Inspection on 15/05/08 for Endsleigh House

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 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 10/08/06

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 44-46 Endsleigh Gardens Ilford Essex IG1 3EH Lead Inspector Stanley Phipps Unannounced Inspection 15 – 29th April 2008 12:00 th Endsleigh House DS0000041823.V362055.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.V362055.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.V362055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Endsleigh House Address 44-46 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) endsleigh.house@gmail.com Mr Yuhya Roojee Mr Yuhya Roojee Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2006 Brief Description of the Service: Endsleigh House is a care home providing personal care and accommodation for ten 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 ten single bedrooms, four of which are located on the ground floor. Access to the first floor is via two sets of stairs. There are four reception rooms on the ground floor, two of which is used for dining and the others for relaxation and viewing television. There is now an additional room where snooker is played and there are two designated smoking areas to the rear of the building. 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.V362055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The inspection was unannounced and was carried out on the 05/04/08 over the period 15/4/08 through to the 25/04/07. At the time of the visit the responsible individual and the registered manager were at various points on the premises and available to provide evidence as part of the inspection process. It was the first inspection since an increase in the number of beds (now ten bedded) available to residents. There were six residents in the home at the time of the site visit and they all made a contribution to the inspection process. An assessment of medication practice, menus, policies and procedures, records required by regulation, residents’ care plans and the environment was undertaken. Discussions were held with several service users, the registered manager and several members of staff, including the deputy manager. Formal interviews were also held with the manager and three residents. The inspection also considered: information provided in the Annual Quality Assurance Assessment (AQAA) provided by the registered person, verbal feedback from external professionals, information provided by the local planning office, along with comment cards that were returned from staff and residents. The inspection found that while there were some improvements since the last inspection, there have been failings in key outcome areas, namely protection and management, which compromised the safety and welfare of residents living in the home. In this regard the service has moved from a good rating to one that is rated - poor. Prior to and at the time of completing this report there have been four safeguarding issues involving two residents and two members of staff. Three of the issues could not be further progressed under safeguarding procedures and it has been recommended for the staff members that were implicated to be reinstated to work in the home. Following the initial site visit, a decision was taken to conduct a management review of the service on the 25/04/08 in light of the concerns gathered then. This resulted in the Commission preparing Statutory Enforcement Notices (SEN) to secure the relevant improvements to the home. These failings are identified in the body of this report. However statutory requirements have not been made in respect of these deficiencies as the enforcement action will be progressed by the Commission’s Regional Enforcement Team. It should be noted that most of the residents expressed their happiness with living at Endsleigh House. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Comply with all statutory requirements set by the Commission in a timely manner to promote improvements to the service. Care plans must detail and identify how needs must be met. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 7 Promote independence and control by acting in line with policies and procedures. Provide appropriate guidance and support for staff in managing complex and specific behaviours. Protect the rights of residents at all times. Record concerns and complaints and how they are handled. Provide specialist training for staff in relation to the residents’ needs. Act in line with policies and procedures at all times. Review the financial policy in relation to compensation. Develop a policy on equality and diversity. 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. Endsleigh House DS0000041823.V362055.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.V362055.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. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents continue to have access to information in making a decision about the suitability of the home. They benefit by having detailed assessments carried out on them and have opportunities to view the service before deciding to live at Endsleigh House. EVIDENCE: Residents have access to information through the home’s statement of purpose and service user guide, the latter of which is given to each individual. The documents do make reference to the services that are provided at Endsleigh House. One individual said that his social worker helped in identifying the home for him and drew the information to his attention, which he was grateful for. The registered provider advised that the documents could be made available in alternative formats, if required. The admission documents of residents were assessed and found to be detailed. There was evidence that information was gathered from referring