Inspection on 10/11/05 for Faircross Avenue

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 38 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faircross Avenue 05/06/07

Faircross Avenue 13/06/06

Faircross Avenue 14/06/05

Faircross Avenue 20/01/05

Faircross Avenue 28/09/04

Faircross Avenue 27/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Faircross Avenue 100 Faircross Avenue Barking IG11 8QZ Lead Inspector Mr Roger Farrell Unannounced Inspection 10th November 2005 04:20 DS0000027898.V270328.R01.S.doc Version 5.0 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 DS0000027898.V270328.R01.S.doc Version 5.0 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. DS0000027898.V270328.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Faircross Avenue Address 100 Faircross Avenue Barking IG11 8QZ 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 591 5655 0208 471 6959 Mr Nasser Kassouri Mrs Beverley Rose Kassouri Mr Nasser Kassouri Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000027898.V270328.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: 100 Faircross Avenue is registered to provide accommodation and support to three people who have learning disabilities. It is a small mid-terrace property situated in Barking, a short walk from shops and transport links. The building falls short of current standards in a number of ways - such as two small bedrooms; an outdoor toilet; and the two communal rooms being used as office space and as a bedroom by staff. All three residents have lived at this home for a number of years. The owners are Mr and Mrs Kassouri, who took over the home as a going concern, being registered in November 2001. Both had worked at the home under the former owner. Mr Kassouri lists himself as the full-time manager. Mrs Kassouri has confirmed that she no longer works at the home as the part-time deputy. They have bought the next-door house and have said for some time they are planning to make the home larger, adding extra places and improving the existing areas such as larger bedrooms with their own showers and wc. DS0000027898.V270328.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 10 November 2005. Sue Bestjan (Regulation Manager) and Roger Farrell (Regulation Inspector) arrived at the home at 4.20pm, and remained through until 7.30pm. The main aim of the visit was to check compliance with the ‘Immediate Requirement Notices’ served at the last visit on in June 2005, and to monitor the action taken to deal with the thirty-one requirements set out in the last report. That report said – “Failings in basic day-to-day care arrangements are taking place. This is the result of there not being a manager at the home taking responsibility for overseeing the service. For long periods new staff - some with little or no previous experience of working with people with a learning disability - are being left in charge, often doing long shifts.” It went on to say – “The overall impression given at these visits was that the residents were being provided with a basic board and lodging service, rather than the professional approach the owners promise in their ‘statement of purpose’. They are failing to manage this home to a safe and acceptable standard. The Commission wants them to provide a detailed ‘action plan’ that shows how they intend to make lasting improvements, and in a way that can be seen at future visits.” At that time the owners were served with four ‘Immediate Requirement Notices’ for failing to maintain adequate standards in the following areas: • To have on display a rota that gives true details about staff cover, including the manager’s hours; • To have available details about staff, including the steps taken to check that they are suitable to work in a care home; • To have available records covering fire safety, including a log of drills and making sure staff know what action to take; • To maintain a record that shows residents are being provided with an adequate choice and variety of food. The owners were sent a letter on 17 June 2005 setting out the Commission’s major concerns. A meeting took place on 6 July 2005 to emphasise to Mr and Mrs Kassouri their legal duties, and the consequences of not carrying out their responsibilities. The last report is available on the Commission’s website at www.csci.org.uk. A copy should also be available on request at the home, along with the owners’ action plan setting out their undertakings on how they intended to achieve compliance. The headline conclusion of this recent visit is that the registered persons have failed to achieve any worthwhile improvements, despite the assurances they provided. The person in charge when the inspectors arrived was again a parttime support worker, who said he had started at the home two weeks earlier. He was polite and co-operative, but could be of limited help as he was not familiar with the home’s records or procedures. He said he had been on duty DS0000027898.V270328.R01.S.doc Version 5.0 Page 6 alone throughout his shift. It was again found that Mr Kassouri was listed as on duty that day, but there was no evidence that he had been at the home, such as an entry in the ‘signing-in book’. When