Inspection on 08/12/06 for Egmont Road (31)

This inspection was carried out on 8th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Egmont Road (31) 25/11/05

Egmont Road (31) 09/09/05

Egmont Road (31) 07/03/05

Egmont Road (31) 29/07/04

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 Egmont Road (31) 31 Egmont Road Sutton Surrey SM2 5JR Lead Inspector David Pennells Key Unannounced Inspection 8th December 2006 12:30p Egmont Road (31) DS0000046244.V301951.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 Egmont Road (31) DS0000046244.V301951.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. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Egmont Road (31) Address 31 Egmont Road Sutton Surrey SM2 5JR 020 8661 5534 020 8661 5694 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) www.caremanagementgroup.com Care Management Group Limited Mrs Lesley Somerville Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 25th November 2005 Brief Description of the Service: 31 Egmont Road is owned, managed and staffed by the Care Management Group (CMG). The project has been open since August 2003 and is registered with the Commission to provide residential care for up to six adults (currently generally in the age range 18 - 40) with learning disabilities - who may have challenging behaviour, autism and / or other complex needs. The home itself is a large semi-detached house (attached to a separate ‘sister’ CMG home - No 33) and is situated in a quiet suburban area of Sutton, within easy walking distance of the town centre with its shops & leisure facilities - and thus also having access to good public transport links. Accommodation within the home comprises of six single occupancy bedrooms all with en-suite facilities (toilet, basin and shower). Communal space is composed of a main lounge, a separate dining area, kitchen, laundry, office, sensory room and a conservatory. A garden is provided at the rear with its own patio area directly off the conservatory at the higher house level, the garden being down a flight of steps. There are sufficient additional communal bathroom / shower and toilet facilities located throughout the home, in addition to the individual en-suite facilities. Problems with water pressure has, however, limited the bathing services in a number of the bath / shower facilities; the registered provider has committed to resolving these issues in the early part of 2007. A vehicle is provided for the exclusive use by the home. There is hardstanding at the front of the home for the parking of two vehicles off-road, with free (though often scarce) parking available directly on the street itself. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector called in to the home at lunchtime and stayed for the whole afternoon – to ensure he met with most service users at home - many were out on his arrival, and some returned from activities in the early evening. Adequate staff members were in evidence on duty and the manager - who was out for lunch with service users initially - was able to assist the inspector in reviewing the requirements and recommendations from the last report, to access other current documentation and to tour the home itself. The inspector was able to observe and engage with the majority of service users during the visit - and he is grateful as ever to them, the staff, and the manager, for their cooperation, welcome and hospitality during the visit. What the service does well: The service provides a real home to service users who have significantly high levels of challenging behaviour, and the service responds well to ensuring that a comfortable and satisfying life is created for the users within the parameters of their abilities. Respondents to the CSCI relatives / friends survey unanimously agreed that they were happy with the overall service provided at 31 (one “very satisfied”) all reporting a positive welcome when they visit, being afforded privacy with their relative / friend, and being kept informed of progress and being involved in decision-making (where appropriate) - if consulted about the care provided. The majority also thought there were enough staff available on duty. Each service user is clearly regarded as an absolute individual - and the plans of care and intervention are well created, and reflect very closely the needs of that specific person. The home is a pleasant and bright environment, providing as homely an environment as is possible for service users who may well be more intent on ‘unpicking’ their world (literally), than appreciating their surroundings. Staffing at the service is provided at a good level to address needs and any possible challenges service users may present; staff cohesion is vital and this is clearly a reality at Egmont 31; training and direct support being central to the ‘reliability’ and strength of the team, in every sense. The service continues to run at a high level of professionalism - and is well task focused; the manager and staff (continuing as a stable and reliable team) are again commended for the service they provide. Egmont Road (31) DS0000046244.V301951.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. Egmont Road (31) DS0000046244.V301951.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 Egmont Road (31) DS0000046244.V301951.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, 3, 4 & 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. The home provides a comprehensive Statement of Purpose which ensures that all necessary information about the service is available both for service users and others enquiring about the home. Prospective service users can be confident that they will have the opportunity to find out about the home, to visit (including staying for short periods) and – through adequate assessment and consultation - be assured that the home can meet their needs prior to making a firm decision to stay. Service users will receive a contract in a communication strategy suited to their needs (though this may not be fully comprehended) - and this seeks to ensure that all ‘terms and conditions’ are known and recognised from the point of confirmation of the contract. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose for the home is a very comprehensive document holding all necessary information as required by the revised Standards, Schedules and Regulations. Important elements – such as the service user’s contract (standard 5) is presented in a ‘Symbols’ style – to enable service users to engage with this part of the document as much as possible. The Complaints procedure is also clearly stated in the symbols style. No placements have been made at the home since May 2005. The service user group’s ages span from 23 to 42; it is more than possible that this community will be settled ‘at home’ for a number of years. Referrals to the home require full and concise information to be provided; admissions are based on a full needs assessments undertaken by the registered provider at a regional level, involving the home’s manager, and a care manager from the relevant placing Local Authority. The introductory phase - including site visits - gives the staff the chance to ensure that they are able to offer an appropriate service, along with assessing compatibility with other service users in this small community of six distinct personalities. The home’s admission policy is conditional to a three-month’s ‘trial’ basis. In keeping with good practice, all the other service users would be consulted / observed about the possibility of the prospective new service user eventually moving in on a permanent basis - and the permanence is then confirmed after a thorough review. Egmont Road (31) DS0000046244.V301951.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, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. The home maintains care plans and assessment documents designed to ensure that the needs of service users are met in a focused and individual way, with their rights to individuality and self-expression being protected, and the wishes and aspirations of the service user being taken into account. Consultation with service users relies on both direct contact and also a broader approach of checking with relatives and carers as well as professionals. Service users can be assured that risk-taking will be an integral part of the support / protection plans put in place by the home, though attention must be paid to ensuring that such risk assessments are introduced / kept up-to-date at all times. Service users and relatives / friends can be assured that information about service users is kept in line with best practice and data protection legislation. EVIDENCE: Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 11 There have been no changes in the service user composition since the last admission to the home in May 2005. At that time, the admissions process was appropriately handled - with information created and dated on the day of admission and full risk assessments being in place within seven days of the admission. An induction checklist and questionnaire had also been completed on the day of admission; ensuring adequate information was gathered to meet specific needs immediately the home engaged with the service user. Ensuring that the service is as close to individual service user’s wishes as possible relies both on contact directly with the service user, and on the accrued knowledge of the service user. Observations by staff members of behaviours and reactions, consultation with relatives and [former] carers, and input from professionals who may well be able to help develop strategies to ‘access’ a service user’s deeper self – all help to develop a fuller picture. All the care plans inspected contained individualised procedures for staff to follow for service user assessed as likely to have challenging behaviour, focusing on positive intervention (e.g. communication support and deescalation techniques - in preference to physical intervention.) Risk assessments are provided for each service user, specifically created to reflect the assessed situation for that individual. Risk assessment is clearly an important part of the ethos / thinking of the home, and is well covered in the associated documentation. Assessments are in place for all, and cover the various aspects of needs, including personal hygiene, community presence, and behaviours likely to challenge the service. Each risk assessment identifies the risk; possible consequences and minimising action to handle the challenge. The registered provider’s finance officer is Appointee with regard to benefit issues for all six current service users. Services users monies held at the home are checked at each daily staff handover. A second member of staff - who witnesses any transaction - countersigns all incoming and outgoing payments undertaken by the home. The majority of service users relate little to each other – the interaction level being generally low, except for encounters between them that are often attempts to draw attention, nonetheless, to themselves or their feelings - not the object of their (sometimes challenging) behaviour. Decision-making for the community is therefore a complex strategy – seeking the best for all whilst respecting individual’s rights to opt out. The manager and staff team achieve an excellent ‘fine balance’ here. The home has a corporate confidentiality policy. The home has recently, through the parent company, renewed the Data Protection notification; this being an important commitment for the home, keeping (as it does appropriately) significant personal records on file on site. Egmont Road (31) DS0000046244.V301951.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, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Service users can be assured that the service provides opportunities for them to engage in activities - both within and outside the home within the local community, and to adopt a lifestyle best suited to the individual. Service users are encouraged to engage with - and are considered by the home to be part of - the local community and are encouraged to exercise their rights in this regard, through proactive use of local community leisure facilities and resources. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choices, rights and decision-making with regard to relationships and their lifestyles. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users are positively encouraged to enjoy and engage with appropriate opportunities presenting themselves in the local community – both ‘main stream’ and within the local learning disability community. Service users regularly engage with leisure pursuits such as swimming, bowling, attending the cinema - and organised Discos are very popular. Opportunities for exercise – be this walking in the park (Morden Hall / Oaks Park / Richmond Park) or engaging in some shopping - or having lunch - around Sutton town centre, or to other shopping venues, all contribute towards enjoyable focused activity. Daily diary notes showed that service users are being provided with numerous opportunities to participate in a wide variety of stimulating social and recreational activities. Service users are supported to participate in a wide variety of individually appropriate and assessed activities - which may include regular attendance at a local day centre, educational centres and other individual locations. Individual assessments make it clear that it would be inappropriate for any of the current service users at the home to take up opportunities for paid / voluntary employment. Contact with local Churches is encouraged – though the elements of service user’s challenging behaviour can sometimes create a strange / difficult dynamic in ‘formal’ settings. The house also has a good relationship with their next-door-neighbouring (CMG) home at No 33, and they sometimes share activities (such as Christmas and Birthday and other celebratory parties, etc.). The home is clear in its Statement of Purpose that visitors and especially family contacts are welcome to the home on an unrestricted basis. The majority of service users have active engagement with their loved ones, and varied approaches cover visits to or from the home. At least half of the current community of service users ‘go home’ regularly - varying from regular monthly visits, to day visits home perhaps just a few times a year. The inspector once again observed several service users and staff preparing for mealtimes - the food which service users evidently enjoy. Safe catering records were seen (refrigerator temperature checks, and food probe temperatures of cooked items). Meal times can be somewhat haphazard - but the food is enjoyed and does bring the community together with a common purpose. Egmont Road (31) DS0000046244.V301951.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 & 21. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s assessment and individual care planning programme. The systems adopted by the home regarding medication ensure the safety and consistent treatment and support for each service user. The home makes every attempt to ensure that details are available to ensure that crises - such as a service user being taken seriously ill or passing away are dealt with in an as sensitive, personal and appropriate way as is possible. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each individual service user is respected and supported in a positive way to be ‘themselves’ as much as possible, without offence or upset to others, whilst their clothes, hairstyles and appearance reflects their gender and ethnic / cultural background. There is little in the routine of the house that is not to a large extent flexible though of course, some service users rely on a the domestic routine to enable them to in-build their own activities. Familiarity with staff, routines and everyday processes are all-important to service users. The idiosyncrasies of each service user are certainly acknowledged, appropriately responded to, and respected. GP and other medical / health professional contacts are made as needed; records of these appointments / visits are appropriately maintained. Specialist practitioners monitor service user’s mental health on both ‘as-required’ and a regular basis. Specialist dental input is gained via Orchard Hill and optical services are also either local community or specialist-worker based. Service users now have Health Action Plans in place - this assisting the personcentred planning of health care needs alongside the daily care plan. The home’s Accident Book & Occurrences Book were both being appropriately maintained. Records of medication administration were well maintained; all medicines received, administered and disposed of [via the Chemist], being auditable. Medication profiles were also available, and clearly identified service user’s current and discontinued medication regimes. The home’s procedures for administering ‘as required ’ (PRN) medication were well detailed to minimise any risks associated with its misuse. Management, team leaders and seniors administer the medication at the home. Management also audit the medication process on a daily basis. The home makes every effort to encourage each service user’s relatives or carers to be clear about any steps that should be taken in times of crisis / death. Such pre-planning is reassuring - and helpful to all concerned at a point of crisis. A good format to record the information is in place, and the manager encourages relatives / carers to record their wishes in this regard. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 good. This judgement has been made from evidence gathered both before and during the visit to this service. Service users can be confident that their comments and complaints are responded to, with appropriate action taken. The home provides support to service users to ensure that they are protected from harm and any form of abuse within or outside the home. EVIDENCE: The home’s complaints procedure is included in the Service User Guide, which is available to the home’s service users in a suitable language / format (e.g. symbols) and also the Statement of Purpose, and includes information about how to contact the Commission for Social Care Inspection should the complainant wish to do so. All the relatives / friends responding to the Commission’s questionnaire indicated they were unaware of the CMG complaints process; information about the CMG complaints procedure should be provided to relatives and friends of service users to ensure that all are aware of what to expect if such an issue is raised. Information should also be provided to relatives and friends of service users - to explain the role of the CSCI, including reporting irresolvable concerns - and accessing inspection reports, if desired. Adult protection policies and procedures are fully in place to support service users, and are known by all staff, who have training in such issues. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 17 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, 26 & 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during & after the visit to this service. Service users may expect the home to be clean and a pleasant & comfortable environment to generally live in, though the specific personal needs aspects of the individual service users resident at the home requires urgent attention in order to provide the best standard of facility for personal care. EVIDENCE: The reinstated kitchen/dining room hatch had still to be ‘made good’ following its reinstatement. Staff members are now able, however, to provide a safer system of serving food through to service users - with the consequently reduced chance of danger through unpredictable behaviour by service users actually within the kitchen area. Outstanding premises issues have now been resolved in general: the installation of blinds in the conservatory and office, the installation of a suitably safe, and permanent heating / cooling system in the conservatory, and the installation of an extractor fan in a service user’s bedroom have all been completed. It is recommended that the office window-mounted extractor fan should be removed, repaired or replaced. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 18 The major water heating issue for the house, arising from the risk of scalding and inadequate water temperatures for heating (to both 31 and 33 Egmont Rd) currently remains. The possibility of risk of scalding from hot water has now been reduced (if not totally eliminated) by the installation of a limiter valve on the entire hot water supply system – however this has resulted in ‘chilly’ water temperatures and other issues, such as the lack of pressure to some points in the house – along with the problems encountered by the neighbouring ‘sister’ home in the hot water / heating supplies they received from the same boiler. Some service users resident on the top floor are having to shower in other service user’s ensuite facilities, due to total lack of sufficient water in their bedrooms and the top floor bathroom - this totally annihilating the concepts of privacy and dignity afforded to service users. The inspector required that proposals to ‘split’ the system into two separate entities be proposed to the Commission since early 2006. It is now - and only now - following the inspection visit and conversations with senior managers of CMG, that the inspector can confirm he has received an undertaking in writing from the Regional Operations Manager to resolve this problem once and for all by early 2007. Both the safety and comfort of service users and staff have been compromised for long enough in this regard, and the inspector looks forward to learning of the work’s completion. This substantial work will involve the home probably being vacated for some days to enable the transfer of the service to the new ‘stand alone’ boiler system. Both the Lounge doors and conservatory doors have been replaced - the conservatory doors, as ‘final exit’ doors, being provided with a keypad system integrated with the fire alarm system for evacuation purposes. A new sideboard is now in use in the dining / activity room. Furnishings generally throughout the home are modern and bright and attractive. The general environment - including bedrooms - is due for redecoration within this next year, the manager assured the inspector. Various items are listed under ‘requirements’ to be dealt with by the CMG maintenance team including properly repairing broken windows in room two on the top floor (where the broken glass is still in situ behind a Perspex pane) and the bathroom in Room One - which had a difficult to close door, which was essential to protect the currently exposed radiator surface and poor shower protection. It was also evident that a second banister rail is needed along the window (to act as additional protection) as one descends the stairs. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 19 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 & 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Service users can rely on the home providing adequate staff in sufficient numbers and duly competent and well-trained to provide a service that seeks to meet their identified needs. The home’s recruitment and staff support mechanisms are organised so as to ensure the safety, protection and wellbeing of service users. Service users can rely on the staff members having sufficient clarity of role and support from senior staff through 1:1 supervision - that the service will be delivered with competence and well-informed proficiency. EVIDENCE: The inspector was able previously to inspect a variety of job descriptions attached to the personal files - which evidenced that the staffing structure is well thought-through and supported the aims of the house. The staffing structure runs from manager, through a deputy manager role, to Team Leaders and then grades of senior support and support worker. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 20 Staffing levels at the home have been maintained to the appropriate level, even though there are currently support worker vacancies at the house; staff members working an extra shift, and one bank worker provide this cover. The manager intends to introduce existing night staff into daytime work from awake night shifts, once the process of establishing a single staff member awake and a staff member on call in the building is established. This move is based on the fact of staff not being needed during the night; once the house has ‘gone to bed’ there is little need for ‘doubling up’ until the early morning. Staff at the home have regular opportunities to renew their training in ‘Dignified management of conflict (‘Dig Man’) – the company’s all-important course in dealing with challenging behaviour. Other training is mapped and monitored by the deputy manager and renewals are booked as needed. NVQ training is still being pursued; eight of the thirteen current staff members have now achieved NVQ Level 2 or above, or a satisfactory (higher) equivalent - the staff team now being trained to well above the proportion required by the national Standard. It is standard practice for CMG not to permit new members of staff to start work until the company has obtained two satisfactory references from their previous employer and a Criminal Records Bureau and PoVA check has been undertaken. Staff files hold signed acknowledgment letters from CMG’s Regional Director as proof that staffs CRB checks have been carried out and are held at CMG’s Head Office. Examination of staff files at random again evidenced regular supervision input to staff – this providing an opportunity for any subjects to be raised by the staff member and for performance and training issues to be examined and followed through. This standard (36) has been exceeded and awarded a ‘4’ score in the recent past - to reflect the excellence in providing support and supervision to staff on a one-to-one basis. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 21 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, 39, 41 & 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Service users and their relatives / friends can rely on the home being run well, and providing a professional service with the best interests of the service user being central to the care provision. The registered providers can be relied upon to take seriously health & safety issues – to the benefit and for the safety of those residing at the home. EVIDENCE: The manager and deputy manager remain the same personnel and staffing at the home continues to be remarkably stable; in the past year, unusually, three staff members have left the home -this being addressed by the reconfiguration of night staff input. This has great benefits to the service users, as new relationship building will be kept to a minimum. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 22 Lesley Somerville is the registered manager of the home. Mrs Somerville has been in day-to-day control of the home since it opened in August 2003, and has at least two year’s previous managerial experience working in another CMG home with service users with similar needs - and an additional fourteen years of experience in care work. She is currently undertaking - and aims to have achieved - her NVQ at Level 4 in Management and Care (Registered Manager Award) by the end of January 2007. The inspector has no concerns about the general management of the home; the structure and support for staff and service users is evident from the general organisation of the house, and the good order of paperwork and the house-based service in general. The registered provider regularly asks relatives for their opinions of the service on paper - to elicit feedback about the quality of the service provision. It can also be confirmed that reports compiled by the home’s Regional Operations Manager following monthly - unannounced - visits to the home, are regularly being forwarded to the Commission, in accordance with Regulation 26 of the Care Homes Regulations 2001. Records seen at the home were generally well kept, accurate and up-to-date. Service users are welcome to view their own files and any personal information held about them by the home - should they so wish - in line with Data Access and Protection principles. The registered provider is duly notified with the information Commissioner under the Data Protection Act 1998, thus ensuring adherence to good practice in general. Health & Safety issues were generally satisfactorily dealt with at the home; all regular, annual and more frequent health and safety checks were up-to-date, with certification available as evidence. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 4 3 5 3 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 1 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X 3 3 X Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA24 Regulation 23(2)(p) Requirement The heating problems at the home require resolution; the current configuration - being interlinked with the neighbouring (separate) service - is unacceptable as in reality neither home is served well by the joint system. Plans to ‘split’ the system to stand alone concepts must be made to the CSCI. Requirement outstanding from 2005 - timescale of 30/01/06 exceeded. It is understood that the system will be completely changed in early 2007. The registered provider must ensure the proper repair of the broken window in room two on the top floor (where the broken glass is still in situ behind a Perspex pane). Timescale for action 31/03/07 2. YA24 13(4) & 23(2)(b) 28/02/07 3. YA24 13(4) & 23(2)(b) The registered provider must 28/02/07 ensure that the bathroom door in Room One is repaired, that protection is provided to the exposed radiator surface, and shower protection provided. Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 25 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 YA22 Good Practice Recommendations Information about the CMG complaints procedure should be provided to relatives and friends of service users to ensure that all are aware of the process and what to expect if such an issue is raised. Information should be provided to relatives and friends of service users to explain the role of the CSCI - including expressing irresolvable concerns and how to access inspection reports. The office’s window-mounted (defunct) extractor fan should be removed, repaired or replaced. 2. YA22 3. YA24 Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Egmont Road (31) DS0000046244.V301951.R01.S.doc Version 5.2 Page 27 - 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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