agencies prior to admitting residents to the home and this forms part of the home’s admissions process. The two service users spoken to were involved in their assessments and the input of relatives was also key to the overall process. Residents’ care plans are generally developed from these assessments, which outlines the actions required to achieve each of the individual’s objectives. Both of the residents spoken to expressed the view that they felt that the service was meeting their needs. Endsleigh House DS0000041823.V362055.R01.S.doc Version Page 5.2 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): (6,7,9) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents generally benefit from having their needs (including their mental health needs), reflected and reviewed in their individual plan, although this could be enhanced further. There was some evidence that they take decisions with support, but this is not the experience for everyone living at the home. Independence is promoted within a risk management framework, but for some of the complex cases, risk management could be improved. EVIDENCE: From the care plans viewed, it was clear that residents are involved in planning their care, which ensures that they are not only aware, but accept responsibility for their direction. As part of this arrangement, they have the benefit of a key worker who works closely with them in setting up and reviewing their individual plan. Most of the care plans viewed were updated and generally individualised, detailing the specific needs of residents. They were borne out of the assessments carried out initially with them. However, in some cases the care plans failed to detail the specific needs of residents, particularly as it related to their complex needs. This meant that strategies for managing some areas of specific needs were not appropriately addressed. This Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 11 compromised the safety and welfare of the individuals concerned, and as such needs to improve. There was evidence that residents were involved in various aspects of the home, e.g. menu planning, activities, outings and how they spend their time. They had access to a range of policies and procedures, as and when they needed to. Residents spoken to showed an awareness of being able to access policies relating to the services they were receiving. Despite this there was evidence that there was at least one case in which the financial policy regarding compensation was not followed by the registered manager neither was it used in addressing a specific matter with the individual concerned. This resulted in a safeguarding referral being made to the local authority by the inspector. Residents were informally consulted on a regular basis in their meetings about various matters in home. It was clear that the foundation was in place to enable service user participation in the home, but improvements must be made to ensure that residents’ involvement is promoted at all times. A system for risk assessment and risk management is in place at Endsleigh House. In most cases they were linked to each resident’s care plan. Staff spoken to understood the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. However, in two of the files examined improvements were required. The risk management for the more complex behaviours did not set about to keep risk to a minimum, and this failing compromised the health, safety and welfare of not only the individuals exhibiting the behaviours, but those individuals living in the home and having to put up with it. The areas of failure were discussed in detail with the manager. It must be stated that this is an area that had been identified for improvement in the Annual Quality Assurance Assessment document, submitted by the registered manager. Endsleigh House DS0000041823.V362055.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): (12,13,14,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to participate in their community, in appropriate activities and are able to maintain and develop social and personal networks of their choosing. Most times residents are supported to exercise their rights, which are respected and promoted by staff in the home. Endsleigh House provides meals that are reflective of service users’ choice and nutritional requirements. EVIDENCE: There was evidence that service users were supported to develop and maintain their living skills, despite having varied levels of motivation. This presents a challenge for the staff team and from observation they were mostly aware of the challenges in providing care and support to the resident group. Each resident has an individual plan of activity that was specific to their choice and interest. From interviews held with residents, they all expressed satisfaction with the range and frequency of activities that they are involved in. One resident spoke of undertaking a degree in moving images, which he attends Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 13 over a five-day period. He would like to gain employment one day and plans to live more independently in the future. Another informed that he does voluntary work for up to two days weekly, which he looks forward to. Most of the residents are involved in some form of activity that is meaningful to them. Residents continue to make use of the community facilities such as the cinema, college, swimming pool and the local parks. Most of them were familiar with the community facilities and so make good use of them. This includes the transportation facilities. Residents receive support in a flexible manner to enable them to enjoy accessing and using the community resources. It was clear that residents were engaging with their community in an effective manner, which is also positive. From assessing residents’ records, talking to the