Inspection on 02/10/08 for Endymion Road, 2

This inspection was carried out on 2nd October 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Endymion Road, 2 14/11/07

Endymion Road, 2 01/08/06

Endymion Road, 2 21/02/06

Endymion Road, 2 07/06/05

Endymion Road, 2 25/01/05

Endymion Road, 2 22/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

CARE HOME ADULTS 18-65 Endymion Road, 2 2 Endymion Road London N4 1EE Lead Inspector Margaret Flaws Key Unannounced Inspection 2nd October 2008 10:00 Endymion Road, 2 DS0000060622.V371702.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 Endymion Road, 2 DS0000060622.V371702.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. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Endymion Road, 2 Address 2 Endymion Road London N4 1EE 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) 0208 341 3888 carlingford@choicesupport.org.uk www.choicesupport.org.uk Choice Support Anna Maria Stuart Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2007 Brief Description of the Service: 2 Endymion Road is a large converted terraced house situated in the Finsbury Park area of North London. The home is registered to provide personal care for up to 6 residents of either sex and over the age of 18 who have a learning disability. The stated aim of the home is to provide a supportive environment where residents can live their lives according to their individual wishes and needs with the assistance of staff. There are 3 floors and all residents have single rooms. There are 6 single bedrooms and 1 sleep-in room for staff; none of the rooms are en -suite. There are 3 bathrooms, and 4 toilets, a kitchen and a lounge. The accommodation is not suitable for residents with physical mobility problems. Choice Support, a large organisation that provides residential services for people with learning disabilities nationally, operates the home. Some housing management is provided by London and Quadrant. Placements at the home costs around £1,300 for each person per week. Residents are expected to pay separately for some toiletries. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to residents and other stakeholders. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 2nd October 2008. The Service Manager, the Acting Manager and the Quality Assurance Manager assisted throughout the inspection and we spoke to several staff present throughout the day. We were shown around the home by staff on duty. The inspection comprised interviews with the management team, staff, observations of and brief interactions with people using the service, and examination of written records, including care records, staff files, health and safety and general home records. We received completed surveys from six staff and pictorial surveys from five residents, which were completed with assistance. The home also provided us with an up to date Annual Quality Assurance Assessment, which gave us good information for this inspection. The quality rating for this service is one star. This means that the people who using this service experience adequate quality outcomes. What the service does well: What has improved since the last inspection? The Registered Person provided an initial action plan of how physical issues in the environment were to be addressed. An agency domestic has been working in the home. Most staff have completed infection control training. Person centred plans are being worked on. A fax machine was purchased. Staff files now included a recent photograph. The manager did register with the Commission for Social Care Inspection. The fire risk assessment was updated. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 7 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. Endymion Road, 2 DS0000060622.V371702.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 Endymion Road, 2 DS0000060622.V371702.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. Prospective residents, their support people and referrers have clear information about the service offered and can be confident that their needs will be fully assessed before moving in. EVIDENCE: There have been no admissions to the home for several years. The home has a clear referral and assessment process for prospective residents who may consider moving into the home in the future. We saw the service user guide. This was clear and in large print, with pictures to help people living in the home to understand it. It is personalised for each resident. Further work has been done to personalise the service user guide with photographs and information about personal preferences. Choice Support calls this a Communication Passport. The Service User Guide does need to include information about what is and what is not included in the fees for service and a recommendation is made. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 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’ individual and changing needs are reflected in improving care plans. Residents are supported to make decisions about their lives, within their abilities and risks and challenges are assessed to protect them. EVIDENCE: Throughout the inspection, we were able to observe interactions between the residents and the staff. Due to the nature of their learning disabilities, residents don’t communicate in conventional ways, and it was difficult to gain their opinions of life in the home. However, five residents responded (with support) to surveys provided in an accessible format and indicated that their wishes were respected and that they could choose where they liked to go, what times they did activities, what they liked to eat and wear. Staff appeared to communicate well with the residents and could interpret and understand their expressed wishes. Staff were able to give good descriptions of how they Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 11 supported people with their choices and how they communicated with them and understand what they were like as people. Residents’ choices were documented clearly. The home has a key worker system and staff described how each key worker reviews residents’ progress with them each month. Each person also