked is the same every week even though different food is planned every four weeks. The Registered Manager said that they are currently trying to address problems with food by supporting the cook/cleaner but this is made more difficult as she does not manage the cleaner/cook as they are employed by the housing association who manage the building. They are attempting to introduce a more healthy food programme in the home. (See Requirement 9) Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. 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’ health and personal care needs are usually fully met by the staff team or by bringing in external professionals. (Medication was not assessed during this inspection as the Commission’s pharmacist inspector had been to the home before this inspection and the lead inspector is still waiting for the report.) EVIDENCE: Service users are offered different levels of personal care depending on their need. The Registered Manager said that the staff team is currently working together to share ways of supporting service users consistently as some staff can get service users to do some things while other staff can’t. Some of the care plans around personal care were unrealistic as they talked about some service users having baths or showers a certain amount of times each week whereas staff and managers stated that in practice this only happened once or twice a month. (See Requirement 10) Service users are supported to access healthcare appointments regularly and where particular issues arise, specialist professional help is sought. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 15 There were several requirements made around medication at a previous inspection that had been assessed by the Commission’s pharmacist inspector earlier in the year. The pharmacist inspector’s report stated: The CSCI Pharmacist visited to follow up on 5 requirements on medication handling made at a previous inspection. All 5 requirements have now been met. One of the requirements related to a report by the Southwark PCT Pharmacist in January 2005, highlighting several shortfalls with medication handling. A copy of this inspection report was provided to the CSCI Pharmacist. There is evidence the home has now addressed all issues. The Manager is arranging for the supplying pharmacist to carry out regular medication audits. It is important for the home to have regular input from a pharmacist to ensure the standard is maintained because of the serious shortfalls noted in the past year, which could have put residents at risk. Policies The home has a good, comprehensive medication policy, dated July 2001, including sections on all aspects of medication control and administration, with additional sections on providing medication for residents when away from the home, handling of errors, self-administration, and weekly stock checks. Staff are following the policy. It is good practise to review all policies regularly, at least 3-yearly. At the next review, consideration should be given to changing the section on Disposal to state meds should be returned at the end of each month, instead of what it currently says, at the end of the treatment period or when expired. Recording/Storage/Supply All medicines were in stock, securely stored, labelled with full instructions and records showed that residents receive their medication regularly. All recording of administration was accurate. Guidelines for staff are available for medicines given on an “as required” basis, stating when the medicines should be given, the maximum dose in 24 hours and the dose interval. All quantities of medicines received and returned are recorded, however it would be clearer if all quantities (including quantities brought forward from the previous month) were recorded on the Medication Administration Record (MAR) charts instead of a separate log, as this would make stock checks easier. It is important that a justified stock check is carried out, not just a stock count, as the home must ensure that the quantity in stock tallies with the quantity Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 16 administered and returned. The manager carries out regular stock checks, and no discrepancies have been found. Training All permanent staff who administer medicines are appropriately trained, and the home keeps a signature list of these staff. The home does employ agency staff, however agency staff only administer under supervision from permanent staff. It is recommended that the Registered Manager assesses the level of training and competence of agency staff before allowing them to administer medicines, and that a signature list is kept for agency staff also. MAR charts must be kept for at least 3 years, and the initials of all staff who administer medicines must be identifiable. The Manager must have a system to assess competence before allowing any staff, permanent or agency/bank, to administer medicines. For guidance, the NVQ 3 Medicines module is an acceptable level of medication training for non-nursing staff. Monitoring/Review The Community Psychiatric team reviews medicines regularly, and there is evidence that staff effectively monitor whether medicines are working, report any side effects, and request input from the prescriber when needed. Self-Administration If there are plans for any residents to move out into less supported accommodation, they should be encouraged and supported by staff to manage their own medication. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. Complaints and concerns from service users and their families are taken seriously and action is taken to try and make things better which means that service users know that staff listen to them and want to try and improve things for them. Staff at the home mostly know what to do if there is a suspicion that service users are being abused which means that service users are protected from harm. Not all staff have received recent training in protection of vulnerable adults and not all staff are completely clear about the procedures to follow when asking service users about abuse which means that an investigation may not happen as it should. EVIDENCE: There is now a comments book that is taken into service user meetings for service users ands their families to write down any concerns they may have. There is more that can be done in this area but the home has made a very positive start on this work. There was a previous requirement that the Registered Person must ensure that independent advocates are sought for all service users with a specific brief to ensure that they are aware of their right to complain, how to complain and supported to voice any current concerns they may have. The managers talked through the work that has been done in this area and although they have found certain agencies, these agencies will usually only help if there is a particular problem, they will not get involved on a general ongoing basis. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 18 Service users have been made aware of what advocates are and two members of staff are going on advocacy training so that the team can get better at doing this with service users. These issues were discussed with the manger and a member of staff and they felt that they could do more to find informal advocates from local community agencies who perhaps shared more of the service users cultural, ethnic, mental health or other social background and experiences. (See Recommendation 3) Not al staff have had training around adult protection and when the inspector discussed the issues with the managers and staff it was evident that although there was a general understanding of what abuse could be and how to respond, there were some differences in understanding of the process of an investigation and how involved staff should get before they contacted a manager or local adult protection team. (See Requirement 16) Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The communal areas of the home have not been decorated for a long time and the home is beginning to look tatty and dirty which means that service users are not living in a comfortable home. EVIDENCE: The inspector toured the communal areas of the home and found that as the home hasn’t been redecorated for a long time it is now starting to appear tatty and dirty in most of the communal areas. The Registered Manager talked again about problems they are experiencing with the cleaner and how staff are attempting to manage the cleaning issues while these issues are addressed. While there are currently some African images around the home there are no Vietnamese or other images and decorations and if the home is being required to redecorate anyway, the issues around reflecting the current service users’ backgrounds in the physical environment should be considered at this time also. (See Requirements 17 & 18 and Recommendation 4) Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Managers and staff do not have clear job descriptions that tell them exactly what their job is which means that they may not be sure about what they are supposed to do and service users may not be supported as well as they could be. Staff have their work assessed by their manager every year and any training they may need is looked at. Generally staff are qualified and trained well enough to do their jobs which means that service users are offered support from people who know what they are doing. EVIDENCE: The Registered Manager stated that job descriptions are not clear and need to be revised. The interim deputy manager and a staff member stated that when they started their jobs they found that the job was not what they expected when they had read the job descriptions and person specification. (See Requirement 19) There was a previous requirement that the Registered Individuals must ensure that following finalisation of the admission criteria, the night time staffing levels are reviewed to ensure that permanent staffing levels are sufficient. This Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 21 review must be sent to the Commission. This review hadn’t been sent to the Commission. The inspector spoke with the Business Manager who stated that following the discussions with SLaM they did not believe that additional staff were needed at night and when current service users needed additional staff for particular emergency reasons the home could bring in staff for those periods of time. The organisation does not keep staff recruitment files at the home and so must complete the Commission’s checklist and keep these at the home for all staff so that the documentation can be assessed during inspections. (See Requirement 20) Staff’s annual appraisals have just been completed and training needs have been identified from these. There is not yet an annual training and development plan in place at the home that sets out what statutory and additional training is necessary for staff to meet the aims and objectives of the home and the assessed needs of service users. (See Requirement 21) Dunton Road, 71-73 DS0000007100.V303551.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 & 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the skills to run the home and understands the needs of service users but she is not able to work full-time at the home and the second manager post is currently filled by an agency member of staff so it is not possible to say yet that this home is well run. The management structure at the home is still not clear to the managers or the staff team and the nursing manager role is causing confusion to the team about what type of referrals they may be expected to take at the home. This has now been sorted out at a senior level in the organisation but has not yet been made clear to staff at the home. The home has some systems in place for monitoring its service but there is not yet a comprehensive quality assurance system in place that makes sure that all areas of the home are regularly assessed and plans put in place to improve every year. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 23 Service users are not always asked about what they want and what they think of the service they are offered. Not all the health and safety procedures are followed which means that service users may be being put at risk of some harm in the home. The home keeps accurate records of service users’ money and staff check them regularly so that service users’ money is kept safe. There is no business/financial plan for the home which shows that the organisation is thinking about what risks there may be for the home in the future and putting in place plans to make sure that the home can continue to run. EVIDENCE: There was a previous requirement that the Registered Person must submit an application for a manager to be registered under the Care Standards Act 2000. This had been done and the Registered Manager had successfully completed her interview. However the inspector had accepted that the manager could apply for the post of Registered Manager as she had been planning to become full time at the home in February 2006. Due to personal commitments this had not been possible and although she now works for thirty hours a week many of these hours are worked from home. She stated that she would not be able to work full time at the home. There was a previous requirement that the Registered Individuals must ensure that both management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained to the staff team. The managers felt that this had not yet been done as they were not entirely clear of their roles. There was a previous requirement that the Registered Individuals must ensure that a nursing qualification is not made a requirement of any post at the home. Again the managers were not entirely clear whether this had been confirmed or not. The inspector spoke with the Business Manager following the inspection and discussed all the above issues. There have been ongoing personnel issues that have affected the organisation’s ability to advertise for certain posts and there have been ongoing discussions with SLaM about the nursing requirements of the home. The inspector was satisfied following the final discussion with the Business Manager that both the organisation and SLaM are now clear that the home would be breaching its registration if it actively sought to employ any nursing staff at the home or if staff offered any nursing care. (See Requirements 22, 23 & 24) Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 24 There was a previous requirement that the Registered Person must ensure that an effective quality assurance system, based on seeking the views of service users, their families and other stakeholders, is in operation at the home. It was clear that service user involvement has improved since the last inspection and relative are involved in the home a lot more as well. However there is still no one system in place that seeks the views of people who use the service and draws up an annual development and business plan that shows how the home will improve to better meet the needs of service users. (See Requirements 25 & 26 and Recommendation 5) There was a previous requirement that the Registered Manager must ensure that all management and staff are made aware of all the health and safety systems that are operated and recorded in the home and understand how they link to their own health and safety responsibilities. Discussions with staff and managers showed that this has improved butt here were still some problems with the health and safety procedures. Fire tests have been missed and health and safety risk assessments were not in the file. The gas certificate was not in the home. (See Requirement 27) The inspector checked all service users’ money and valuables held in the home. All accounts matched the records (except for one which was five pence down). The Registered Manger was not aware of an annual business/financial plan in place for the home. (See Requirement 28) Dunton Road, 71-73 DS0000007100.V303551.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 2 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 2 2 X X 2 2 Dunton Road, 71-73 DS0000007100.V303551.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. Standard YA1 Regulation 5 Requirement The Registered Individuals must ensure that the Service Users Guide is revised so that it is more accessible and useful for the current service users and people who may wish to move to the home. The Registered Individuals must ensure that the staff team and potential referral sources are clear about the admission criteria and levels of need the home can work with. Previous requirement: Unmet timescale 31/03/06 The Registered Manager must ensure that all a service users’ needs, including any cultural, ethnic, relationship and sexuality, gender and social needs are assessed prior to them moving to the home and consideration given to whether the home can adequately meet those needs before a decision is made to offer them a place. The Registered Manager Timescale for action 31/10/06 2. YA2 12(1)(a) 13(4)(c) 31/07/06 3. YA2 15 31/08/06 4. YA6 15 & 18 (1) (c) 31/08/06 Page 27 Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 (i) 5. YA6 15 6. YA6 15 7. YA9 12 (1) 8. YA9 12 (1) 9. YA17 16 (2) (i) 10. YA18 YA6 12 (1) must ensure that all staff who are required to do so, are aware of how to draw up a clear care plan with service users that addresses all area of need equally. The Registered Manager must ensure that staff use language in care plans that is appropriate to be read to service users and that care plans are read in detail with service users before they are asked to sign them. The Registered Manager must ensure that all reference to illegal activity is immediately removed from any care plan and staff are made aware of why this is not appropriate. The Registered Individuals must ensure that all staff involved in conducting risk assessments and drawing up risk management plans have received training in doing so and can do this effectively. The Registered Manager must ensure that all risk assessment and management plans are reviewed so that the clearly and effectively show how significant risk are to be managed or minimised. The Registered Manager must ensure that service users are happy with the food that is provided for them and that varied, healthy and nutritious diet. The Registered Manager must ensure that care plans in the area of personal care are reviewed so that they set realistic goals for service DS0000007100.V303551.R01.S.doc 31/07/06 28/06/06 30/09/06 31/08/06 31/07/06 30/08/06 Dunton Road, 71-73 Version 5.2 Page 28 users. 