Inspection on 16/12/05 for Egmont Road (33)

This inspection was carried out on 16th December 2005.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Egmont Road (33) 27/09/07

Egmont Road (33) 28/09/06

Egmont Road (33) 10/02/06

Egmont Road (33) 14/02/05

Egmont Road (33) 15/07/04

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 (33) 33 Egmont Road Sutton Surrey SM2 5JR Lead Inspector David Pennells Unannounced Inspection 16th December 2005 09:05 Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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 (33) DS0000046264.V260672.R01.S.doc Version 5.0 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 (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Egmont Road (33) Address 33 Egmont Road Sutton Surrey SM2 5JR 020 8642 6890 020 8642 8271 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 Mr Mohamed Ismael-Poo Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/02/05 Brief Description of the Service: 33, Egmont Road is owned, managed and staffed by the Care Management Group (CMG). This residential care home was opened on 14/07/03 and is registered with the Commission for Social Care Inspection to provide care for up to six adults with learning disabilities with associated mental health issues and behaviours of a challenging nature. The home itself is a large semi-detached Edwardian building excellently situated in a suburban area of Sutton - close to local shops, transport links and other amenities are available, nearby, in the main town centre. There is parking for two cars on the front driveway, and free parking in the street. Accommodation within the home comprises: six single occupancy bedrooms; (one of which has an ensuite toilet and bath, the remaining having toilets and showers), a kitchen, a separate dining area, a comfortable living room, a laundry and an office. There is an additional bathroom for communal use, and toilets situated on both the ground floor and upper floor to meet service users’ and staff members’ needs. All areas are attractively decorated and furnished. There is a garden – grassed - at the rear, with an upper level open-air patio. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a morning visit, the inspector leaving at about 12.30pm. During his visit, the inspector was able to meet service users, staff and with the manager, Mr Ismael Poo – who was able to assist the inspector in reviewing the previous requirements and recommendations, furnishing necessary documentation and describing the present conduct of the home. A number of service users enthusiastically took the inspector to see their own rooms, as well as proudly escorting the manager around the communal areas. The home runs on a pleasantly informal basis, the service users being relaxed about coming into the office, sharing excitements and concerns, and clearly engaging in all aspects of the home’s life. The inspector is grateful to all at the home for the welcome and hospitality received during his visit. What the service does well: What has improved since the last inspection? The home has succeeded in addressing most issues raised at the last inspection visit: - a policy and procedure concerning pressure areas has been evolved and put in place; - a focus on eliciting details from relatives concerning ‘last wishes’ and emergency measures has resulted in clearer records being kept for each service user; Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 6 - lockers have been provided for the safety of staff personal property whilst working at the home; - fire alarm records have improved; - appropriate fire-safe provision has been made for those who wish their bedroom doors to be left open; - the home’s dishwasher has been replaced; - attention to storing hazardous chemicals has improved; - the call bell system panel has been upgraded to ensure safety is uppermost at all times in the home. 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 (33) DS0000046264.V260672.R01.S.doc Version 5.0 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 (33) DS0000046264.V260672.R01.S.doc Version 5.0 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 & 5. The home provides a comprehensive Statement of Purpose and Service User Guide 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] - and this ensures that all ‘terms and conditions’ are known and recognised from the point of confirmation of the contract. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 9 EVIDENCE: The registered provider provides an excellent Statement of Purpose in accordance with the Care Homes Regulations 2001 and standard 1. The home has also compiled an excellent Service Users Guide that includes all the information required and is presented in a format more suitable for the people for whom the service is intended. CMG has developed an excellent contract / statement of ‘Terms and Conditions’; this also form part of the home’s Service Users Guide. These contracts / agreements clearly state the room to be occupied by the service user, the terms and conditions of occupancy, including periods of notice, fees charged, including extras, arrangements for reviewing needs and progress and the homes rules on smoking and alcohol. The manager advised the inspector that all of the homes referrals - except the most recent, which was accepted on an ‘emergency admission’ basis - were each based on a full needs assessment, undertaken by the home’s Regional Manager in consultation with the various Care Managers from the relevant Placing Authorities. The manager would also be involved in assessments for potentially new service users. Health and Social Services comprehensive assessments were available in the home from the relevant placing authorities, in keeping with good practice. Four