has a support plan with actions attached. The reorganisation of care records that was happening at the last inspection has continued over the past year. A Quality Assurance Audit, also since the last inspection, indicated that care records still needed improvement. The previous manager had been receiving support in this from an Assistant Manager seconded from another service, supported by another manager. Progress has been made in the development of person centred plans, meeting a requirement from the last inspection. Risk assessments for all the residents are now kept in one folder and had been reviewed in July/August 2008. Improvements in these risk assessments have been made since the last inspection. We looked at the risk assessments for two people. These had been recently reviewed and showed actions taken to minimise risk. In one person’s case, the risks assessed included maintaining balance, risk of falling and risk of choking while eating. Actions to minimise these risks were documented. Another person’s risk assessment had been expanded following a serious incident earlier in the year and further actions taken to ensure that staff follow guidelines that are in place. Incident records have been reorganised systematically to help staff reports, monitor and act appropriately. Staff training on aspects of working with challenging behaviour has continued over the past year, with a view to improve their capacity to work better with the identified risks to the people living in the home, in particular risks associated with their autism. Endymion Road, 2 DS0000060622.V371702.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): 12,13,15,16,17 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. People living in the home are generally supported in their choices of daily activities and personal development. People are given the opportunity to take part in a variety of activities both within the home and in the community. The food appeared reasonable in quality, healthy and well presented. Residents can participate in shopping, the preparation of meals and menu planning. EVIDENCE: On the day of the inspection, four residents attended day centre and two others spent some time at home and some time out in the community (at bowling and having lunch). We observed residents expressing their wishes about what they would like to do, both during the day and when other residents returned from the day centres. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 13 Activities remain similar to those offered at the last inspection but there have been some improvements. A psychologist, who provides ongoing input, reviewed activities for one person and actions have been taken as a result, for example, this person now plays football and spends more active time out of the home. One person does trampolining, others go to the pub, disco, swimming, cinema, and on other community outings. Since a recent unannounced visit by Haringey Council, the basement sensory room has been made functional. It now offers a space for people to spend quiet time with staff doing aromatherapy, having a foot spa, art and playing games. The Regional Manager said that the home has been considering accessible transport through the motability scheme. We discussed how such a scheme might be used in the home and the issues involved in protecting residents’ rights and choices if a car was purchased by one of the residents. The management team said that they will assess the feasibility of this option. There was reasonable evidence of how residents are supported to develop on a personal level within their capacity and each person also had a cultural needs assessment. These are of a good standard, and provide guidance for staff about the residents’ ethnic, cultural and religious needs and preferences. Some residents use Maketon and sign language to communicate with each other and the staff. Using some newly developed sections of peoples’ care plans, key workers work alongside the residents to identify their dreams and aspirations and are looking at practical ways in which these can be addressed. Staff were able to describe how they support the residents using action planning. Staff said that the residents particularly love the visual elements of their new communication passports. Staff showed us the pictorial menus. On the day of the inspection, one person was at home for lunch and the others were on outings or at day centres. The food provided appeared healthy, nutritional and what people wanted to eat. Staff said that residents contribute to menu planning, shopping and food preparation. The kitchen, however, still feels institutional. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 14 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. Peoples’ personal care and health needs are assessed; their wishes respected and needs monitored to protect their wellbeing. They are protected by the home’s medication policy, procedures and day to day practice. EVIDENCE: There was reasonable information in the care files about how peoples’ personal care needs were to be met, with an emphasis on encouraging and supporting independence. Staff were clear about how their needs and wishes were respected. We looked at the healthcare information in four people’s files. The quality of this information was good and peoples’ health needs were regularly assessed and monitored. Doctors, dentists and opticians provide residents with regular healthcare check-ups. Check ups were recorded in the diary and handover books. All residents now all have a health action plans. Accessible information about their health needs are included in their Communication Passport documents, which are pictorial and explain health issues and checks in a simple format. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 15 One of the senior staff took us through medication in the home. They were able to describe the steps they take in administering and recording medication. They also described how information about medication is communicated and how the team carries out medication checks to ensure the residents’ safety. The medication policies and procedures in the home cover how medications are stored, administered and recorded in the home. The medication is provided by Boots in the bubble pack system and was stored securely, appropriately and at the required temperature. There were records of administration and all medication coming in and going out of the home. We checked the MAR (medication administration records) for two people. No errors or omissions were identified on this inspection. Their doctor had regularly reviewed residents’ medication and staff have been trained in handling medication. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 16 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 and 23 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 and their representatives can feel that their views are listened to, and will be acted on, to protect and safeguard them. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Training of staff in the area of protection is regularly arranged by the home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. EVIDENCE: The complaints procedure is available for the residents in an accessible format, written in plain language, large print, and includes pictures to help residents to understand the process. Complaints received had been properly recorded and investigated. However, some investigations did not make it clear what actions had been taken as a result of a complaint. The managers said that outcome information, if a complaint is resolved at a higher level, is kept at the Choice Support main office. However, this makes it difficult to know if a complaint has been resolved. A recommendation is given that all complaints have clear outcomes achieved and documented in the home. Choice Support has developed a clear safeguarding policy and procedure. This incorporates the local authority’s procedures. Staff we spoke to were able to Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 17 demonstrate a reasonable understanding of what they would do in reporting a safeguarding concern. Staff have received training in safeguarding people. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 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. Some improvements in the environment are being made to benefit people living in the home but other areas still need improvement. Hygiene arrangements in the home do not fully protect people living there. EVIDENCE: At the last inspection, the physical environment of the home was rated as poor. This reflected concern that significant maintenance, building and decorative improvements were not being made and that there was no overall plan to address these issues. There were also concerns noted in the previous report about the state of the residents’ rooms, the relatively spartan and unhomely environment provided for people to live in and the lack of sound cleaning arrangements. At this inspection, we discussed the physical environment at length with the Area Manager. She said that there had been ongoing issues ever since Choice Support took over the building in a state of poor repair. We recognised that Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 19 some residents experience challenging behaviour and that this can result in regular damage to the fabric of the building and fixtures and we gave consideration to this. Since the last inspection, the following steps have been taken and the Commission for Social Care Inspection has generally received regular progress reports from Choice Support on work done, meeting a previous requirement. This has included: The lounge has been redecorated, new pictures put up and attempts have made to make it more homely. The hall and stair areas have been painted. Some improvements have been made to the kitchen – it has been painted and flyscreens fitted - but the fixtures and fittings need replacement and it still feels institutional. There was exposed copper piping attached the water heater in the kitchen that needed protecting. Bathrooms have been refurbished and redecorated and, in most cases, new toilets, showers, washbasins have been put in and the surrounds retiled. However, we did notice that the tiled edging in one second floor bathroom still needed to be done; a toilet seat was loose and needed fixing and the heater in one bathroom didn’t work. We were informed that these were being addressed on the inspection day. We toured residents’ rooms. It was evident that staff have tried to make people’s bedrooms comfortable and homely, with varying degrees of success, Some rooms have been redecorated. New carpet has been laid in one person’s room. However, one person had a curtain in their rooms that was torn and dirty and the window did not shut properly. This must be replaced and repaired. In two rooms, we found that televisions were not working. In one case, staff said that this had been the case for several months. This clearly limits the choices available to residents. A requirement is given that residents’ televisions be repaired and kept in working order. On the day of the inspection, several workmen were working in the home. They made repairs to a small kitchen that staff said was being prepared for teaching skills to residents. Staff surveyed said that the garden and the kitchen needed more work to make them more homely spaces. Some work has been done on the garden but as outlined above, the kitchen still needs significant improvement. Staff are all having infection control training and an agency staff cleaner has been coming regularly, generally meeting two previous requirements. However, the cleaner only covers four hours, three days a week and it was Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 20 evident from comments and observations on this inspection that the cleaning hours may not be sufficient for the tasks to be undertaken. As the inspector indicated previously, this is a very large home where residents have complex needs and behaviours live and the time allocated may not be adequate to ensure good cleanliness and hygiene. A requirement is given that the domestic hours be reviewed. On this inspection, we noted that there were no paper towels in the paper towel dispensers, no toilet paper in one toilet, a soap dispenser was off the wall and there was no soap in the toilets and bathrooms. Although the domestic staff member was working through the first part of the inspection and restocked these, it was clear that these items may not have been replenished continuously. A requirement is given that the hygiene arrangements in the home be improved to ensure that there is always paper towels and soap in all bathrooms and toilets. The recording and actions as a result of incidents has improved and there is a clear documentation trail to follow. Staff are all trained in health and safety. Endymion Road, 2 DS0000060622.V371702.