contacted, Mr Kassouri said that he had been at the home until 1pm. Further, the staff member said that he did not believe Mr Kassouri was the manager. When asked, the longer established staff member who arrived to cover the evening and night shift also said that she did not believe Mr Kassouri was still managing the home. A number of requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. Unmet requirements impact upon the welfare and safety of service users and as many of these are repeated over several inspections, the Commission for Social Care Inspection is considering what action it will take to secure compliance. What the service does well: What has improved since the last inspection? The owners had been told that a failure to show that they are achieving the required improvements would lead to the next stages of legal action, and this can include prosecution. The key findings at this recent visit were: 1. Management Cover. The two previous inspection reports have raised the matter of Mr Kassouri as the full-time manager needing to demonstrate he is at the home as shown on the duty rota. On the day of this visit Mr Kassouri was listed on the rota as on duty from 8am through to 3pm. As stated above, the person on duty since 12 noon said he had not seen Mr Kassouri that day. Mr Kassouri had not signed-in or signed-out in the “Blue Book,” as inspectors were told was the procedure in the home. There was no other record of a change to that day’s cover. When contacted on the phone Mr Kassouri said that he had been at the home until 1pm, leaving to go to the Town Hall that afternoon on business relating to the home. Evidence was requested to show that he had been at the home the previous day. None could be offered, again there being no entry in the signing-in book. On 6 June 2005 the owners were served with an ‘Immediate Requirement Notice’ instructing them to have a rota available that is a true record of staff cover, including the manager’s hours on duty, and any variations such as details of duties being undertaken off-site. Over recent rota sheets Mr Kassouri DS0000027898.V270328.R01.S.doc Version 5.0 Page 7 was listed as working at the home each weekday between 8am and 3pm. This pattern of full-time manager presence was re-confirmed by the owners in their latest ‘statement of purpose’ extract sent to the Commission on 7 October 2005. The Commission’s consistent finding this year is that the rota on display at the home is not a true record in that it gives a misleading and false account of the level of cover and on-site management presence. The Commission believes that the registered persons are knowingly attempting to mislead by persisting in having available a record that is false. Consideration is being given to taking enforcement action against the registered persons on this matter. 2. Fire Safety Arrangements. Previous inspection reports have raised concerns about fire safety arrangements. At the visit on 20 January 2005 the owners were served with an ‘Immediate Requirement Notice’ for a failure to maintain the smoke alarms in working order. At the visit in June 2005 they were served with a further ‘Immediate Requirement Notice’ for failing to ensure that staff knew what action to take in response to a fire alert, and to maintain a record of drills. The issue of retrospective entries being made in the fire log was raised in the last report. A letter was received from one of the staff saying that she took ‘full responsibility’ for this matter. It must be stressed that the Commission holds the registered persons responsible for maintaining authentic records. At this recent visit on 10 November 2005 the part-time support worker on duty on the afternoon shift was asked about what actions he would take if there was a fire. The sequence of actions he described was to evacuate residents; close windows and doors; then re-enter the building to tackle the fire if safe to do so. Considerable prompting was needed before he made reference to the priority action of calling the emergency services. The person on duty for the evening and night shift was also asked about her actions if an alarm sounded. Her response was - to check the alarm unit to make sure that it was not a ‘low-battery’ problem; then to call the manager. Asked if her priorities would be different at night, the sequence she described was - to check the area where the alarm was activating; evacuate residents; then call the manager on her mobile phone. Again, it was only after prompting that she referred to the need to call the emergency services. Despite prompting, she did not mention the important step of closing the critical fire doors, which were wedged open. The part-time support worker on duty on his own from 12 noon to 6pm said he had started at the home two weeks earlier. He was asked to present a copy of the fire procedure. He could not find a copy, nor point out the version on display in the room. He said that he had received brief instructions on fire procedures, but said that he had not signed to confirm his understanding as he was not given a written induction programme as the ‘computer was down’ and a copy could not be printed. He said he had not