staff, resident and community professionals, it was noted that residents are encouraged to develop and maintain relationships with their friends and families. At the time of the visits, one resident spoke candidly of preparing for visiting his mother. He explained that he has very good relationship with his family and looks forward to this experience. Some residents communicate with their loved ones by phone, which is again positive. Relatives are also invited to and attend social events in the home such as barbeques and birthdays events. During the course of the inspection staffing interactions with residents were appropriate and more importantly respectful. Residents were addressed by their preferred names and staff were observed checking with them their preferences around food and activities. Advocacy information is made available to residents and the key worker system is used as a means of ensuring that the rights and needs of residents are respected and provided for. Ironically, there was some evidence to indicate that the rights of one resident were compromised due to the lack of appropriate procedural guidance e.g. on dealing with the recuperation of financial compensation, the failure to follow existing guidance and the failure to appropriately report and act upon concerns raised by the resident concerned. These failings must be addressed to reduce the risk of any further possibility of a reoccurrence and are addressed in the section of the report related to protection. During the course of the inspection menus were available, and in discussions, residents confirmed that they are involved in choosing them and as such they reflected the cultural preferences. Most of the residents expressed positive views about the quality and quantity of the food provided at Endsleigh House. One resident stated that the food is better at times, but importantly he felt that his cultural needs were satisfied. Checks carried out indicated that there was a good supply of food and drink, which is accessible to all residents. Service users could eat where they preferred and the mealtimes were flexible and have a take- away option when they feel like. They are also encouraged to eat healthy depending on their individual needs and to this end they are Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 14 encouraged to prepare meals as far as feasible possible. This is consistent area of the homes operations. Endsleigh House DS0000041823.V362055.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): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. This is generally enhanced by the staffing input and support with medication. EVIDENCE: Four of the six residents spoken to confirmed that they were happy with the way in which staff provided personal support to them. This is coordinated through the key-worker system used in the home. They have their individual style of dress, which was consistent with their choice, culture and personality. It was noted however that for one resident, there was a lack of information regarding his cultural needs. This was raised with the registered manager for improvement. In at least one case an allegation was made regarding the failure of staff to safeguard a resident while supporting him with personal care. This was dealt with through the local authority’s safeguarding protocol, which concluded that the alleged failing could not be substantiated. Staff were generally sensitive when making interventions to support individuals where certain choices were inappropriate and this is positive. Most of the staff Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 16 on duty during the course of the inspection exhibited a good understanding of the needs of the current service user group. Residents are given good support to ensure that their health needs are provided for. They were all registered with a GP and records assessed indicated that arrangements are in place for them to see other health professionals such as the dentist, chiropodist and the opticians. They also have the benefit of getting support to attend their outpatients’ appointment should they require this. Feedback received from external professionals confirmed that they are contacted at the soonest opportunity should specialist support e.g. psychiatric input is required. This means that early interventions can be made to ensure that resident distress is kept to a minimum. There was evidence of input from professionals such as the psychologist, the psychiatrist and the community psychiatric nurse. Records in relation to appointments and the contacts made with external professionals were appropriately maintained. Discussions were held with the registered manager about the need to enhance the quality of recording, and tools used to monitor the changes in residents’ mental state and the triggers for relapse to ensure that their mental health needs are better provided for. At the time of the visit, residents were receiving support with medication. An improved medication policy was in place to include guidance on promoting residents’ independence with their medication, although at the time nobody was able to manage their medication independently. The area that was outstanding from the last inspection was in relation to the inclusion of guidance in the use of cytotoxic drugs, and the inclusion of ‘managing spillages’ in the home. The registered manager confirmed that he would be completing this piece of work imminently and so it was agreed that he proceed without further delay. Medication storage was good and all staff with the responsibility of supporting residents with their medication have had training to so do. There was evidence from the recording systems in the home to confirm that drugs stocks are appropriately recorded and monitored at Endsleigh House. Residents are therefore assured that their health care support needs are well-provided for. Endsleigh House DS0000041823.V362055.