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 and 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. Staff have the skills, competencies and experience to meet the assessed needs of residents. Residents may need a higher level of staff support at times to fully meet their needs. Staff are safely recruited and generally well trained to support and protect the residents. EVIDENCE: We saw the rota for the week of the inspection. There were three staff on duty on the morning shift of the inspection. Management back-up was provided by an Acting Assistant Manager and a seconded part time manager from another part of the organisation. The rota indicated that there were generally three staff on each shift. However, staff all indicated in the surveys they returned that there is a need for more staff on duty on the late shift and on the weekends when the residents are all at home. For example, one resident requires one to one support at home and two to one support in the community. A requirement is given that the home reviews the staffing levels to ensure that the residents receive the level of support that matches their needs. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 22 We checked the records for four staff. The files appeared to be in better order than they had been at the previous inspection. The main staff files are held at the Choice Support headquarters and copies held at the home. In the files we saw, all staff had had pre-employment checks completed before they started work, including Criminal Records Bureau checks and written references obtained. A new staff member described a thorough induction, with good initial training and shadowing time in place. This induction was properly documented. Staff all confirmed the thoroughness of the pre-employment checks they received prior to starting work. Staff members’ files now include a recent photograph, meeting a requirement from the last inspection. Interactions between staff and residents were observed to be appropriate, professional and relaxed. The staff team were positive about the way they work together to meet the best interests of the people living in the home. Supervision records indicated that formal supervision had been patchy, reflecting some of the management instability since the last inspection. However, all staff surveyed said that, despite this, they generally had good supervision and felt supported. A recommendation is given that formal staff supervision meet the frequency of six times annually and that this frequency be sustained. In the Annual Quality Assurance Assessment, the manager stated that seven staff have NVQ2 or above. Improvements have generally been made in filling training gaps. Staff described recent training they received in communication, advanced manual handling, health and safety and sexuality. The staff training records demonstrated that they had generally received a range of core training including first aid, food hygiene, medication, safeguarding adults, health and safety, fire safety, moving and handling and, in other areas of good practice, such as healthy eating, report writing and person centred planning. A requirement for staff to have infection control training was met. Staff still need formal training in autism, which constitutes their core work. We saw evidence that staff were booked for autism training in this October. Agency domestic staff receive training, for example, in safeguarding adults, infection control and working with challenging behaviour. The organisation is working to address equality and diversity issues in its services by providing introductory equality and diversity training. We spoke to four staff on duty throughout the day. They were generally positive about the gradual improvements being made in the practice and culture of the home. They said they felt they were well resourced and generally supported to do their jobs. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 23 Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 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. People living in the home would benefit from stable and better resourced management. Quality assurance systems are in place to consult with the people who use the service and significant others. They would benefit from ongoing improvements in the organisation of information. People living in the home are generally protected by the home’s health and safety policies and procedures, but some fire safety issues need addressing. EVIDENCE: The management pattern in the home over the past two inspections has been somewhat disrupted. Just before this inspection, the current manager, who had been in post for two years, resigned. She had finally made progress Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 25 towards meeting a requirement to register as manager with CSCI but then resigned. There have also been issues with the continuity of previous Assistant Managers. An Acting Assistant Manager, supported by a manager from another home, are currently covering as a short term arrangement. The organisation originally put in these additional management resources to support the home earlier this year. An audit by Choice Support’s Quality Assurance team also identified issues with record keeping in the home and weak use of management systems. Since that time, some improvements have been made to the record keeping and systems, which remains an ongoing process. One issue of concern identified at the last inspection was that the home did not have good computer