11. YA23 YA35 13 (6) & 18 (1) (c) (i) The Registered Individuals must ensure that all staff have received recent training in adult protection issues and that the staff team discusses these issues as a group so that everyone is clear about the procedures to follow in the home in the event of any allegations. The Registered Individuals must ensure that all communal areas of the home are redecorated to an acceptable standard and that this redecoration is based on the preferences of service users e.g. all chipped paint is made good, curtains are fully fitted to the windows, kitchen drawers and cabinets are made good and flooring is free from stains and not worn through. A plan for the completion of this work must be sent through to the Commission. The Registered Individuals must ensure that all areas of the home are clean. Any furniture, fittings or area of decoration that cannot be effectively cleaned must be replaced. The Registered Individuals must ensure that all staff and management person specifications and job descriptions are reviewed to ensure they accurately describe the essential competencies and requirements for each post in the home. 30/09/06 12. YA24 23 (2) (d) 31/10/06 13. YA30 23 (2) (d) 31/07/06 14. YA31 18 (1) (a) 31/08/06 Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 29 15. YA34 19 (1) (b) & (4) 16. YA35 18 (1) (c) (i) 17. YA37 YA38 18 (1) (a) 18. YA37 18 (1) (a) & s 11 Care Standards Act 19. YA37 YA38 18 (1) (a) The Registered Individual must ensure that the Commission’s recruitment checklist is completed and held on file at the home for all staff. The Registered Individuals must ensure that all individual staff’s training needs are brought together into an annual training and development plan that sets out the required statutory and additional training the staff team needs in order to meet the aims and objectives of the home and the assessed needs of the service user group. This plan must identify when the training needs will be met. A copy of this plan must be forwarded to the Commission. The Registered Individuals must ensure that both management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained Previous requirement: Unmet timescale 31/03/06 The Registered Individual must ensure that both management posts are advertised and a new application for Registered Manager made to the Commission as soon as that post is filled. The Registered Individuals must ensure that a nursing qualification is not made a requirement of any post at the home. Previous ongoing requirement: Previous 31/08/06 30/09/06 31/08/06 31/07/06 31/07/06 Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 30 timescale 31/03/06 20. YA39 24 The Registered Person must ensure that an effective quality assurance system, based on seeking the views of service users, their families and other stakeholders, is in operation at the home. Previous requirement: Unmet timescales 31/12/05 & 31/03/06 The Registered Manager must work with staff and service users to develop a comprehensive and effective system of service user involvement that allows service users to comment on and influence the service they receive. The Registered Manager must ensure that all health and safety procedures are operated effectively and all the required documentation and records are in place. The Registered Individuals must ensure that there is a business/financial plan in place for the home that is in line with regulations. A copy of this report must be forwarded to the Commission. 30/09/06 21. YA39 12 (1) (2) (3) & (4) & 24 30/09/06 22. YA42 13 (4) (a) & (c) 31/07/06 23. YA43 25 (2) (c) 31/10/06 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 YA1 Good Practice Recommendations The Registered Individuals should begin work on establishing exactly how each service users’ fees break DS0000007100.V303551.R01.S.doc Version 5.2 Page 31 Dunton Road, 71-73 2. YA2 3. YA20 4. YA20 5. YA20 6. YA20 7. YA22 8. YA24 9. YA39 down and put these in their service user guide. (This will become a legal requirement on 01/09/06 for current service users and 01/10/06 for new service users). The Registered Manager should consider with the staff team ways in which they can make sure the preassessment process is made more sensitive to service users’ needs and how more information can successfully be gathered. The Registered Individuals should review the medication policies regularly, at least 3-yearly. At the next review, consideration should be given to changing the section on Disposal to state meds should be returned at the end of each month, instead of what it currently says, at the end of the treatment period or when expired. The Registered Manager should ensure all quantities of medication (including quantities brought forward from the previous month) were recorded on the Medication Administration Record (MAR) charts instead of a separate log, as this would make stock checks easier. The Registered Manager should assess the level of training and competence of agency staff before allowing them to administer medicines, and that a signature list is kept for agency staff also. The Registered Manager should ensure that if there are plans for any residents to move out into less supported accommodation, they should be encouraged and supported by staff to manage their own medication The Registered Manager should ensure that staff research further into local agencies and people who can become informal advocates for service users ideally who share some of the service users ethnic, cultural, gender, mental health and other social backgrounds and experiences. The Registered Individuals must ensure that the required review of the decoration of the communal areas includes plans to make sure the decoration reflects the cultural, ethnic and other backgrounds of all service users. The Registered Individuals should consider using a professional, externally accredited quality assurance system in the home. Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dunton Road, 71-73 DS0000007100.V303551.R01.S.doc Version 5.2 Page 33 - 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. 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