Inspection on 27/09/07 for Gate House

This inspection was carried out on 27th September 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gate House 09/09/08

Gate House 09/02/07

Gate House 15/06/06

Gate House 05/12/05

Gate House 19/07/05

Gate House 04/11/04

Gate House 16/06/04

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

CARE HOME ADULTS 18-65 Gate House 238 New Cross Road London SE14 5PL Lead Inspector Ornella Cavuoto Unannounced Inspection 27 September & 4 October 2007 10:00 th th DS0000025620.V343458.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 DS0000025620.V343458.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. DS0000025620.V343458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gate House Address 238 New Cross Road London SE14 5PL 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) 0207 6356883 Mr Lynval Palmer Mrs Marjorie Palmer Ms Hazel May Parkinson Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) DS0000025620.V343458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 27th June 2006, one service user over the age of 65 years, with a mental disorder, can be accommodated. 9th February 2007 Date of last inspection Brief Description of the Service: Gate House is a care home providing support and accommodation for up to nine men and women who have support needs due to mental ill health and who are aged between 18 and 65 years of age. Accommodation is provided in 5 single and 2 double rooms although one service user has moved into a single room from a shared room since the last inspection. Service users admitted to the service have to be relatively physically able as access to the upper floor is via a staircase. The home is privately owned and located in a residential area of New Cross Road in South East London with good access to London Underground and mainline rail stations at New Cross Gate. There are also a number of bus routes stopping close to the home. Service users also have access to a wide range of local amenities and community resources. The home makes information available about the service they provide to potential service users on request by phone or letter. Also CSCI inspection reports are made available on request. The home’s monthly fees are £650.00 as from January 2007 and no additional charges are made. This information was provided to CSCI February 2007. DS0000025620.V343458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present for part of the inspection but had to leave whilst the inspection was still being conducted and feedback had to be given at a later date over the telephone. The inspection also involved speaking to three service users with whom case tracking methods were used. Two of the support staff were also spoken to. Other inspection methods included a tour of the premises and inspection of care records. Although some improvements were identified at this inspection in that nine of the previous requirements had been met, there are some areas where requirements have been repeated for the past three inspections that have taken place. The home needs to take action to address these requirements as continued failure to comply will result in enforcement action being taken. Seven new requirements were identified as a result of this inspection. What the service does well: What has improved since the last inspection? The home’s statement of purpose and service user guide has been updated providing current and prospective service users with the information they need about the home. DS0000025620.V343458.R01.S.doc Version 5.2 Page 6 Risk assessments have been reviewed regularly although further improvements in respect to risk assessments are still required. The home had updated its medication policy although some further improvements were still needed. Improvements had been made in the way complaints are logged. The home had taken measures to replace items of service users’ bedroom furniture. Improvements had been made to the way new staff are inducted and the home had continued to ensure staff receive training in required mandatory topics and to do specific training courses to meet individual and collective needs of service users. What they could do better: 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. DS0000025620.V343458.R01.S.doc Version 5.2 Page 7 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 DS0000025620.V343458.R01.S.doc Version 5.2 Page 8 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&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and current service users do have access to the information they need about the home. Service users moving into the home have their needs and aspirations assessed. Terms and conditions had been issued to service users EVIDENCE: Subject to a previous requirement both the home’s statement of purpose and service user guide had been updated since the last inspection and these were found to meet with regulation and the National Minimum Standards (NMS). The home has had one new admission since the last inspection. The personal file of the service user was inspected and there was evidence that relevant reports including the last Care Programme Approach (CPA) review had been obtained to ensure that the home could fully assess whether they would be able to meet their needs. At the last inspection it was identified that all service users had been issued with a statement of terms and conditions but only one had been signed by the service user to indicate they had read and understood the document. At this inspection four personal files were inspected and it was found all included a statement of terms and conditions that had been signed although one did not DS0000025620.V343458.R01.S.doc Version 5.2 Page 9 specify the fees to be paid. This was addressed and the fees were written in but the documents did not specify by whom the fees were payable and room numbers had not been included which has been raised at a previous inspection. In addition, evidence needs to be provided that a copy of the document has been issued to all service users living in the home (See Requirements). DS0000025620.V343458.