taken part in a fire drill, nor knew if one was planned. The last entry in the ‘Weekly Alarm Tests’ for 4 DS0000027898.V270328.R01.S.doc Version 5.0 Page 8 November 2005 said – “AB’s bedroom – needs changing’. He said he did not know if this had been done, had not been shown how to check the smoke alarms, and could not find the supply of smoke alarm batteries or back-up spare unit. The part-time support worker responsible for the next shift said that she had taken part in a fire drill, but also could not find the record of recent fire drills. The inspectors were shown the ‘Fire Drill Log Book’ (Red Book), but staff believed that this was an older version no longer used, as the entries suggested. One of the service users was able to say where to find the spare smoke alarm batteries. Despite the assurances the owners provided in response to the ‘Immediate Requirement Notices’, and in their last action plan, the findings at this visit again demonstrate continuing shortfalls in fire safety arrangements. The Commission consider that the registered persons are failing to take adequate measures to protect the safety of residents. Consideration is being given to taking enforcement action on this matter. 3. Food. The last inspection report said the arrangements for meals showed a lack of coordination and a slapdash approach in this fundamental area of care. The meals provided to residents were not those listed on the menu. For instance, lunch on both subsequent days of the last visit was take-away chicken and chips. One resident who did not want this had to go and buy his own sandwiches. The arrangements found at this recent visit showed the same negligent approach to meal planning, along with failures of basic food hygiene standards. The menu said that lunch was to be ‘Chicken Pie, Mixed Veg and Mash’. The meal offered was sausage, beans and mashed potatoes. The staff member on duty said that fresh cauliflower and/or broccoli had also been prepared. There was no evidence that fresh vegetables had been provided. The plated meal for one resident had been left in the microwave from lunchtime through to the evening when an inspector pointed out that this was contrary to basic safe food practice. The evening meal listed on the menu was ‘Tuna Bake’. What was being prepared were sandwiches. Asked why the cooked meal was being substituted, the staff member said that one resident had been asked, and had said he wanted a sandwich. As at the previous visit, the staff member conceded that the foodstuffs available determined what food is served. When asked, the staff member on duty could not say what were the lunch and evening meals listed on the menu for the shift he had covered. This is further evidence that the menu on display is a misleading and false record. There is no record of the food residents are actually served. The staff member on duty acknowledged that some food items in the fridge were beyond use including cheese and vegetables, and agreed to throw them DS0000027898.V270328.R01.S.doc Version 5.0 Page 9 away. The owners were served with an ‘Immediate Requirement Notice’ for a failure to ensure basic food hygiene. This included the inside of the fridge being dirty, including a residue of food debris in the bottom container. The owners wrote back saying - “The fridge is always clean…Fresh food is bought and stored appropriately…All food items are well labelled.” This claim is not accepted as it contradicts the evidence found at the visit. The Commission believes the owners are failing to plan, monitor and maintain a record that demonstrates residents are being provided with wholesome and nutritious meals that are varied, properly prepared and stored in accordance with basic food safety requirements. Consideration is being given to taking enforcement action against the registered persons for failing to demonstrate that they are providing residents with adequate, varied and safe food. 4. Registered Manager. At the meeting with the Commission on 6 July 2005 Mr Kassouri said he was considering withdrawing as the manager responsible for supervising the dayto-day operation of the home. It was said that negotiations were taking place with a prospective manager. Nothing further was notified on this matter. At this visit, both staff referred to another person listed on the rota as being the manager. For instance, the staff member on duty said he needed to call the manager to ask for guidance on locating the records being requested, and to confirm who was providing ‘on-call back-up’. He called this alternative person. An inspector spoke to this person who said she was not the manager, adding that she was not ‘officially’ on-call, was not available to come to the home, and advised Mr Kassouri be contacted. The longer established staff member who arrived to cover the later shift also suggested that this other person had become the manager ‘about three months ago’. Documents seen also referred to this person as the manager. When contacted, Mr Kassouri said that he was still the manager, and staff in charge over the two shifts were wrong in referring to another person as such. That staff left in charge of the home are not aware of who is the