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) People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The management of complaints and concerns places residents at risk of being unsafe. Although safeguarding protocols are generally followed by the management and staff in the home, recent management practices also places residents at risk of being in an unsafe environment. EVIDENCE: A satisfactory complaints procedure is in place at the home and all residents were aware of this. From discussions held with them, they generally felt able to raise issues of concern, should they feel the need to. They also demonstrated an understanding of their right to complain and the complaints procedure is widely advertised throughout the home and in their statement of purpose. However there was at least one person who reported raising a concern which resulted in nothing being done about it. It was also the case that with the incident raised there was no formal record of it, despite the registered manager knowing about it directly. There was no complaints record and the registered manager was instructed to keep one in order to comply with Regulation 22 of the Care Homes Regulations 2001. A satisfactory policy on safeguarding adults is in place at the home and this includes clear guidance on ‘whistle-blowing’, although the registered manager needed to obtain the most recent safeguarding adults protocol. Staff, as part of their induction, are taken through the safeguarding adults guidelines of the home. Most of the staff also had training in dealing with challenging behaviour and a policy on dealing with aggression - verbal and physical - is in place. At the start and during the course of the inspection there were several serious safeguarding issues, arising out of allegations made by residents against the Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 18 management and two members of staff at the home. The registered manager complied with the various protocols and processes as stipulated by the local authority i.e. Redbridge. During the course of the investigations steps were taken by the Commission and the local authority to promote the safety of all residents living in the home. From the investigations carried out by the placing authority and the police, there were to be no further actions on up to four of the allegations. However, one issue remains live under safeguarding and is currently being pursued by the lead officer for safeguarding adults in Redbridge. The placing authority has made several recommendations for improvement, despite the fact that the issues could not be substantiated, as it was clear that there were several flaws in ensuring and maintaining a safe environment for the residents living at Endsleigh House. As stated earlier, the Commission was in the process of issuing statutory enforcement notices to achieve improvements in the service in relation to the protection of people who live in the home. As a result of this action, the requirement section of this report will not detail all the actions required for improvement. Endsleigh House DS0000041823.V362055.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. JUDGEMENT – we looked at outcomes for the following standard(s): (24,27,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents live in a clean, purpose built and suitably designed home that matches their needs and lifestyles. They enjoy using their facilities, which are homely and personal, including their bedrooms. Communal spaces are designed with service users in mind enabling diversity, privacy and independence. The home is generally fit for its purpose. EVIDENCE: There were several improvements to the environment, which at the time of the inspection was still undergoing refurbishment works. The home is now a tenbedded service and with the development, residents gained a snooker room. During the course of the inspection, it was discovered that the registered manager proceeded to carry out a loft conversion to create two additional bedrooms. This was done without notifying the Commission, although the local planning authority confirmed that planning permission was sought by the registered manager in this respect. The environment was stimulating, airy, bright and both service users were quite pleased with it. The home met the requirements of the local fire, environmental health and safety and the Building Acts and Regulations. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 20 One hundred per cent of the feedback received from residents was positive about the quality and facilities provided at Endsleigh House. As such they all expressed happiness in living there. Remedial works identified at the last inspection were carried out to a good standard. Several residents allowed their rooms to be examined and they were in good condition and reflective of each individual. Due to the refurbishment works several residents were relocated and a meeting was held with them to inform them of this. The registered manager again failed to notify the Commission. This failure is being dealt with by the Regional Enforcement Team. All residents were satisfied with their personal spaces, which is positive. Some work was required to the upstairs bathroom and the registered manager was in the process of undertaking this as part of his refurbishment plans for the home. Bathrooms remained accessible to residents and they were satisfied with them. The laundry facilities were designed to promote the service users’ independence as far as possible. It was also designed to ensure that service users could develop their skills in this area. An infection control policy is in place and service users and staff are encouraged to work within this e.g. handwashing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The layout of the home is such that foul linen is well away from food preparation and so the risk of the spread of infection is minimised. The services and facilities do comply with the Water Supply Regulations 1999. It must be noted that the feedback received service users and from relatives was quite positive about the cleanliness and quality of the environment. Endsleigh House DS0000041823.V362055.