service users have been resident at the home since July / August 2003, when the home was first opened. The remaining two service users arrived at the home in early 2004, and there have been no changes to the population since then. Examining the general profile of service users and their dependency levels, there has been little change in the general overall level of need / dependency since the last major inspection of the home. No admissions to the home have been made since May 2004 and all service users were admitted with full social services comprehensive assessments and all necessary paperwork is in place to ensure that newcomers are well supported through immediate and long-term care planning. As stated in the standard 6 section below, the home is implementing a new system of progress recording and care plan implementation; this bodes well for the future success of the home. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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. 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. 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. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 11 EVIDENCE: Individual care plans had been developed for all service users, these being generated from their care management holistic assessments, with additional input from the annual reviews and from the home’s own ongoing assessment. The manager now ensures that all documents are signed and dated. The inspector’s recommendation that the action / bullet points set in the care plans should be referred to in the day-to-day notes / record is now finding fruition in the new approach to record keeping. Care planning and the associated record keeping was being moved into a new system at the time of the inspection visit; the new system provides a file box per service user, in which the self-care skills audit and the individual action plans (derived from the full care plan) are stored – alongside the day-to-day notes for the individual – thus ‘connecting’ the recording with the aspirations / intentions and goals of the care plan. Service users are clearly well supported to take risks and to ‘be themselves’ as much as is practicably possible. Staff members, for example, have been equipped more recently with a ‘deferment strategy’ to address the problems encountered with one service user who presents problems in the home with racist attitudes. It was felt by staff that this was now effectively addressing the problem and dealing with the issue – at the same time as protecting both service users and staff of a black / minority ethnic background. Risk assessments seen were comprehensive for each individual and clearly relevant. A standard CMG format is in place in regard to these documents. The age of the six service users ranges from 23 to 37, with the average age being just over 30 - this helping the provision of a sensitive ‘generationally appropriate’ service. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home – using local community resources, and to adopt a lifestyle best suited to the individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choices and decision-making. Links with ‘home’ are encouraged to ensure that support from this source and external contacts remain. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting individual dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 13 EVIDENCE: As far as a service user’s capacity allows, all service users are encouraged to engage in meaningful activity - and to lead a fulfilling lifestyle within the peergroup context. The home encourages appropriate social and interactive engagement with staff, with those outside the home, and with each other. The level of development of a social skills base, however, does not obstruct a service user’s right to engage with the community whatever their specific needs / abilities. The home also encourages spiritual concepts - through some service users attending religious services as appropriate. Service users are supported to take part in activities and skills engaged in prior to entering the home, if they wish. The service users accommodated at the home have behaviours which would make the concept of paid employment more difficult; the focus, however, on training / education - at whatever level may be suitable - and thus enabling service users to maximise their skills and independence, is kept a priority. A focus on swimming and bowling, keep fit, sports and leisure encourages physical activity, whilst attendance at the Cheam Centre, the Mencap social club / Discos and Adult Education centres - address the social / vocational learning aspects / needs of some service users. Service users are encouraged to engage with local community resources - both learning disability-focussed / specific and also ‘mainstream’. The availability of a 5-seater vehicle allows for engagement with local venues such as parks, cinemas, pubs, shops and the local countryside. Service users really enjoy sharing the trips arranged to take a service user to their parents’ homes; when others accompany them - both as company, and for the pleasure / enjoyment of the trip and also the associated refreshments. The home encourages service users to maintain family links and friendships inside and outside the home. All but one of the service users had regular contact with at least one of their parents and regularly visited them away from the home environment (five were due to be away form the home for at least a day over the Christmas period – some for as long as a whole week or more). Some parents collected their ‘charges’ from the home - and the staff drove some service users to their parent’s home base. Relatives are also positively welcomed at the home. “This is home,” said one service user to the