manager is of major concern. This adds to the problem created by the registered manager, Mr Kassouri, not being at the home when he is claiming to be on duty, and shows confused lines of accountability. Staff left in charge of the home must be aware of who to contact in an emergency, and their availability to come to the home if necessary. The owners have been told that it is a legal duty to notify the Commission of any change in the manager arrangements. Further, at the meeting on 6 July 2005 it was confirmed that Mrs Beverley Kassouri has not covered shifts at the home for sometime, and should no longer be listed as the deputy as this infers an additional on-site supervisory presence. It was agreed that Mrs Kassouri should not therefore be included on the duty rota. However, she is still listed on current rota sheets, though consistently entered as being ‘off’. Only staff providing duty cover should be included on the rota. DS0000027898.V270328.R01.S.doc Version 5.0 Page 10 5. Staff Vetting Records. The registered persons are required to carry out vetting to make sure that staff are suitable to be in contact with vulnerable adults. The last report described how the owners had failed to make arrangements to present the necessary records to show that these checks had been carried out. They were served with an ‘Immediate Requirement Notice’ saying these records must be maintained and made available. The response they provided was not sufficient to fully confirm that they had obtained two written references, and new CRB enhanced certificates prior to staff starting. Staff files must also have documentation that verifies the person’s identity, and as appropriate confirms permission to work in the UK and any conditions that may be attached. During this recent visit Mr Kassouri was contacted, as staff on duty could not find many of the general records requested. Mr Kassouri said he was not in the locality, and therefore unable to easily get to the home. At a subsequent visit inspectors will want to see the staff files. If the manager is not on site, reasonable notice will be given to the registered persons to arrange access to the requested records. A failure to do so will result in the Commission taking enforcement action. Further, it was again found that duty staff only knew other staff by the ‘first name’ used on the rota. It is expected that the responsible person in charge can present details of each staff member’s full name, the position they hold, how long they have worked at the home, and their normal contracted hours. It is also expected that records are available showing the relevant qualifications and training undertaken by each person employed. What they could do better: Although service users spoken to did not appear very unhappy on the day of this inspection, the overall findings of this inspection report a level of compliance so far below legal requirements and national minimum standards, this undoubtedly has a real impact on their overall welfare. Inspection reports this year have set out an extensive range of problems, and describe how the registered persons are not maintaining this service in accordance with the regulations and national minimum standards. They have been served with six ‘Immediate Requirement Notices’ for failings in key areas of their responsibility. The way the home is being operated means that evidence is not readily available at inspection visits to substantiate the commitments the owners have made to address the problems. The Commission have written to the registered providers saying that enforcement action is being considered. Due to the circumstances described above, it is again necessary to carry forward all requirements notified in the last report. Given the extent that these DS0000027898.V270328.R01.S.doc Version 5.0 Page 11 items have needed to be re-notfied, shorter timescales have been set. In the requirements list at the end of this report, items 2 to 4 have been carried forward for the fourth time; items 4 and 5 have been notified in two previous reports. Items 6 to 31 are re-notifications. Further requirements have been added regarding food safety. Re-notification does not prejudice the Commission’s position on proceeding with enforcement action or seeking prosecution. Further visits will take place, including checking those standards not tested since April 2005. 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. DS0000027898.V270328.R01.S.doc Version 5.0 Page 12 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 DS0000027898.V270328.R01.S.doc Version 5.0 Page 13 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 This group of standards were not fully tested at this visit. EVIDENCE: The Statement of Purpose handed to an inspector contained misleading and sometimes wholly inaccurate information. For instance, it stated the home has planned and structured menus, which included service users choices and preferences and were nutritionally balanced- this was found not to be the case. The Statement of Purpose also made reference to service user satisfaction surveys, of which there was no evidence and that management review all quality systems. It also referred to a staff