and office communication equipment. The computer is not linked to the organisation’s server, intranet and email system. Choice Support expects its managers to remain in good contact and management staff travel to the Bow office, often daily to either to collect and send emails, to access documents or take documents there using a portable computer storage device. At the last inspection, a recommendation was made to address this issue because of the amount of management time this took away from the home. Also, at the previous inspection, the fax machine in the home was not working, which was contrary to Regulation Sixteen. A requirement was made to address this. As a result, the home purchased a new fax machine but on the day of the inspection, management and staff were unable to get this machine to work and could not locate the manual. A requirement is given that the fax machine be made workable, with clear instructions available. We discussed these concerns with the temporary management team and the Area Manager. They said that Choice Support plans to have the home connected to the organisation’s computer server, intranet and email system by November 2008. A requirement is given that the home have a properly resourced management communication system to enable managers to be fully present in the service. The Area Manager said the home was in the process of recruitment following the manager’s resignation. The current management arrangements are adequate on a temporary basis, but considering the home’s history of management instability, it is important that the home recruits and registers a competent and permanent manager as soon as possible. A requirement is given. This person needs to be based at Endymion Road to continue to make service improvements and be well resourced with good communication systems and organisational back-up. The organisation of records has been an ongoing issue and while some improvements had been made prior to the last inspection, a Choice Support Quality Assurance audit identified concerns in this area and put in additional Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 26 management resources to support the home’s previous manager in to resolve them. The team are making progress in addressing this issue. The home has a quality assurance system, a satisfaction survey given to the residents, to give them a chance to say what they think of the service. This was in large print and has pictures to help people living in the home to understand it. As part of this inspection, five residents completed pictorial surveys (with support), which indicated their satisfaction with the home and the service. Families of the people living in the home are also involved and consulted. This was documented in the care files. We saw health and safety records, which were of a reasonable quality. Water, fridge and freezer temperatures were monitored. There is a good organisational health and safety policy and procedure in place. Fire alarm and fire equipment checks had been done. A fire risk assessment is in place, meeting a requirement from the last inspection. However, at this inspection, we identified that actions had not been taken in response to the Fire Authority’s visit and the recommendations that they had made. A requirement is made for these actions to be taken and the fire safety authority invited to reassess. There is a new fire panel in the downstairs hallway. Gas, electric and portable electrical appliance testing were up to date. There was no evidence of water testing being done but the Acting Assistant Manager was able to describe the legionella checks that were booked and planned for the week of the inspection. We are confident that these will carried out. Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 27 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 x 2 x 3 X 2 2 x Endymion Road, 2 DS0000060622.V371702.R01.S.doc Version 5.2 Page 28 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 YA25; YA7 YA24 YA24 Regulation 23(2)(c) Requirement The Registered Person must ensure that all residents’ televisions in their bedrooms are kept in working order. The Registered Person must ensure that a torn and dirty curtain in one person’s room is replaced and the window that does not shut properly is repaired. The Registered Persons must ensure a competent and permanent manager is recruited and registered with CSCI. The Registered Person must ensure that there is always paper towels and soap in all bathrooms and toilets. The Registered Person must ensure that the laundry flooring and sink are replaced. The Registered Persons must ensure the domestic hours in the home are reviewed to realistically meet the needs of the service. The Registered Person must ensure that the staffing levels are reviewed to ensure that the residents receive a level of DS0000060622.V371702.R01.S.doc Timescale for action 31/12/08 2. 23(2) 31/12/08 3. YA37 8 31/01/09 4. YA30 16(2) 31/12/08 5. 6. YA30 YA30 23; 16(2) 18 (1) 31/12/08 31/12/08 7. YA33 18(1) 31/01/09 Endymion Road, 2 Version 5.2 Page 29 8. YA37 16(2)(a) 9. YA42 23(4) 10. YA37 16(2)(a) support that matches their needs. The Registered Person must 31/12/08 ensure that staff understand how to use the fax equipment provided. The Registered Person must 31/12/08 ensure that actions are taken in response to a Fire Authority’s visit to address the recommendations they made and a further visit arranged. The Registered Person must 31/12/08 ensure that there is a properly resourced management communication system in place to enable managers to be fully present in the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA22 YA36 Good Practice Recommendations That the Service User Guide includes information about what is and what is not included in the fees for the service. That complaints have clear outcomes documented in the home. That formal staff supervision targets meet a frequency of six times annually. Endymion Road, 2 DS0000060622.V371702.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 Endymion Road, 2 DS0000060622.V371702.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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