Inspection on 27/09/07 for Egmont Road (33)

This inspection was carried out on 27th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Egmont Road (33) 28/09/06

Egmont Road (33) 10/02/06

Egmont Road (33) 16/12/05

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 Key Unannounced Inspection 27 September 2007 11:00a th 27/09/07 Egmont Road (33) DS0000046264.V347262.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 (33) DS0000046264.V347262.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 (33) DS0000046264.V347262.R01.S.doc Version 5.2 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 Ltd Victoria Fleur Nickless Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 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 in 2003 and is registered with the Commission for Social Care Inspection to provide care for up to six adults with learning disabilities with associated 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 that 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 room, a comfortable living room, a laundry and an office. A sensory room for people to use is provided on the ground floor. 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, brightly decorated and furnished in a modern, contemporary style. There is a garden - grassed - at the rear, with an upper level open-air paved patio with seating and tables. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent a day from mid-morning to late in the afternoon visiting the house; this was a surprise visit, which fortunately found the manager present - who was able to assist the process of inspection of documentation and care records. All those who live at the home were met during the visit and clearly showed and said that they were well settled and part of the community at the service. We are grateful to all at 33, Egmont Road for their welcome, help and positive cooperation during the visit. What the service does well: What has improved since the last inspection? Service user meetings have been revived - to strengthen the concept of ‘corporate’ decision making within the house - and to ensure equity in such processes. The previously named ‘Reward Board’ has been transformed into an activity board - clearly showing the positive side of each person’s everyday engagement. The issue of the heating and hot water provision - which is supplied from boilers situated in No 31 - the sister CMG house next-door - has created real problems in the past. Remedial work (which required the recent evacuation of the premises) has been undertaken which has now, despite some minor teething problems, resolved the problems. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 6 Care staff holding an NVQ in Care to minimally Level 2, now exceeds the 50 level required by national minimum standard. Staff records evidenced a thorough recruitment processes - shown by the wellmanaged and presented documentation held at the home. Staff support through personal 1:1 supervision is now being established well within the service, with regular attention being given to each staff member. The transfer of a full time worker from another project has helped with the representation of male staff within the service - and, with two other male staff members, this provides positive role model support to the two males who are resident at the service. The ‘new’ manager - Vicky Nickless - had recently successfully undertaken her interview for registration as manager with this Commission, and is properly recognised as the registered person in day-to-day control of the home. The general management approach of the home is evidently now well established - and the manager is to be commended for ensuring that all the administrative side of the service has been reinstated - to an excellent level, which can only bode well for the direct service provided to the people who live at 33, Egmont Road. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Egmont Road (33) DS0000046264.V347262.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 (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comprehensive Statement of Purpose and Service User Guide which ensures that all necessary information about the service is available for those using the service and others enquiring about the home, including a statement of terms and conditions of occupancy. People considering using the service will have the opportunity to find out about the home, to visit (including staying for short periods) and - through prior assessment and consultation - be assured that the home can meet their needs, before making a decision to stay at the home. EVIDENCE: The home’s Statement of Purpose has been reviewed and updated. The manager reflected that the document could be more accessible through the better use of symbols / pictures. CMG has a contract / statement of ‘Terms and Conditions’ within the home’s Service Users Guide. The contract / agreement clearly states 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. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 9 Four people using the service - two males and two females - have been resident at the home since July / August 2003, when the home was first opened. The remaining service user - a female - arrived at the home in May 2004. One person has more recently left the service, and a replacement is yet to be identified. The age range currently spans fourteen years - from midtwenties to late thirties. There has been little change in the general overall level of need / dependency since the last inspection of the home. Ethnic backgrounds of those living at the home include Anglo : African - as well as the British culture being strongly represented. Religious focuses are also acknowledged - being important for three who attend Christian church Services at their own will. All referrals to the home are based on a full needs assessment, in consultation with the various Care Managers from the relevant Placing Authorities and CMG’s Assessment Team staff. The manager would also be quite rightly involved in the assessments for potentially new service users, once the initial selections have been made - as compatibility of the newcomer must be seen as a vital component in the process. Health and Social Services Comprehensive Assessment documents were available in the home from the relevant placing authorities, in keeping with good practice. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that the needs of people using the service are identified and met in a focused & individual way - documented in their care plans, with the wishes & aspirations of each person taken into account. Service users can be assured that their voice can be heard through the service user consultation meetings. Those resident at the home can be assured that risk-taking will be an integral part of the support / protection plans put in place by the home to promote each service user’s independence and ensure fun and fulfilment. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 11 EVIDENCE: The manager has introduced an approach to running the service that aims to provide ‘a fun and stimulating environment in which to live that promotes individuals to achieve their wants and aspirations’. Individual care plans have been developed for all those using the service, these being generated from the care management holistic assessments, with additional input from the individual, the annual reviews and from the home’s own ongoing assessments and observations. Monthly summaries are written by keyworkers, related to the care plan aims and objectives. Record keeping was noted to be well maintained - the manager is developing ‘grab files’ for each person using the service - which will include summaries of key points relating to the person, such as the care plan review guidelines and the current risk assessments. ‘Service user meetings’ have been revived and minutes seen evidenced a twomonthly cycle of decision-making gatherings. These promote the concept of corporate decision-making, and ensure equity in such processes. There are a number of very strong personalities within the service user group, with assertive attitudes - and the need for democratic decision-making is vital to keep this fair balance within the house. Those using the service users are clearly generally well supported to take risks and to ‘be themselves’ as much as is practicably possible. Risk assessments seen were comprehensive for each individual and were clearly relevant to their individual circumstances. A standard CMG format is in place in regard to these documents. Egmont Road (33) DS0000046264.V347262.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those using the service can be assured that the home 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 them as an individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for each person’s own choices and decision-making. Links with ‘home’ are encouraged to ensure that support from this source and external contacts remain. People using the service can expect to receive a good standard of nutritious and wholesome food -to their preferred choice - meeting individual dietary needs, and in an atmosphere that seeks to ensure that mealtimes are a pleasant and enjoyable time. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 13 EVIDENCE: As far as capacities allow, all those using the service are encouraged to engage in meaningful and fun activity - and to lead a fulfilling lifestyle within the peergroup context of the home (all service users are within a similar ‘generational’ age group). The home positively encourages appropriate social and interactive engagement with staff, with those outside the home, and with each other. The level of a person’s social skills base does not obstruct anyone’s right to engage with the community - whatever their specific needs / abilities. The home also encourages spiritual concepts - through some service users (three) attending religious Services (with staff or families) as appropriate. People are supported to take part in activities and skills development engaged in prior to entering the home, if they still wish. Those living at the home have behaviours that would make the concept of paid employment more difficult. The focus, however, on training and education - at whatever level may be suitable - enables people to maximise their skills and independence. Three people attend the Cheam centre for a number of sessions respectively each week and all five are now enrolled at Sutton College of Learning for Adults (SCoLA) for courses as varied as Personal safety to Dance & Drama. Another ‘Beginner’s Art’ course is being accessed elsewhere - by one person. People are also encouraged to engage with local community resources - both learning disability-focussed / specific and also ‘mainstream’. Attendance at the Mencap social club & Discos, Swimming, Gym, address the social and physical aspects / needs, contributing to each person’s fulfilment and potential. The on-site house vehicle allows for engagement with local venues such as visits to parks, cinemas, pubs, shops and the local countryside. People really enjoy sharing the trips arranged - even, perhaps, to take another person to their parents’ homes, going as ‘company’ - just for the pleasure / enjoyment of the trip, and also the associated refreshments. The entire community of five residents accompanied by six staff have recently enjoyed a group holiday away at the Queen Elizabeth Activity Centre in Hampshire - while the heating and water supply issues were dealt with at 33. Relatives / friends are positively welcomed at the home - within a care-planned context. The home encourages the maintenance of family links and friendships inside and outside the home. All but one of the service users has regular contact with at least one of their parents and visits them away from the service itself. Some parents collect their relative from the home - and staff drove some to their parent’s home base. Some find it difficult to stay at their parents’ home, positively preferring to return to their ‘own space’ at 33, Egmont Road. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 14 Each resident has their monies held in building society accounts for which they themselves are the sole signatory; each is supported to access finances appropriate to their need. Records are kept carefully of any such transaction and of monies held in safekeeping on their behalf at the home. Relatives generally keep overarching responsibility for financial arrangements. Those using the service sit down with staff and plan the next week’s menu personal favourites being tempered by staff encouraging service users to think of ‘sensible eating’. A weekly ‘takeaway’ is also a popular opportunity to try out new cuisines. The home encourages everyone to engage / assist in the preparation and cooking of food - as far as practicable, and staff members offer advice and support regarding food hygiene and nutrition. The kitchen continues as a central ‘hub’ of the home. Staff members also use the mealtime opportunities to discuss activities and people’s feelings about a variety of things over meals. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their personal, health care and emotional / psychological needs will be recognised and met by the home’s assessment and care planning programme, with appropriate external (specialist) support being accessed as appropriate. The system adopted by the home regarding medication ensures 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. Service users and their relatives / advocates can be assured that they will be supported through life events and any level of possible trauma, including the (currently unlikely) death of a service user. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 16 EVIDENCE: Those using the service receive support and advice from appropriate health care professionals – firstly from the local and very supportive GP, but also including specialist psychological and psychiatric input, as may be required. Service users are offered annual health checks, and records of all healthcare related appointments / visits are appropriately maintained. The fully completed Health Action Plans have recently been fully introduced for each service user at the home; they are an excellent summary of identified need and involve people in making decisions about their own healthcare. All that remained was for the GP to be invited to ‘sign the documents off’ - happily the home has a positive relationship with their GP. Each service user generally benefits from the continuity of support through having a designated keyworker; the key worker is principally responsible for ensuring that the service user’s individual needs and preferences are explored and met, being responsible for the monthly summary reflecting the care plan achievements and aspirations. The home uses the monitored dosage system of medication administration, through the use of ‘blister packs’, having Boots the Chemist as supplier. The systems for recording were examined by the inspector and found well maintained throughout. Egmont Road (33) DS0000046264.V347262.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users 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 - through the maintenance of robust adult protection policies and procedures, and resultant practice. EVIDENCE: The home’s complaints procedure is included (in symbols format) in the Statement of Purpose / Information Handbook and contains information about how a complainant can contact the Commission should they wish to do so. The procedure has clear timescales given and time frames for the resolution of such complaints. A record book for all concerns / complaints made about the service at the home is kept, with records of action taken, outcomes and feedback noted as part of the resolution process. The CMG Policy and procedure for ‘Abuse’ now refers directly to the Local Authority’s Guidelines for dealing with any incidents use - and ensures that the Local authority (the lead agency in such issues) is contacted in the first instance - should an issue arise. The home is in possession of the most recent 2005 version of the Local Authority (Sutton Borough) protocol. Previous adult protection issues arising at the home have been dealt with appropriately by both the home and the provider organisation. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the service may expect the home to be a safe, clean and a pleasant & comfortable environment to live in. Private space meets the needs of the individual service user well, and promotes the concept of privacy and the opportunity to express their own character through the room’s 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 ‘communal’ toilets and bathing facilities are additional to the en-suites provided in each of the service user’s bedrooms. Residents individually furnished their bedrooms, which were reasonably decorated in a personalised style. Redecoration is ‘in the offing’ and each Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 19 occupant has chosen their own colours and new items of furniture -some of which were on order. Each has their own lockable storage space in which to keep their valuables; they are also offered a key to their bedroom. Each bedroom has ensuite toilet facilities - five have a shower, and one has a bath. Communal space is generous; there is a large comfortable lounge, a dining room, an office, a large well-ordered kitchen, an attractive upper patio area, and a large (grassed) garden. The downstairs has been recently redecorated and all those using the service had a say in the colour scheme, new furniture, etc. The lounge carpet has been replaced and the kitchen flooring renovated. The ground floor sensory room has been reinstated, providing a good place to ‘chill’ if life gets hectic - and to provide ‘time out’ for any who feel the need for such relaxation. No service users smoke - so the home has been fully non-smoking for some while. If staff members or visitors do smoke, they have to pursue this habit outside the building. The staff sleeping-in room is on the second floor. 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, having a sluice-cycle. CMG operates a full and comprehensive list of policies and procedures for the control and prevention of infection within the home. The home continues to be kept very clean - and free from odours at the time of the inspection. Egmont Road (33) DS0000046264.V347262.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 - 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those using the service can rely on the home to provide adequate staff in sufficient numbers, duly competent to provide a service that seeks to meet identified needs, through providing a well trained and qualified staff team. 