post, which no longer exists- an activities co-ordinator. The owners need to look at Standard 1.1 and 1.2 and ensure that this information is available. The requirement on this matter has been carried forward again. DS0000027898.V270328.R01.S.doc Version 5.0 Page 14 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 This group of standards were not fully tested at this visit. EVIDENCE: The requirement on Standard 6 has been carried forward again. Formally it has been stated that the manager acts as ‘key worker’ to all three service users. Subsequent checks will want to evaluate how this fits in with the time the registered manager is spending at the home. Checks will also be made on Standard 7 – how service users are assisted to make choices about their money. Although service users spoken to did not appear very unhappy on the day of this inspection, the overall findings of this inspection report a level of compliance so far below legal requirements and national minimum standards, this undoubtedly has a real impact on their overall welfare. DS0000027898.V270328.R01.S.doc Version 5.0 Page 15 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, 16,17 Not all of these standards are not covered in this report. EVIDENCE: The requirement on having evidence to show that residents are being supported to be involved in worthwhile activities is re-notified. That sufficient staff cover is being provided to allow activities to be included forms part of the expectations. The requirement on demonstrating that residents are being offered a say in meal planning also features in the list of requirements, along with the expectation that varied and wholesome food is provided. The owners have previously been asked to have a system for monitoring the quality of meals. Some foodstuffs in the fridge were going mouldy- such as carrots and some cheese- these were thrown away, although staff were reminded to do so twicean Immediate Requirement Notice was served on the home. DS0000027898.V270328.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These areas were not tested at this recent visit. EVIDENCE: DS0000027898.V270328.R01.S.doc Version 5.0 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 The requirements covering complaints and protection procedures are repeated, including ensuring that persons left in charge of he home can locate the required procedures and recording format. EVIDENCE: The complaints procedure was displayed and had the correct contact details of the Commission. However, it was not written in a particularly user-friendly language, it is recommended that it is re-written in a way that is easy for service users to understand. The procedure made reference to the Social Service Ombudsman, which is incorrect and must be amended. One service user said that if they had a complaint they would talk to the manager. However, as outlined in other areas of this report, there is some confusion about who the manager was. A member of staff when questioned was able to outline different areas that may constitute abuse and the roles of the statutory agencies who would need to be contacted regarding any concerns. DS0000027898.V270328.R01.S.doc Version 5.0 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 Over a number of years the owners have talked about upgrading the home as part of incorporating the next-door house. No firm proposal or business plan has been received. Residents continue to be provided with a poor standard of accommodation, such as - two of the bedrooms being very small; their lounge being used as the staff bedroom; the dining room doubling as the office; and an outside toilet. There are also major concerns about fire safety arrangements. The bathroom was unpleasant, with a strong odour, making for a poor environment for service users EVIDENCE: Earlier in this report the continuing poor standard of fire arrangements were described. The requirements on these matters have been carried forward. Insufficient evidence was found to show compliance with the two ‘Immediate Requirement Notices’ on fire safety served at the previous two visits. Further legal action is being considered on this matter. The bathroom smelt strongly of stale urine; a towel rail was held together with tape, and there was a heavy layer of dust. DS0000027898.V270328.R01.S.doc Version 5.0 Page 19 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): 31-36 inclusive It is of major concern to the Commission that staff are unsure of who is the manager, particularly as no change of the registration has been notified. This can put service users at risk, as staff are not clear about reporting responsibilities. There is risk where a staff group do not have any real leadership. That the details on display showing the registered manager’s duty times were again found to be false is a matter now being considered as grounds for further legal action. This is also the case regarding access to records on staff. EVIDENCE: Staff were unclear as to the management arrangements in the home- the registered owner stated he was still the manager, whereas staff were under the impression that another staff member was to take over as the manager. This had clearly been relayed