inspector – who apparently now finds it difficult to stay at home, preferring to return to their own space at 33, Egmont Road. The house routine revolves around the service users - and not vice versa. Observations by the inspector confirmed that service users continue to be treated with respect and dignity, with acceptance - and a focus on individual Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 14 needs and abilities under-pinning all engagements with the individual. Service users also clearly have the opportunity to ‘join in’ or ‘opt out’ of activities. Each resident has their monies invested in building society accounts for which they themselves are the sole signatory; each service user is supported to access finances appropriate to their need. Relatives / parents tend to have the overarching responsibility for finances, the registered provider being appointee only to one service user; two service users have benefits paid directly into their own accounts. Menus seen showed a wide variety of different food options being available, with consideration given to the nutritional value of the meals provided – as well as the ‘enjoyment factor’. Menus are jointly planned with staff – personal favourites tempered by staff encouraging service users to think of ‘sensible eating’. The home expects service users to engage / assist in the preparation and cooking of foods - as far as they are able - and staff members offer advice regarding food hygiene and nutrition. Staff members also use the mealtime opportunities to discuss activities and service users’ feelings about a variety of things during the meals. Dietary intake is closely monitored only if the need to ‘study’ someone’s intake is identified as a specific need. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s assessment and care planning programme, with appropriate external support being accessed as appropriate. The systems adopted by the home regarding medication ensure the safety and consistent treatment and support for each service user. The systems and relationships formed with other professionals ensure a high standard of input in this regard. Service users and their relatives /advocates can be assured that they will be supported through any level of possible trauma, the house being well prepared to face and confront eventualities, including the (currently unlikely) death of a service user. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 16 EVIDENCE: Service users receive specialist support and advice from appropriate health care professionals – firstly from the local, supportive, GP but also including specialist psychology and psychiatric input, as may be needed. Service users are offered minimum annual health, and records of all healthcare related appointments / visits are appropriately maintained. No incidents resulting in any service users being admitted to hospital have occurred in the home since it’s opening. A policy and procedure concerning pressure areas and relief has now been put in place to alert staff to issues arising from either service users taking to their bed or having reoccurring habits which threaten such areas. Each service user also benefits from the consistency and continuity of support through having a designated keyworker, who is principally responsible for ensuring that the service user’s individual needs and preferences are explored and met. The home has now moved fully to the best-practice method of monitored dosage system of medication administration - through the use of ‘blister packs’ – having moved supplier to Boots the Chemist. The systems for recording were examined by the inspector and found well maintained – with especial note being drawn on this occasion to the ‘PRN’ (‘when required’) medication being particularly well documented and recorded. The manager had ensured that accurately drawn up guidance sheets for each individual had been completed, and sent to the GP – who had willingly considered these conditions with regard to each individual (which were described in writing by the GP as ‘very clear – I am happy to sign them….’), adjusted doses or instructions as felt appropriate and returned the documents fully signed / endorsed. It is good to observe the home and practitioner working so well with each other. The home is positively commended for its efforts in this regard. Personal letters sought by the management from relatives / advocates now sit confidentially on each service user’s file detailing steps that should be taken in case a service users is taken ill or should pass away. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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. Service users and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescale. The home provides support to service users to ensure that they are protected from harm and any form of abuse, however the policy and procedure relating to investigating allegations of abuse and dealing with vulnerable adults does not blend in with the local authority procedure adequately – thus putting service users at possible risk of mishandling of such situations. EVIDENCE: The first judgement paragraph states the last inspection’s assessment finding that the home’s complaints process - and continues to be - satisfactorily met. The second standard - reviewed at the last inspection in February 2005 contained a ‘strong recommendation’ requesting that the registered provider take urgent steps to ‘tie in’ the CMG Adult Abuse policy with that of the host local authority (London Borough of Sutton – a newly revised procedure being issued in 2005). This has not been done, and the inspector is concerned that the two policies continue not to concur. The ‘current’ CMG policy (April 2002) does not cover immediately reporting the issue directly to the local social services care management team – a protocol that is now established with all care providers within the Borough (and common to other Boroughs too). A number of the staff team have undertaken training on ‘Vulnerable Adults’ – and been involved with adult protection issues relating to service users at the home - however the possibility of confusion, and therefore potential delay of correct reporting and seeking advice in such incidents, could put service users at possible risk from mis-management of such a situation if & when it arises. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30. Service users may expect the home to be a generally safe, clean and a pleasant & comfortable environment to live in, though attention to the issues identified in the infrequently used top floor bathroom should be addressed. Private space meets the needs of the individual service user well, and promotes the concept of privacy and the chance to express their own character through content, furnishings and decoration. EVIDENCE: The home has been open since July 2003 and as such is regarded as a ‘new home’ in national minimum standards terms. This is reflected in such aspects as all bedrooms having ensuite facilities, and the communal space being substantial and well planned. The heating issues at no 33 still is yet to be properly resolved; the control of the heating supply from next door (no 31) is unsatisfactory, additional heating units (not free-standing), or an override mechanism, must be introduced into the home, to enable local control of the temperature. Staff lockers have now been provided in the house on the top floor to enable staff to individually secure possessions whilst working in the home. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 19 All bedrooms - which were decorated to a high standard - were well furnished, and in a strongly personalised style by each service user. Each room has ensuite toilet facilities - and five have a shower, and one has a bath. Bedrooms have been provided with both furniture and fittings sufficient to meet the individual occupant’s needs and lifestyle, in accordance with this standard, and the home’s Statement of Purpose. Each service user has their own lockable storage space in which to keep their valuables; service users are also offered a key to their bedroom. The communal toilet and bathing facilities are adequate and additional to the ensuite s provided in each bedroom. The top floor bathroom – though not frequently used - must have the extractor fan restored to working order, and the radiator panel must be covered to maximise safety precautions. Communal space is generous; there is a large lounge, a dining room, an office, a large well-ordered kitchen, an attractive patio area, and a large (grassed) garden. No service users smoke - the home is declared non-smoking. If staff members do smoke, they have to pursue this habit outside the building. Staff sleep-in accommodation is on the second floor. The home continues to be kept very clean - and free from odours - at the time of the inspection. The home’s laundry facilities are located on the ground floor and are suitably positioned to ensure that soiled articles are not carried through any areas where food is stored, prepared or eaten. The room is fitted with its own hand washbasin. The washing machine is capable of washing foul laundry at appropriate temperatures, being a sluice-cycle washing machine. CMG has a comprehensive list of policies and procedures for the prevention and control of infection within the home. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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): 32, 34, 35 & 36. 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. Staff members are well supported through management oversight on a day-today basis, but the need for regular professional supervision input is identified and would be beneficial to encourage a personal and specialised approach. EVIDENCE: Staff members are aware of the home’s jobs descriptions and policies and procedures, which are kept available in the staff office; they are required, during their induction process, to familiarise themselves with all such documents and their content. Staff files examined evidenced full content as required by Regulations and listed in Schedule 2 and 4, including evidence of induction and training undertaken and planned. A minimum of 50 of the care staff team should be qualified - nominally to NVQ Level 2 - in Care by the end of 2005; progress to meet this standard continues; over 35 of the current staff team are either qualified or progressing towards to this level; The organisation will have to focus very Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 21 carefully in the next few months as the 50 figure should now be met. With the change in staffing at the home, the near 100 First Aid training figure for the home has fallen; the manager must seek to ensure that all staff are suitably trained in First Aid practices. Staff files hold letters from CMG’s Regional Director as proof that staff CRB checks have been carried out and are held at Head Office. More recently the inspector has verified the CRB records of all staff - at the CMG Head Office in Wimbledon. It is the declared standard practice for CMG not to permit new members of staff to start work until two satisfactory references (one from their previous employer) and a Criminal Records Bureau check have been obtained. Management currently arranges for at least four members of staff to be on duty both on the early and late shifts, this ensuring a minimum ratio of 2:1 staff support for service users throughout the day. At night there is always minimally one ‘waking’ and one ‘sleep-in’ member of staff on duty in the house. Formal staff supervision processes at the home, though developing, have suffered set backs and a requirement continues to be set against standard 36. Both the manager and deputy have received supervision training and it is hoped that the formal process be soon properly put in place. The manager continued to offer 1:1 sessions to staff as required, and obviously spends time with his co-working deputy manager. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 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, 39 & 42. 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 seek opinions and comments about the service from both service users and their advocates. The home will take seriously and act upon issues raised for their attention. Health & safety issues are properly addressed and heeded – to the benefit and for the safety of those residing at the home. EVIDENCE: The manager’s intention to leave his employment at the end of the month of December will be a significant departure – as Mr Poo has been at the home since its inception. Mr Ismael-Poo’s contribution to the development of the house has been significant, and he is highly respected by his staff and peers, and relied upon by his group of resident service users. It is hoped that the managing company will ensure as short an interregnum as possible prior to Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 23 appointing a new manager and proposing them to the Commission for registration. Though a relatively small home, due to the high dependency and unpredictability of service users, the need for a solid management input is vital. It is, of course now a prerequisite (since 01.01.06) that a manager at any registered home is now qualified or training to qualify to NVQ Level 4 in management and care – the Registered Manager’s Award (RMA). This issue will be raised with the new incumbent of the manager’s post, if necessary, at the earliest opportunity. The registered provider, CMG, now send regular questionnaires to relatives and care managers - this pro-forma is returned directly to CMG Headquarters - and then passed back to the home for information and appropriate action. Service User meetings are held regularly, and the manager is vigilant in listening out for expressed needs / preferences. Two questionnaires were returned from relatives to the Commission – both expressing general satisfaction with the home and the service provided. A specific issue raised by one commentator was discussed with the manager and the inspector was satisfied that sufficient action was being taken by the home to address the issue raised. Issues concerning health and safety issues raised at the last inspection of the home have now been resolved: - Testing of the home’s fire alarm system has now been sharpened up, with all necessary detail, specifically showing what steps staff members have undertaken when testing the system. - ‘Dorgard’ facilities – which safely hold a door open if they do not have an electromagnetic door holder – have been fitted to service user’s doors where necessary. - A new call bell system panel has been installed since June of 2005, thus making the call system effective and useful for both service users and staff. - The home’s dishwasher has been replaced – thus ensuring that a sterilisation system is available for crockery, cutlery and other kitchen / dining utensils. - COSHH regulatory precautions – the management of substances hazardous to health - were at this visit well observed; the inspector did not find any inappropriately stored cleaning material containers. Excepting the need to address extraction and radiator covering issues in the top ‘hip-bath’ bathroom on the top floor (rarely used), no outstanding health and safety issues were in evidence at this inspection visit; all maintenance, servicing and safety checks were well recorded, and adequate to the home’s safe conduct. Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Egmont Road (33) Score 3 3 4 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000046264.V260672.R01.S.doc Version 5.0 Page 25 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 YA23 Regulation 13(6) Requirement The registered provider’s policy with regard to adult abuse must be amended to accurately tie in the approach required locally under the jointly agreed (and newly-revised 2005) London Borough of Sutton Vulnerable Adults Procedure Guidelines. (Previous report’s ‘strong recommendation’ not actioned.) Timescale for action 28/02/06 2 YA24 23(2)(p) The heating issues at no 33 must 28/02/06 be resolved; the control of the heating supply from next door (no 31) is unsatisfactory, additional heating units (not free-standing) - or an override mechanism - must be introduced into the home, to enable local control of the home’s temperature (24.6). (Timescale of 30.07.05 not met.) The top floor bathroom must 28/02/06 have the extractor fan restored to working order and the radiator panel must be covered to maximise safety precautions at DS0000046264.V260672.R01.S.doc Version 5.0 Page 26 3 YA27 13(4) & 23(2)(p) Egmont Road (33) the home. 4. YA36 18(2) Staff must be offered regular, formal, individual staff supervision as soon as practicable, once the senior staff members have been suitable trained (36). (Timescales of 30.10.04 & 30.06.05 not met.) 28/02/06 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 YA31 Good Practice Recommendations A minimum of 50 of the care staff team must be qualified - nominally to NVQ Level 2 - in Care by 2005 (31). Egmont Road (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 27 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 (33) DS0000046264.V260672.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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