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. JUDGEMENT – we looked at outcomes for the following standard(s): (32,33,34,35,36) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally staffing levels do reflect their needs and by the provision of training and supervision for staff to enable them to fulfil their roles. However, staff would benefit from having key pieces of specialist training to carry out their duties more safely. Improvements in staffing recruitment and supervision means that staff are more enabled to carry out their duties to residents. EVIDENCE: In observing practice staff demonstrated their ability to positively engage and interact with service users. It is fair to say that even at times when a service user became anxious, staffing interventions were generally appropriate. However, this was against evidence, which informed that where there are difficult behaviours to contend with, staff fall short of what is expected of them. One of such behaviours described involves a resident inappropriately manipulating his private parts in the communal areas, regardless of the staffing intervention/s or other residents being present. The care plan and management of the behaviour was non-specific and in many respects ineffective. This needs to improve. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 22 Despite this, most of the residents were generally relaxed and from looking at their records, there was evidence that staff at times demonstrated good tact and skill when engaging with them. It was noted that some of the staff had achieved at least an NVQ Level 2 in Care and two were working towards obtaining a Level 3 in Care. This means that staff would have a good understanding of the basic principles of care. From examining the rosters, there was evidence that the combination and numbers of staff were adequate to meet the needs of service users. Residents expressed satisfaction with the staffing input in relation to their care and support. Written feedback received from staff indicated that there are sufficient numbers on duty on a daily basis to meet the needs of the resident group. External professionals spoken to also confirmed that the staffing levels were generally adequate to meet the residents’ needs. Four staffing recruitment files of staff were examined and an improvement was noted in the robustness in the recruitment practices undertaken by the registered manager. All checks required by regulation were undertaken prior to staff taking up duty at Endsleigh House. Residents are now assured that all staff are thoroughly screened prior to engaging with them. They are therefore more protected from the risk of coming to harm, which is a positive outcome for them. A training and development plan is in place for the staff. The responsible person informed that there is dedicated budget for training, which is positive. However, there was a lack of training in relation to the specialist needs of service users and their mental health problems, which must be addressed. It must be said that service users currently living there have very complex needs in that for some it was a case of mental health plus either learning disability or personality disorder with or without substance misuse. There was also no evidence of training or even a policy on equality and diversity for the staff. This is an area for improvement. Feedback from staff indicated that they felt supported to carry out their duties in the home. Supervision and appraisal records were examined, which indicated that there were improvements in both the frequencies of supervision and appraisals carried out for the benefit of staff. A deputy manager is now in post and this has had a positive impact on achieving this improvement. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 23 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): (37,39,41,42) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management systems are in place to provide a quality service at Endsleigh House. This includes systems for quality assurance, record keeping, and the promotion of health and safety in the home. However, improvements are required in the operational management of the home to ensure that residents’ rights and best interests are promoted. A policy on equality and diversity must be available for staff to ensure that they are guided on dealing with the diverse needs of the service user group and the financial policy needs to be reviewed in relation to obtaining compensation from residents. EVIDENCE: The registered manager is an experienced mental health professional who has completed the RMA (Registered Manager Award). He provided evidence of courses that he attended since the last inspection to keep abreast of developments in the field of mental health. The staff and most of the residents are quite comfortable with him and the open door approach he uses to Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 24 encourage engagement and integration with both groups. He also has the respect and confidence of mental professionals who provided feedback on his professional capability and integrity. However, it is currently alleged that he failed to protect a vulnerable resident and this is currently looked at under safeguarding protocols. He also failed to follow his financial policy on at least one occasion. Added to that he failed to carry out his regulatory responsibilities to