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: Staffing levels run at least three members of staff 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. A recent proposal for the sleeping-in staff member to be shared with the sister house directly next door Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 21 (No 31) has been developed and evidence suggests that this would be a viable proposition unless specific circumstances require a more focused input. The home has the manager, three senior support workers, two support worker ‘2’ - and 5 support workers. Two night staff and three bank workers complement the team. The position of ‘deputy’ is currently open to recruitment and this would be beneficial to the service and supportive of the manager and the rest of the staff team. The identified need to recruit more male support workers to ensure that role modelling and appropriate personal care services can be provided to the two males using the service has been assisted by the transfer from another CMG home of a male worker - to augment the second full time male and a male bank worker. At least 50 of the care staff team are now qualified - nominally to NVQ Level 2 - in Care. The proportion of the [now thirteen] staff members who hold such an award is just above the minimum level, but developing - three are undertaking training currently - which will result in ten staff being qualified, some to level three and some of whom are far more highly qualified. Staffing records examined at the time of the inspection visit were noted for their organisation and comprehensiveness; it is good to see an establishment underpinning its service with the firm foundation of good recording. The records evidenced the registered provider ensuring that all appropriate checks (references, CRB checks) are undertaken and fulfilled before staff commence. Formal staff supervision at the home has now been re-established and is operating to meet the needs of individual staff members. Until recently 1:1 sessions have been offered to staff on an ‘as required’ basis, but now the routine is stabilising. Clearly, with the settling of the home’s new manager, staff can be offered formal, individual staff supervision regularly - though the recruitment of the deputy manager will make this process that much more consistent and reliable. Egmont Road (33) DS0000046264.V347262.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 - 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives / friends can rely on the service 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 issues raised for their attention from both those using the service and their advocates - through both the quality assurance and complaints mechanisms - and embodied in the Company’s policies and procedures, this contributing to both the wellbeing and safety of those residing at the home. The Company ensures that health & safety issues are properly addressed responded to – to the benefit and the safety of both those residing at, and those working in, the home. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager, Victoria Nickless, has a degree in learning disability care and is undertaking her Registered Manager’s Award - and aims to complete this task by May 2008. Both staff and those using the service are encouraged to participate in the dayto-day operation of the home, to make their views known through regular ‘service user meetings’ and to voice their opinions at reviews, and through the home’s Quality Assurance and Complaints / Grievance procedures. Quality Assurance surveys are regularly sent out to relatives, representatives and friends / advocates of those using the service to encourage feedback about the quality of the service provided. Responses are received centrally and collated, prior to being sent on to the home itself. The home now has a wellcompleted ‘QA’ file - which will help focus work for the near and distant future. The home’s Service Development Plan was seen but projections had expired during 2007. It is recommended, now that the manager has settled in post, that the plan be updated to incorporate more recently identified needs, projections and aspirations. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes ‘CMG Times’ - an in-house Staff and service user focused magazine. Unannounced visits by area manager representatives of the registered provider are being carried out on a regular basis, and the subsequent written reports are being forwarded to the Commission. Recently the format of the documentation has changed to mirror the format of the Commission’s KLORA (Key Lines of Regulatory Assessment). Such visits involve checking specific documentation and the premises, and interviewing both those using the service and staff members. Financial checks are also a routine part of the auditing process. CMG has a comprehensive set of policy and procedures that cover the broad spectrum of needs identified for care homes; they have been quite recently revised; they have a clear focus for guidance provided by these documents. The inspector reviewed all essential health & safety issues at this inspection visit which had been declared in the AQAA; all were in order - and reflected the declaration, other than those areas where more recent work had superceded the dates given. All were found to be in order. All maintenance, servicing and safety checks were well recorded, and adequate to ensure the home’s safety and conduct. Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 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 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 X 3 3 3 3 3 3 3 Egmont Road (33) DS0000046264.V347262.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA38 YA39 Good Practice Recommendations The recruitment of a deputy manager is advised to support the manager and the staff team. The service development plan should be updated to evidence the long-term planning and quality assurance input contributing to service development. Egmont Road (33) DS0000046264.V347262.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Egmont Road (33) DS0000046264.V347262.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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