Inspection on 10/08/06 for Endsleigh House

This inspection was carried out on 10th August 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Endsleigh House 21/10/08

Endsleigh House 15/05/08

Endsleigh House 25/10/05

Endsleigh House 08/08/05

Endsleigh House 25/01/05

Endsleigh House 19/01/05

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Endsleigh House 46 Endsleigh Gardens Ilford Essex IG1 3EH Lead Inspector Stanley Phipps Key Unannounced Inspection 10th August to 25th August 2006 10:20 Endsleigh House DS0000041823.V307466.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 Endsleigh House DS0000041823.V307466.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. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Endsleigh House Address 46 Endsleigh Gardens Ilford Essex IG1 3EH 0208 554 1167 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) yroojee@gmail.com Mr Yuhya Roojee Mr Yuhya Roojee Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Endsleigh House is a care home providing personal care and accommodation for five individuals between ages 18-65 with a history of mental illness, who need support in order to live in the community. It is privately owned and managed by Mr Yuhya Roojee. The home is located on a residential street in Ilford and is close to all community facilities. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. Endsleigh House consists of five single bedrooms, two of which are located on the ground floor. Access to the first floor is via two sets of stairs. There are two reception rooms on the ground floor, one of which is used for dining and the other for relaxation and viewing television. A small conservatory has been constructed for service users who smoke. A rear garden that is domestic in scale is available for the enjoyment of all service users and is easily accessible from the kitchen and smoking area. A group of staff is on hand to provide twenty-four care and support to service users. A statement of purpose is made available to all service users and/or their relatives in the home and each individual is provided with a service user guide. Fees are charged at £800.00 per week and service users are expected to pay for their own toiletries, which are variably priced. Service users also have to make a contribution to their annual holidays where the cost is above £200.00. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and a key inspection of the service for the inspection year 2006/2007. This meant that all key standards were covered as well as any other standard for which a requirement was made at the last inspection. The visit was done over two days beginning on 10/8/06 at 10.20 am and ended on the 25/8/06. This allowed for meeting all the service users, most of the staff and an external professional. The inspection found further improvements to the service, although there was one area in which remained outstanding and this was in relation to maintaining staffing records in line with regulation. The registered person should be note that repeated failings to comply with requirements may adversely affect the welfare of service users. In this respect the Commission would pursue enforcement action to achieve compliance, if they are not met by the revised date. There were several other areas identified for improvement from this inspection and they are detailed in the main body of this report. Generally service users are provided with a satisfactory level of service and this was evident from both written and verbal feedback obtained from them. An assessment of menus, policies and procedures, records, service user plans and the environment was undertaken. Detailed discussions were held with staff, including the manager and a formal interview was held with an external professional as part of the case tracking of a service user. Formal interviews were held with two service users and detailed discussions were held three others. The inspection also considered the written feedback provided by service users and staff, which was excellent in terms of the number of responses received. One relative and up to four health and social care professionals also provided written feedback. All individuals were happy with living in the home and this included the most recently admitted service user. What was noticeable on the first day of the visit was the degree of flexibility service users had in lieu of the fact that it was summer and they very much individually engaged with their daily plans. Some got up early did what they had to do and went back to bed, while others woke up later in the day because they were on a summer break. It was noted at the time of the visit that the registered person had applied for a variation to increase the number of beds in the home, to ten. As such works were taking place to an adjoining property acquired by the registered person that formed part of a row of terraced properties. This had little or no effect on the service users currently living in the home. What the service does well: Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 6 The staff generally continued to provide a fairly safe environment for service users to live and develop. Service users are in receipt of a satisfactory level of care and support particularly in relation to their mental health needs. This was evident from the long periods of stability that service users enjoy. Service users enjoy their autonomy and involvement in making decisions in relation to their care and what they would like to do in the home. This was clear from their involvement in activity planning e.g. a recently held summer barbecue. The management and staff also work well with ensuring that service users maintain links with their friends and families and service users are quite pleased with this. There was also evidence to confirm that the health care needs of service users are adequately provided for. Staff were proactive in ensuring that needs once identified are acted upon and this included ensuring that service users attend their appointments as necessary. What has improved since the last inspection? What they could do better: Service user plans could detail all the needs of service users, including their changing needs. Risk assessments needed to be reflective of key risks. It is also important to link the risk assessments to the service user plans. The medication policy was in need of review to ensure that adequate arrangements are in place to safely support service users. Improvements are necessary to the environment to ensure that it is safer and more comfortable. This includes the upstairs bathroom. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 7 The recruitment practices needed to be more robust in ensuring that staff working with service users, are thoroughly screened to so do. The staff training plan must indicate the timescale for providing the training to improve their skills and competence. Annual appraisals would be positive in developing staff and as a result improving the quality of service provision. Risk assessments are required to ensure a safer environment at Endsleigh and greater effort is needed to maintain staffing records in line with regulation. It is important that the registered manager comply with all requirements made, and in particular – those made previously. 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. Endsleigh House DS0000041823.V307466.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 Endsleigh House DS0000041823.V307466.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): (2,5) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users continue to have the benefit of their need, thoroughly assessed in determining the suitability to meet those needs. Service users at Endsleigh House also have the benefits of a contract with the home. EVIDENCE: The case records of the most recently admitted service user were assessed and an interview was held with him. The outcome of this indicated that a detailed assessment was carried out with him prior to his admission to the home. The registered manager carried out the assessment and is qualified by virtue of his mental health qualifications, to so do. This assessment also incorporated information provided by the placement authority and hence gave a solid background and an overall picture of the individual’s needs. It was positive to see that the service user was involved in the process as this enabled him to contribute to the identification of his aspirations. He was quite positive about his involvement and the home. All previous service users had a copy a contract on their file and this detailed the obligations of the provider as well as what the service user could expect and the price of the service he is to receive. A contract was also in place for the most recently admitted service user and this document clearly outlined his rights in relation to life at Endsleigh. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,9) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from having their needs documented in their individual plans. They are positively encouraged to determine what they would like to do and risk assessments are carried out to promote their safety. However, both service user plans and risk assessments could be improved to enhance the quality of care provided to service users. EVIDENCE: Most of the service user plans assessed were detailed and generally covered the needs of service users. The strength of the service user plans was primarily around the mental health needs of service users and this is positive. They could be however enhanced by including other areas of needs particularly social care and personal development needs. It was noted that in some cases there was evidence of this, but this should be in place for each individual. There was at least one case in which the changing needs of the service user were not included in his service user plan and this needs to improve. In all cases there was evidence that service users were involved in the preparation of their care planning and this included the setting of their individual goals. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 11 Service users spoken to were happy with the support given to them by the management and staff regarding what they would like to achieve as individuals. This is done in many cases with their key worker and/or the input of the manager. One service user spoke of wanting to do sign language and planned to do so in September 2006. Another completed a Higher National Certificate and is pursuing a Higher National Diploma in year 2. In his interview he wished to gain part-time employment with a view to regaining his independence. In discussion with another service user who had completed a basic computer course, he was full of praise for the input of staff in supporting him to make decisions that were in his best interests. This is a strong area of the homes operations. A detailed examination of the risk assessments carried out on service users indicated that they were updated and generally linked to the service user plans. It is tool that were in most cases effectively used to ensure that service users maximise their potential within a risk management framework. This meant that service users independence was promoted in a safe manner. In the case of the most recently admitted service user, a key risk though assessed was not linked to the service user plan. This was discussed with the manager as an area that required improvement to ensure that staff are aware of the actions required in dealing with the risk/s identified. The benefit for the service user would be ensuring his safety. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are encouraged to participate in appropriate activities and are able to maintain and develop social and personal networks of their choosing. They therefore confidently exercise their rights to choice and user involvement whilst at Endsleigh House. All service were satisfied with the range and content of meals provided at the home. EVIDENCE: Each service user continued to have an individual plan of activity that was specific to their individual choice and interest. It was noted that the levels of interests and involvement was based on aspirations and the levels of motivation from individual to individual. One service user enjoyed music that was culturally suited to him and he was encouraged to develop in this area. He played a demo tape of his work and was quite proud of it. However he was also encouraged to support his premiership club and spoke positively of this. Another service user enjoys computer and play station games and there was evidence that he had the resources and opportunities to enjoy the experience. Service users went on a holiday to Centre Parcs and they quite enjoyed that as Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 13 a group activity. One service user commented ‘it was great’ while another stated that ‘ it was so relaxed that you didn’t even feel as though you were part of a care home.’ All service users spoken to informed that they enjoyed the summer barbecue, which was held the week before the first inspection visit. This is positive and it the management and staff worked with individuals and the group in engaging them in activities, best suited to them. Service user involvement in the local community involved accessing a range of resources and leisure facilities again, dependent on choice and needs. There was evidence of service users accessing colleges, cinema, the local parks and swimming pools. They were also accessing the local shops using the local transport facilities and were quite comfortable doing so. One service user spoke fondly of playing pool in Ilford at Bollywood. The most recently admitted service user was observed getting out to the shops for his personal effects and making his way independently to and from using a cab firm. All service users were able to engage with the community in an effective manner i.e. to achieve their individual needs and aspirations. There was evidence that service users continued to enjoy the benefits of maintaining their networks, which for some involved families and for othersfriends. Various plans were in place during the course of the inspection for service users to meet with either their siblings or parent/s. In discussion with a service user he expressed the choice to go out and meet with his friends. The rational being that he preferred his friends not getting in the way of other service users, but also – a way motivating himself to get out and about. Relatives and friends were invited to the recent barbecue (5/8/06) and during the inspection at least two service users were having private telephone conversations with their loved ones. This is a strong area of the homes operations. Advocacy service information is made available to all service users and although this had not been taken up, service users spoken to were aware of opportunities for accessing advocacy. Four service users felt that they were capable of handling their own affairs with guidance from staff. It was noted that a fifth service user has the involvement of his father and this is positive. In this respect his father attends reviews and contributes to the service user’s best interests. This is positive. The menus and food prepared on the day was assessed and found to be satisfactory. Initially concern was raised over what was a limited supply of dry goods, but the staff and management informed that shopping was due on the first day of the inspection. The staff are flexible in meeting the dietary needs of service users, although attention is needed to ensure that meals actually eaten – are recorded. Meals were varied and lunch on the day was chicken curry with rice and a green salad. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 14 The home has service users from various ethnic backgrounds with minority ethnic service users forming the majority. The dietary provision reflected this. Service users called out to the inspector to see the meal provided on the day with one commenting ‘it is nice’. They are encouraged to prepare meals with staff guidance as a way of improving their culinary skills. Meal provision at Endsleigh was satisfactory and service users spoken to confirmed this. Endsleigh House DS0000041823.V307466.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20,21) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from the satisfactory arrangements that are in place to monitor and support service users with their health and personal care. Staff maintain effective links with external professionals to ensure that the emotional needs of service users are met. Guidance is now in place to deal with a death occurring in the home. More guidance is required for staff in supporting service users with their medication. EVIDENCE: All service users in the home were independent in relation to their personal needs. At best, some may require prompting and it was observed that the levels of prompting varied from individual to individual. There are instances where service users may need reminding of their appointments of various kinds and staff were observed engaging with them in a positive manner. All service users expressed satisfaction with how personal support was provided to them. They knew their individual key workers and were able to describe the positive impact of their involvement with them. One service commented that ‘the staff help me to think things through’. All service users were registered with a GP and records indicated that the dentist, opticians, psychiatrist and community psychiatric nurses were involved in providing a service to individuals at Endsleigh House. Staff were pivotal to ensuring that work with external professionals were in the service users best Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 16 interests. They understood their limitations and worked well in ensuring that relapse indicators for service users were acted upon in a timely manner. This ensured that service users are able to maintain good periods of stability and as a result a good quality of life. The findings of this standard were supported by feedback received from health and social care professionals. One such comment included, ‘the care home gives a high standard of care and meets the needs of service users’. At the time of the visit all service users requiring medication to improve and maintain their health, were given support by the staff to so do. All staff handling medication were provided with training to safely carry out this function. Medication storage was generally satisfactory, although the capacity may need reviewing at some point in the future. More than likely this would need increasing. The administration of medication in the home was satisfactory, however the medication policy lacked guidance around: the self administration of medicine, the use of controlled and cytotoxic drugs and arrangements for handling spillages in the home. This was discussed with the manager and guidance left on how this could be improved. An improvement was noted in relation to the provision of guidance for staff should they have to deal with the death in the home of a service user. They are now able to identify the actions required to support other service users, promoting the dignity of the deceased as well what support they could expect, if this event occurs in the home. This is positive. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and their relatives are assured that when complaints are raised – they would be acted upon. Satisfactory arrangements were in place to ensure that service users are protected from abuse. EVIDENCE: A satisfactory complaints procedure is in place at the home and all service users were aware of this. From interviews and feedback forms viewed, they had no qualms about raising issues of concern. The management and staff encourage service users to raise concerns where possible in service user meetings that are held regularly. Minutes of these meetings bore evidence of this. Feedback received from health and social care professionals indicated that they have had no reason/s to make a complaint about the operations of the home. Staff interviewed showed an awareness of the service users’ right to complain and the support they would provide if necessary. There were no complaints in the home’s complaints record. Satisfactory adult protection protocols were in place to ensure that service users were safe at Endsleigh House. This included an adult protection policy, which includes whistle blowing. The registered manager also had the local authority’s adult protection protocol in the home for the benefit of staff. Training has been provided for most staff in handling abuse, although up to four staff needed to have training in dealing with abuse. The registered manager proposed to prioritise this training to provide staff with the confidence and knowledge in handling abuse. There have been no adult protection matters in the home to date. Endsleigh House DS0000041823.V307466.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (24,27,30) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users enjoy the benefit of living in a generally clean and comfortable environment. A number of improvements are required however to ensure and maintain the safe and homely feel to Endsleigh House. EVIDENCE: The home was clean and generally maintained to a good standard. Service users have access to all parts of their environment and enjoy doing so, be it; having a smoke, sitting out in the garden, having a meal or relaxing in the main lounge. In speaking with them they were happy with the quality of the facilities in the home and how it’s overall maintenance. A variety of plants were observed throughout the home and this added to the homely feel of the environment. Most of the furnishings were in good condition although a twoseater settee was in need of replacing. The registered manager advised that one was ordered and was due for delivery soon. There were a number of items requiring improvements and they included: replacing the cracked tiles on the kitchen floor, placing a strip over the carpet in under the doorway, just outside the ground floor toilet, acquiring external garbage bins, along with the areas identified in PJ’s bedroom. In this respect, the showerhead needed cleaning; the toilet seat needed stabilising and Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 19 repairing the damage to the bed frame before it deteriorates further. Another service user required a linen basket. There was some improvement in the upstairs bathroom and this was made more homely with pictures fitted to the bathroom walls. A new bath panel was in place, but was however left in its raw state, with no decorative finish at all. This took away from the enhancement of the bathroom and the registered manager is required to have the panel decorated. One service user tends to use this bathroom, as the other bedrooms have en-suite facilities. In discussion with him he was also of the view that this facility could be improved. The home was generally clean and tidy. This is a joint effort between the service users and staff, which is positive. The laundry area is separate, adequately maintained with facilities for the control of infection e.g. hand – washing liquids along with the programming ability of the washing machine. Service users are supported to wash their laundry, as part of their skill development and this is positive. The registered manager confirmed that the services and facilities complied with the Water Supply Regulations 1999. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35,36) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A dedicated staff team, most of whom have a basic qualification in Care, is on hand to provide for the needs of service users at Endsleigh House. Service users stand to benefit further once the home’s training plan is delivered. Greater safeguards are required during recruitment to ensure the protection of service users and staff development would be improved, with the provision of staffing appraisals. EVIDENCE: From the staffing records up to eighty per cent have acquired at least an NVQ level 2 qualification in Care, with five near completion of their NVQ Level 3. Once completed, the relevant staff would have a greater understanding of the needs of the service user group and this is positive. Plans were also in place to ensure that all the staff achieve their NVQ level 3 in Care training. During an interview with a care coordinator, she was pleased with the staff’s understanding of the varied needs of the service user for whom she was responsible. This is particularly important as that understanding forms the basis to providing support and making appropriate interventions with the service user. It was established from interviewing the service user that he was happy working with the staff, as they were patient, understanding and willing to support him. Staff interviewed demonstrated an understanding of the service user’s needs and were clear on setting boundaries and motivating the individual. This represents a positive outcome particularly for the individual. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 21 An assessment of the staffing records indicated that most staff were recruited in line with current employment and regulatory guidance. The registered manager had in the past demonstrated a robust recruitment strategy that ensured the safety of service users. However, during the course of the inspection – the file of the most recently recruited staff was assessed and was unsatisfactory. Adequate checks were not made e.g. ensuring that the staff member had the right to work in the United Kingdom; a POVA first check was not carried out; the individual was accepted with a CRB check from another organisation and there was no evidence of a health declaration. There was also the fact that a verbal reference was taken, and a record of this was not in place. The registered manager acted swiftly on the day and the individual’s employment ceased with immediate effect, to undertake the required checks. However the practice placed service users at risk and should not be repeated. The registered manager carried out a training needs analysis for the staff team and went on to identify appropriate training for the staff. However in many cases apart from the NVQ level 3 in Care there were no timescales as to when the training would be provided. Up to four staff did not receive their basic food and hygiene training and they are expected to support service users with meals. This is an example of placing service users at risk and as such key mandatory training needs to be prioritised. There was an improvement in the support provided for staff in that formal supervisions were carried out more regularly. Staff interviewed indicated that they felt supported by the process, which would enable them to carry out their duties with greater confidence. In discussion with the manager and from the staff files, there was no evidence of appraisals, which would support staff development. This would have a positive impact on improving the quality of care provided to service users. Although the manager informed that all staff have a probation, there was no record to evidence that they were carried out. This is useful tool for addressing performance in relation to quality and should be recorded. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,41,42) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Management systems enable service users to receive a good standard of care at Endsleigh House. An experienced manager remains in place and leads a committed group of staff in supporting service users. The overall quality of care would be improved once required actions to enhance service users’ safety are carried out. This includes keeping records for the protection of service users in line with regulation. EVIDENCE: Staff, service users, relatives and external professionals were of the view that the home is well managed. The manager is directly involved in the daily operations and is on the last unit of completing his RMA award. It was noted that he attended very few courses over the last year, but was aware of recent developments in the field of mental health. This is useful in ensuring that any related changes could be applied to the service provision at Endsleigh. He has a sound knowledge the needs of all service users in the home and is able to share his expertise with staff for the benefit of service users. An example of this was where a service user became quite anxious on the day about his finances and appropriate action was taken by the manager to reduce this. Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 23 There was evidence of quality monitoring in the home as service user and relatives surveys were carried out prior to the inspection. The manager also sent out quality assurance questionnaires to other professionals e.g. social workers and community psychiatric nurses. An annual development plan was in place with useful outcomes for service users such as: exercising rights, making choices, staying healthy. Plans were also in place to introduce person centred care planning, with a six-monthly review throughout the year. The registered manager was also actively seeking to increase the number of female staff in the home as currently – none was employed. It became knowledge that this was something that a service user raised as part of his feedback and it is positive that service users feel listened to. Policies and procedures were generally updated, apart from the one on medication. This is a satisfactory area of the homes operations. Although there was some improvement in the records held for the protection of service users since the last visit, there was a gap in relation to staffing references as indicated in standard thirty-four of this report. It is required that evidence that two written references must be in place for all staff working in the home. The previous requirement regarding records would be therefore repeated in this report. There was evidence that actions were taken to promote the health and safety of service users and this included staff training in health and safety, safety signage, fire drills and procedures, risk assessments on safe working practice topics, fire training for staff and the maintenance of updated gas and electrical certificates. It was observed that environmental health visited in April 2005 and there were no outstanding issues to date. However improvements were required to ensure that COSHH risk assessments are carried out along with a lone person working risk assessment. The latter is extremely important as one person works on night duty with five service users that have complex needs. The assessment must detail the risks involved and the actions taken to reduce the identified risks. Endsleigh House DS0000041823.V307466.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 X 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 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X 2 2 x Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1)(2)(b) Requirement The registered manager is required to ensure that all service user plans reflect their personal, social and health care needs as well as their changing needs. The registered manager is required to ensure that risk assessments accurately reflect the key risks for service users and are linked to the service user plans. The registered manager is required to review the medication policy to include all areas identified in Standard 20 of this report. The registered manager is required carry out all works identified in standard 24 of this report. The registered manager is required to decorate the bath panel in the upstairs bathroom. Timescale for action 31/10/06 2. YA9 13 31/10/06 3. YA20 12, 13 31/10/06 4. YA24 23 15/10/06 5. YA27 23(2)(d) 31/10/06 Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 26 6. YA34 7. YA36 8. YA36 9. YA41 10. YA42 19(1)(a)(b)(c) The registered manager is required to ensure that a robust recruitment is carried out for all staff in line with regulation. (Also see standard 34). 18 (1)(c)(i) The registered manager is required to include in the training and development plan, clear timescales, with emphasis on food hygiene, adult protection, infection control and induction training. 18(2)(a)(b) The registered manager is required to carry out annual appraisals for staff. 19 The registered manager is required to maintain records for all service users in line with Schedule 2 of the Care Homes Regulations 2001. (This is a previously made requirement - Timescale of 21/01/06). 13 The registered manager is required to carry out COSHH risk assessments and, a lone person working risk assessment. 31/10/06 31/10/06 25/11/06 31/10/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Endsleigh House DS0000041823.V307466.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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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