notify the Commission of significant events, under Regulation 37 of the Care Homes Regulations 2001, in a timely manner. As stated earlier, the Commission is in the process of issuing statutory enforcement notices to bring about the required improvements. As such requirements relating to failings in keeping appropriate records and reporting under Regulation 37 would not be repeated in this report. An annual development plan is in place for the home. Service user surveys have been carried out in August 2007 and plans were in place to carry out an internal audit of the service. The views of professionals are acquired at annual reviews and this information is used as part of the overall quality assurance process. The views of staff and residents are also obtained from regular meetings held which are well-documented. Residents therefore benefit from a service that is aimed at reviewing its performance in developing the service. There was some improvement in the records held under Schedule 2 of the care Homes Regulations 2001. However, given the findings of this inspection it became clear that the quality of recording in relation to incidents, concerns raised and the management of complex behaviours were far from satisfactory. Further the financial policy currently used failed to make any reference to incidents occurring in the home, when an individual is genuinely relapsing. This opens up opportunities for abuse. The policy also failed to take into consideration individual circumstances, when seeking compensation from residents for damage to property, which also leaves residents wide open to abuse. There is also no policy on equality and diversity and so it is difficult to see how decisions are weighted and proportional. This needs to be reviewed. Improvements were noted in the health and safety practices in the home, as COSHH and a ‘lone – working person’, risk assessments were carried out. This means that both staff and residents are safer living in the home. The health and safety file was assessed and all records on appliance safety, fire safety and electrical safety were in order. There was evidence that staff have as part of their induction, appropriate training in health and safety. Food storage and handling was generally safe in the home and the laundry facilities were appropriate and in line with Regulation. Staff and residents are generally safe while at Endsleigh House. Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 25 Endsleigh House DS0000041823.V362055.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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 X 2 3 x Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 27 NO 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 Requirement Timescale for action 30/06/08 2. YA7 3. YA9 4. YA14 15(1)(2)(b) The registered manager is required to ensure that all care plans detail and identify the action/s to be taken in meeting residents’ needs. This is to ensure that people’s individual needs are properly met. 12 The registered manager is required to ensure that policies and procedures are followed at all times in the promotion of resident’s independence and control. This is to ensure that people are properly protected from harm. 13(4)(c) The registered manager is required to ensure that risk management strategies for complex and specific needs are clearly identified and developed for all residents. This is to ensure that people’s individual needs are properly met and they are safeguarded. 12 The registered manager is required to ensure that appropriate steps are taken i.e. in line within a reviewed financial policy framework, to protect the rights of residents – DS0000041823.V362055.R01.S.doc 30/06/08 30/06/08 30/06/08 Endsleigh House Version 5.2 Page 28 5. YA22 12, 13 6. YA22 22 7. YA32 12 8. YA35 19(5)(b) 9. YA37 12,13 10. YA41 YA42 25 at all times. This is to ensure that people are safeguarded from harm. The registered manager is required to ensure that a system is in place to record any concern/ complaint that is brought to his attention. This is to ensure that people’s individual concerns are properly addressed. The registered manager is required to ensure that a record of concerns/complaints and how they are handled is maintained at all times. This is to ensure that there is evidence that people’s individual concerns are properly addressed. The registered manager is required to ensure that staff detail difficult behaviours and receive appropriate support to manage the identified behaviours. This is to ensure that people’s individual needs are properly addressed. The registered manager is required to ensure that all staff receive specialist training e.g. in mental disorders, substance misuse and dealing with behavioural disorders. This is to ensure that people’s individual needs are properly understood and addressed. The registered manager is required to act in accordance with his policies in promoting the rights and best interests of residents. This is to ensure that people who live and work in the home, are protected by the home’s policies and procedures. The registered manager is required to review the financial policy in relation to : 1) compensation to protect the DS0000041823.V362055.R01.S.doc 30/06/08 30/06/08 30/06/08 31/07/08 30/06/08 30/06/08 Endsleigh House Version 5.2 Page 29 rights and best interests of residents and 2) develop a policy on equality and diversity for the benefit of staff and residents. This is to ensure that people’s individual needs are properly addressed and they are safeguarded from harm. 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.V362055.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Endsleigh House DS0000041823.V362055.R01.S.doc Version 5.2 Page 31 - 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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