to service users, as the house meeting minutes for 23.9.05 record that this person was taking over as manager. Staff were also unclear as to the whereabouts of some records. The registered person must ensure staff are competent to do their jobs. Please refer to Requirements 19 to 25 listed at the end of this report. DS0000027898.V270328.R01.S.doc Version 5.0 Page 20 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): 37-43 inclusive The home is poorly managed, with multiple and repeated failings, putting service users at risk. A major reason why this service is failing is because the registered manager is not spending time at the home overseeing day-to-day arrangements. EVIDENCE: As outline in this report, there was evidence of inaccurate and misleading records- this is unacceptable, as the registered persons are required to have integrity. The rota showing a manager presence is misleading, both in how it purports to show more than one person being on duty during the day, and suggests that staff are being supervised. The overriding theme of recent inspections is the registered persons’ failure to show that they are operating this home to a safe and satisfactory standard – including how they have responded to matters re- DS0000027898.V270328.R01.S.doc Version 5.0 Page 21 notified in reports, and those instructed through ‘Immediate Requirement Notices’ – to which failures in basic food safety have now been added. There was a current Pubic Liability Insurance Certificate displayed. Many of the records requested on this inspection could not be found by staff on duty. All statutory records must be available for inspection at all times. DS0000027898.V270328.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 X X X x Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X x LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score 1 1 1 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x Standard No 37 38 39 40 41 42 43 Score 1 1 1 1 1 1 1 DS0000027898.V270328.R01.S.doc Version 5.0 Page 23 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 2 Standard YA1 YA40 Regulation 4 12(1) 17. Requirement Timescale for action 21/12/05 3 YA43 23(4) 4 YA23 13(6) The Statement of Purpose must contain accurate information Review the policies and 21/12/05 procedures, making sure these are relevant to the service provided in this setting. Increase the frequency 21/12/05 of tests of the fire alarms to each week, and keep a record of these checks. Entries in the fire log must be made following each test. (This must say what action has been taken to correct faults.) Have in place 21/12/05 documentation and systems that give clear guidance on the procedures to be followed regarding alleged or suspected abuse, including the Barking and Dagenham local guidelines on abuse procedures, and DS0000027898.V270328.R01.S.doc Version 5.0 Page 24 5 YA22 22 guidelines to follow on responding to an allegation of abuse that are specific to this home. The complaints procedure making reference to the Social Service Ombudsman, must be amended. The registered persons must take adequate precautions against the risk of fire, including arrangements for detecting and giving warnings of fire, ensuring the maintenance of all equipment, including smoke detectors, and taking action where faults are found. This must involve staff on duty knowing how to replace batteries, and having a supply of backup batteries on site. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (20 January 2005) Have available at all times a duty rota that is a true record of staff cover, including any variations to the planned cover. This must include the manager’s hours on duty, and details of duties being undertaken off-site. An ‘Immediate 21/12/05 6 YA24 23(4) 21/12/05 7 YA33 17(2)/Sched2,para 7 21/12/05 DS0000027898.V270328.R01.S.doc Version 5.0 Page 25 8 YA1 4/Sched 1 9 YA6 15 10 YA12 16(m),(n) 11 YA16 12(2) 12 YA17 16(2)(i) requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (15 June 2005) Have available an up-todate statement of purpose. This needs to include an accurate description of the staff cover provided, including - the number, designation and contracted time of each post - including the manager hours and other supervising positions such as deputy and team-leader. Have available an up-todate service user plan. This needs to include who will take a lead on supporting the service user with identified needs, such as having an allocated keyworker. Consult with service users, and arrange a suitable programme of educational, leisure and social activities. Provide sufficient staff cover to enable these activities to take place. Maintain a record of such activities. Consult with service users regarding the daily routines and arrangements in the home, such as offering a reasonable choice and variety of meals. Provide suitably wholesome, nutritious and varied meals. An DS0000027898.V270328.R01.S.doc 21/12/05 21/12/05 21/12/05 21/12/05 21/12/05 Version 5.0 Page 26 13 YA17 14 YA17 15 YA22 16 YA23 17 YA23 ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. 17(2)/Sched4,para13 Maintain a record of the food provided in sufficient detail to enable an inspector to determine whether the diet is satisfactory. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (15 June 2005) 24 Operate a system for reviewing standards of service, including monitoring the quality of meals, and how planning menus involves consulting with service users. Maintain a record of these checks. 22; 17(2)/ Have available a record Sch 4. of complaints, and guidelines for staff to follow where a complaint or concern is made. Ensure that the responsible in charge is aware of these procedures, and can locate the complaints record. 18(4) Ensure that all staff are aware of the action to take if they become aware of, or suspect abuse - including their duties in line with the whistle blowing policy, and in line with the GSCCs code of practice. 18(4) Ensure that all staff are DS0000027898.V270328.R01.S.doc 21/12/05 21/12/05 21/12/05 21/12/05 21/12/05 Page 27 Version 5.0 18 YA42YA23 23(4)(d) 19 YA42 23(4)(e);17(2)/ Sch4 20 YA42YA24 23(4)(c) (i) 21 YA31 8(1)(b)(i) 22 YA33YA32 18(1) issued with a copy of the GSCCs code of practice. Make adequate arrangement for all staff to receive training in fire safety and response, including making calling the fire brigade a priority task. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (15 June 2005) Carry out at suitable intervals fire drills, and have available a record of these drills, saying which staff were involved, and the action taken where problems were found evacuating the building. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (15 June 2005) Make adequate arrangements for containing fire, including making all staff aware of the need to close critical fire doors, such as those protecting the staircase. Ensure that there is a full-time manager in day-to-day charge of the home. Ensure that staff have the necessary skills and experience for the tasks they perform, including the needs of adults with 21/12/05 21/12/05 21/12/05 21/12/05 21/12/05 DS0000027898.V270328.R01.S.doc Version 5.0 Page 28 a learning disability. 23 YA34 19 Carry out the required assessment of competency and range of checks on staff prior to them commencing work at the home. Have available all the required information on staff that demonstrates a responsible management approach to the selection and vetting of staff, in accordance with Reg 19, and as set out in Schedules 2 and 4. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. (15 June 2005) Ensure that all staff receive induction and training in core areas, including the safe handling of medication, food hygiene; first aid; fire safety; and general health and safety issues. Ensure that the staff team has the required skill mix, including achieving the advised qualification quota. Ensure that all staff are appropriately supervised, and maintain a record that demonstrates that individual supervision is occurring at least six times in a year. Have available documentation that demonstrates that the 21/12/05 24 YA34 19/Sch2; 17(2)/ Sch4. 21/12/05 25 YA35 18(1)(i) 21/12/05 26 YA35 18(1) 21/12/05 27 YA36 18(2) 21/12/05 28 YA37 10(3) 21/12/05 DS0000027898.V270328.R01.S.doc Version 5.0 Page 29 29 30 YA38 YA38 7(3) 12(4)(a) 31 YA39 24 32 YA39 24 33 YA41 17 manager is undertaking appropriate training, including working towards achieving the required qualification. The registered person must have integrity and demonstrate this Operate the home in a manner that is open and accountable. This must involve staff being aware when the manager will be on duty in accordance with the details set out on the duty rota. At least once a year carry out a review of the service, including consulting with service users and their representatives. Provide the Commission with a copy of the service improvement plan. It is recommended that this include the plans to expand and upgrade the home, and projected timescales when these improvements will be introduced. Reference should also be made to the arrangements for the service users during the period of any building activity affecting their living arrangements. Have available for inspection the required documentation. It is expected that the responsible person in charge of the home is aware of, and can locate DS0000027898.V270328.R01.S.doc 21/12/05 21/12/05 21/12/05 21/12/05 21/12/05 Version 5.0 Page 30 34 YA42 23(2) 35 YA42 13(4)(c) essential documents such as the fire log, accident book, complaints details, health and safety certificates, and the full names of staff working at the home. Have in place a system for responding to defects, such as reporting when the phone has broken, and providing a tv that works. Have in place procedures and monitoring to make sure food is handled, prepared and stored in a safe manner. This must include that staff receive instruction on basic food hygiene practice. There must be a system for safe storage – such as the condition of the fridge – and ensuring stock is discarded when past its advised ‘use-by’ date. An ‘Immediate Requirement Notice‘ was served on this matter on 10 November 2005. 21/12/05 21/12/05 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 DS0000027898.V270328.R01.S.doc Version 5.0 Page 31 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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