Inspection on 28/09/06 for Egmont Road (33)

This inspection was carried out on 28th September 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 6 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) 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 28th September 2006 11:30a Egmont Road (33) DS0000046264.V305248.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.V305248.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.V305248.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 Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 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. 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.V305248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a late morning to late afternoon on the Thursday, and the inspector revisited the house the following Monday (02.10.06) to finish off reviewing some of the personnel paperwork. The inspection was conducted with the deputy manager, Glynnis Gorman - who was acting in to the position of manager, supported by the manager of the service immediately adjacent to 33, Egmont Road. The previous incumbent, Mohamed Ismael-Poo, had moved to another service within the company’s ownership a while before the inspection visits. On the second day of the visit, the inspector found himself in the curious situation of conducting an inspection within the home (principally the office) with the deputy manager - whilst the home’s newly-appointed manager, Victoria (Vicky) Nickless - was present at the home receiving ‘induction’ from the Regional Operations Manager, Peter Culshaw. The deputy and staff at the home had no idea that the new manager was starting at the home on that day - she had just ‘turned up’ on the doorstep - and this created a very strange dynamic in the house that day, disturbing both staff and service users. It is to be hoped that the ‘effects’ of this unconventional start has now been forgotten, and that the unit has moved on to new focuses. The inspector wishes to thank the deputy manager, the staff and the service users for their welcome and hospitality extended during his visits. What the service does well: 33, Egmont Road provides a service to clients who have challenging behaviour and the inspector remains confident that the focus and dedication of the staff team working with the service users will continue under the new management. The culture of the house ensures that each service user is regarded personally - and the plans of care and intervention are generally well formed, though a revisit to the reflecting on the needs of the specific individual person is needed. The home is a pleasant and bright environment, providing a homely environment for service users who use the space and facilities very well. The service generally continues to run at a reasonable level and focus. With the coming together of the new staff joining the existing team at the home, the prospect for the future should see the good service restoring itself imminently, thanks to the hard work put in by the core staff who have held the place together over the summertime. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The three paragraphs immediately below highlight ongoing issues: The issue of the heating and hot water provision - which is supplied from boilers situated in No 33 - the sister CMG house next-door - creates real problems still. Shower and bath water can go cold with no notice - and the thermostatic cut off for heating is dependent on the temperature of the other house. This continues to be an unsatisfactory situation, and the inspector raises the requirement that the issue be addressed again. Regarding the proportion of the [now eleven] care staff who hold an NVQ in Care to minimally Level 2, two current staff members have the award, two new starters were ‘bringing theirs with them’, and four staff were ‘in the process’ of attaining their qualification. The home is therefore again required to meet this target as soon as is possible; the timescale for at least 50 care staff to be qualified was 31.12.05 - the figure will remain below this until at least two of the four who are training have completed their award. Staff records appeared this time to be another area which must be properly addressed; it is understood that a new protocol and understanding between the head office personnel department and home’s managers will resolve the problems in future; however at the time of the inspection it was extremely difficult to establish the facts of evidence of a thorough recruitment processes due to the piecemeal way in which information (which is of inestimable value to the manager) was provided to the home. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 7 Staff support through personal 1:1 supervision - inevitably, due to the short staffing reported further below in the main body of the report - remains an outstanding issue - though the deputy manager is to be commended for keeping the house on an even keel during the time of short staffing and management deficit. The arrival of the newly appointed manager on the second day of the inspection answered the inspector’s concerns about the appointment of a manager to the vacancy; it is now important that the application for registration is submitted to the Commission without delay. The inspector was, notwithstanding the above, generally satisfied with the input / service found at the home, and trusts that the ‘new phase of life’ about to be started, with the change of manager at the home, will develop positively. 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.V305248.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 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 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, prior to making a decision to stay at the home. Service users receive contracts and this ensures that all ‘terms and conditions’ are known and recognised from the point of confirmation of the agreement. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 10 EVIDENCE: The above statements carry forward from the last key inspection visit - there being no indication of significant changes. CMG has developed an excellent contract / statement of ‘Terms and Conditions’; that forms part of 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. A full Statement of Purpose is available in accordance with the Care Homes Regulations 2001 and Standard 1. The home’s excellent Service Users Guide includes all the information required and is in a format more suitable for the people for whom the service is intended. Four service users - two males and two females - have been resident at the home since July / August 2003, when the home was first opened. The remaining two service users - both female - arrived at the home in early 2004, and there have been no changes to the population since then. The age range spans fourteen years - from 24 to 38. There has been little change in the general overall level of need / dependency since the last major inspection of the home. Service user backgrounds include roots within Muslim and Hindu faith backgrounds - as well as Christian / ‘C of E’ and minority ethnic perspectives: African / Nigerian and Malaysian - as well as the British culture, have been recognised. All referrals to the home have been based on a full needs assessment, 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. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. The home maintains assessment documents designed to ensure that the needs of service users are identified and met in a focused and individual way in their care plans, with the wishes & aspirations of the service user being taken into account to an extent. Service users can be assured that their voice can be heard through the temporarily faltering but generally well-maintained service user consultation meetings. Service users 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 fulfilment. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both before and during the visit to this service. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 12 EVIDENCE: Individual care plans have been developed for all service users, these being generated from the care management holistic assessments, with additional input from the annual reviews and from the home’s own ongoing assessments. Management usually aim to ensure that all documents are signed and updated; on a random audit of files, it was apparent that more recent review updates have been lost (monthly since April ’06) due to short staffing; the ‘Individual Action Plan’ and ‘Overview of Activities’ were both over a year old. It is now hoped that, with recently increased staffing at the home, such issues can be ‘pulled back’. The inspector strongly feels and recommends that there should be more effort to ‘unpick’ the substantial assessment documents to enable clearer goals to be set for both staff and service users to understand and implement. Whilst the general routine of each service user is well known, the focused needs of each individual would be better served if more closely developed. Service user meetings had not been held at the home since April 2006. These should be revived as soon as practicable, to revive the concept of corporate decision making - and ensuring equity in such processes. There are a number of strong ‘characters’ within the service user group - and the need for democratic decision-making is vital to keep a fair balance within the house. 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 (including an assessment for each concerning the possible effects of the recent heat wave) and were clearly relevant. A standard CMG format is in place in regard to these documents. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 13 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 - 17. Service users 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 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 14 EVIDENCE: As far as service users’ capacities allow, all service users are encouraged to engage in meaningful 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 encourages appropriate social and interactive engagement with staff, with those outside the home, and with each other. A new innovation seen at the home was a ‘reward board’ - where the ‘good behaviour’ of service users would be positively recognised and consequently rewarded. Sadly, some service users had already decided (from some unknown source) that the board was the ‘naughty board’; this concept will have to be monitored and used only if in the long-term is appropriate and not infantilising. The level of development of social skills base 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 (with staff or families) as appropriate. Service users are supported to take part in activities and skills engaged in prior to entering the home, if they wish. Those accommodated 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 - enabling service users to maximise their skills and independence - is seen a priority. Service users are also encouraged to engage with local community resources both learning disability-focussed / specific and also ‘mainstream’. Attendance at the Cheam Centre, the Mencap social club / Discos and Adult Education centres - address the social, physical and learning aspects / needs of service users; Cookery, Dance & Movement, Swimming, Gym, Arts & Crafts, Massage and Self-care Skills Courses all contribute to service user’s fulfilment and potential. The availability of a 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 - even to take a service user to their parents’ homes - when others accompany them - as company, 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 has regular contact with at least one of their parents and regularly visits them away from the service environment. Some parents collected their ‘charges’ from the home - and staff drove some service users to their parent’s home base. Relatives are Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 15 also positively welcomed at the home - within a care-planned context. Some service users find it difficult to stay at their parents’ home, preferring to return to their ‘own space’ at 33, Egmont Road. Each resident has their monies held in building society accounts for which they themselves are the sole signatory; each service user 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 hold overarching responsibility for financial arrangements. Menus show 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. The kitchen is certainly a central ‘hub’ of the home! Staff members also use the mealtime opportunities to discuss activities and service users’ feelings about a variety of things during the meals. The Inspector shared food with service users on the first day of his visit, and found the time to be creatively used throughout. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. 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 in this regard. 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 17 EVIDENCE: Service users receive support and advice from appropriate health care professionals – firstly from the local and very supportive GP, but also including specialist psychology 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. Health Action Plans are currently being introduced for each service user at the home. Each service user generally should benefit from the consistency and continuity of support through having a designated keyworker (though staff shortages more recently have temporarily compromised this); the key worker is principally responsible for ensuring that the service user’s individual needs and preferences are explored and met. The home has 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 – though a ‘glitch’ was noted with ‘PRN’ (‘when required’) records relating to cross-referencing. The home has been previously positively commended for its efforts in ‘getting medication right’ - and the GP’s cooperation with the need for accurate records in relation to each service user continues to be a clear factor in this good practice. 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.V305248.R01.S.doc Version 5.2 Page 18 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): 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. 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, so that a complainant knows what to expect - 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. The CMG Policy and procedure for ‘Alleged Abuse’ now refers directly to the Local Authority’s Guidelines for dealing with any incidents of Adult Abuse - 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.V305248.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 & 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 regarding heating and the supply of continuous hot water must 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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both before and during the visit to this service. 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 issue of the heating and hot water provision - which is supplied from boilers situated and controlled in No 31 - the sister CMG house next-door, creates real problems still. Shower and bath water can go cold with no notice Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 20 and the thermostatic cut off for heating is dependent on the temperature of the other house. This continues to be an unsatisfactory situation, and the inspector raises the requirement that the issue be addressed again. It has been reflected that the system was in place when the premises were first registered (and therefore ‘approved’ by the Commission), however the reality of the effectiveness of the provision could not have been predicted then (especially in high summer). Inevitably, the fact that such important essential services are compromised, leads the inspector to designate the ‘adequate’ judgement for this set of standards. The communal toilet and bathing facilities are additional to the en-suites provided in each of the service user’s bedrooms. The top floor bathroom – though not frequently used (and generally locked) - has now been provided with a radiator cover - and the inoperative extractor fan has been replaced. 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. 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. 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 sleeping-in accommodation 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 provides a 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.V305248.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 & 36. Service users can rely on the home providing adequate staff in sufficient numbers and duly competent to provide a service that seeks to generally meet identified needs, though basic NVQ skills levels are yet to be achieved. 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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both before and during the visit to this service. EVIDENCE: Staffing has now increased - thanks to recent recruitment of support workers, and the arrival of the new manager - to a level where the ‘establishment’ of staff will ensure that familiar faces provide the service, rather than there being a reliance on ‘bank’ workers (even though some of these have been ‘familiar’ from other CMG homes). Once these new staff members have settled in, it is to be hoped that the previous consistency within the service will return. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 22 The manager and a senior support worker have left the home more recently leaving a deficit in staffing across the summer months - regular staff being reduced to seven individuals, and resulting in significant overtime for those staff as well as ‘bank’ cover. 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. Discussion with the deputy manager touched on the need to recruit male support workers - to ensure that role modelling and appropriate personal care services can be provided to the two male service users. The inspector reflected that this could probably be seen as a ‘genuine occupational qualification’ and encouraged further exploration of this issue. A minimum of 50 of the care staff team must be qualified - nominally to NVQ Level 2 - in Care. The proportion of the [now eleven] care staff who hold such an award is below the minimum level, comprising: two current staff members, with two new starters ‘bringing their NVQs with them’ - and four staff are ‘in the process’ of attaining their qualification. The home is, therefore, again required to meet this target as soon as is possible; the timescale for at least 50 care staff to be qualified was 31.12.05 - the figure will remain below this level until at least two of the four who are ‘in training’ have completed their award successfully. Staff records are another area which must be properly addressed; it is understood that a new protocol and understanding between the head office personnel department and home’s managers will resolve the problems in future; however at the time of the inspection it was extremely difficult to establish the facts of recruitment processes - due to the piecemeal way in which information (which is of value to the manager) was provided to the home. The principle reason for the inspector’s return to home on the second day was to clarify points which had been raised - but could not be answered on the first day of the inspection, due to the paucity in some respects of the paperwork available at the home. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 23 Formal staff supervision processes at the home, though developing, have suffered set backs, due to the short staffing recently - and a requirement continues to be set against standard 36. Both the previous manager and deputy had received supervision training - and it was hoped that the formal process would be properly in place. However 1:1 sessions have been offered to staff ‘as required’ rather than on a routine basis - and obviously during the short-staffed period over the summer this had become even more difficult to countenance. With the arrival of the home’s new manager it is hoped that this requirement will become a thing of the past; staff must be offered regular, formal, individual staff supervision as soon as practicable. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 24 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, 40 & 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 take seriously issues raised for their attention from both service users 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 working in, the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 25 EVIDENCE: The arrival of the newly appointed manager on the second day of the inspection answered the inspector’s concerns about the registered manager vacancy; it is now important that the application for registration is submitted to the Commission without delay. 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. Four questionnaires were returned from relatives to the Commission – all indicating general overall satisfaction with the service provided - one raising an issue concerning their loved-one, which was passed on to the deputy manager. Both staff and service users are encouraged to participate in the day-to-day operation of the home 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 service users to encourage feedback about the quality of the service provided. The responses are received centrally and collated, prior to being sent on to the home itself. The home has now received a substantial QA file - which requires focused work in the near future. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes ‘Resident Times’ as well as the more global in-house Staff magazine. Unannounced visits by representatives of the registered provider are being carried out on a regular basis, and the subsequent written reports are being forwarded to the Commission. Such visits involve checking documentation and the premises, and interviewing both service users and staff. CMG has a comprehensive set of policy and procedures which cover the broad spectrum of needs identified for care homes; they have been very recently revised and the inspector is impressed by the clear focus and guidance provided by these documents. The inspector reviewed all essential health & safety issues at this inspection visit (fire / temperature checks /accident & incident records / etc.) and all were found to be in order. All maintenance, servicing and safety checks were again well recorded, and adequate to the home’s safety and conduct. Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 26 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 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 1 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 3 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 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 2 X 3 3 X 3 X Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement [a] Efforts must be made to ‘unpick’ the substantial assessment documents to enable clearer goals to be set in the care plan for both staff and service users to understand and implement. [b] Documentation must also be regularly reviewed within best practice and the company’s declared timescales. Timescale for action 31/12/06 2. YA24 23(2)(p) The heating issues at no 33 must 31/12/06 be resolved; the control of the heating supply from No 31 is unsatisfactory, additional heating units (not free-standing) - or an override mechanism - must be introduced to enable local control of the home’s temperature. (Timescales of 30.07.05 & 28/02/06 not met.) A minimum of 50 of the care staff team must be qualified nominally to Care NVQ Level 2. (Original deadline of 31/12/05 and subsequent requirement of 30/06/06 not met.) 31/12/06 2. YA32 18(1) Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 28 3. YA34 17 - Sch 2 Staff records must be kept fully and monitored / audited - to ensure full compliance with the appropriate Schedules of the Care Homes Regulations 2001. 18(2) Staff must be offered regular, formal, individual staff supervision as soon as practicable, once the senior staff members have been suitable trained. (Timescales of 30/10/04, 30/06/05, 28/02/06 & 31/03/06 not met.) The manager of the home must be proposed to be registered by the Commission as soon as is practicable. 31/12/06 4. YA36 31/12/06 5. YA37 8 31/12/06 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 YA8 Good Practice Recommendations Service user meetings should be revived as soon as practicable to revive the concept of corporate decision making - and ensuring equity in such processes. That the use of the ‘Reward Board’ should be monitored to ensure its purpose is appropriate and that is does not serve to ‘infantilise’ / discriminate against particular service users. That to recruit male staff, the use of gender specific advertisements could probably be seen as a ‘genuine occupational qualification’ - further exploration of this issue is encouraged. 2. YA16 3. YA33 Egmont Road (33) DS0000046264.V305248.R01.S.doc Version 5.2 Page 29 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. 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