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&9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were generally comprehensive with changing needs and personal goals being reflected but not all service users had an up to date care plan in place. There was evidence that service users have been supported to make their own decisions. Risk assessments still did not clearly address all risks presented by service users in particular how risks associated with their mental health problems were being managed EVIDENCE: At the last inspection four personal files were inspected and all had completed care plans in place apart from one service user who had moved in a month previously. It was reported by the registered manager that this service user was still undergoing a trial period and assessment. The other care plans were identified as covering all areas required within National Minimum Standards (NMS) to ensure the needs of service users were addressed. They had also been signed by service users and all had been reviewed on a six monthly basis with evaluations written up against each identified need that clearly outlined DS0000025620.V343458.R01.S.doc Version 5.2 Page 11 whether there had been progress or the needs of the individual service users had changed. Progress reports had also been written up by key workers. At this inspection the personal files of four service users were inspected. Of these two had care plans in place. Overall, these had addressed all required needs. Also, as identified at the last inspection care plans had been reviewed six monthly and were signed by service users. Service users spoken to that were case tracked were aware of their care plans. In respect to the other two service users who did not have care plans in place, one had only moved in approximately six weeks prior to the inspection. Again, it was reported by the registered manager that because the service user had only recently been admitted they were still on a trial period and undergoing assessment. However, the other service user had been living at the home for nine months and although there was some evidence of notes of meetings held with the service user to discuss their support needs there was no evidence available that this information had been drawn up into a working care plan that had been signed and therefore agreed with the service user. This is unacceptable. A very detailed care plan covering all the service user’s needs was sent to CSCI following the inspection the date of which indicated this had been drawn up six months after the service user’s admission. Yet, this was not on the service user’s file and had not been made available on the day of the inspection. It was also recorded in a different format from the other care plans. The home needs to ensure all service users have a care plan drawn up with them as soon as possible after their admission to the home. This information also should be kept within service users’ personal files (See Requirements). Service users spoken to confirmed that they are supported by staff to make their own decisions and they are able to manage their own finances. Previous inspections have identified that risk assessments had not addressed all risk taking behaviours with service users, for example for one service user that works locally on a casual basis and is potentially at risk of being exploited this had not been explored within a risk assessment or their care plan although it was noted that it had been discussed in Care Programme Approach (CPA) reviews. In addition, it has been previously identified that although service users had risk assessments completed as part of the CPA process that highlighted risks such as self – harming or violent and aggressive behaviour, a risk management plan for dealing with these risks had not been completed by the home either in service users’ individual care plans or within a separate document. At this inspection it was identified that the risk assessment used by the home had been slightly modified to include challenging behaviour as well addressing the risks presented by service users when using household equipment such as the kettle, the cooker amongst others and also in going out in the wider community. However, apart from the care plan sent to CSCI following the inspection that had addressed individual risks presented by the service user overall there was still limited evidence that this area had been adequately addressed, for example one risk assessment had specified that one of the service users could become aggressive in relation to using alcohol but no DS0000025620.V343458.R01.S.doc Version 5.2 Page 12 measures to control or reduce this risk was specified. The requirement in this area has now been outstanding for three inspections. Continued noncompliance will lead to enforcement action being taken. Subject to a previous requirement that risk assessments should be regularly reviewed this had been addressed (See Requirements). DS0000025620.V343458.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have been supported to become involved in meaningful and valued activities providing them with opportunities for personal development. Service users have been involved in the local community and have also been supported to maintain family links and personal relationships. Daily routines of the home do promote independence. Overall service users have been provided with meals that are healthy and nutritious. EVIDENCE: There was evidence that service users had been supported to take part in fulfilling activities that are aimed at assisting their personal development, for example one service user who had previously completed a food hygiene course and had obtained a recognised certificate but which had expired had signed up at a local centre where they support individuals to do food hygiene, work experience, basic IT and other activities to redo the certificate. The long term aim of the service user was to be able to secure employment doing kitchen DS0000025620.V343458.R01.S.doc Version 5.2 Page 14 work. Some of the other service users had also attended the centre to partake in activities as well as attending day centres locally where they are engaged in a range of social and educational activities. Furthermore, one service user does some casual work locally, which the home has supported them to do. Service users spoken to confirmed they do make use of the local community using local shops, library, leisure centres and have also attended church. All the service users have freedom passes to allow them to make use of transport facilities. Where appropriate service users have been supported to maintain family links and regularly visit family members. Service users spoken to confirmed this. In respect to personal relationships, two of the service users have partners. One of the service users often spends weekends at the home of their partner whilst the partner of the other service user regularly visits them at the home. The routines of the home do promote independence, choice and freedom of movement. During the inspection service users were observed coming and going from the home as they pleased. Service users have keys to their rooms and they are expected to undertake household chores as a means of preparing them for independent living. Two of the service users are supported to cook for themselves, which was confirmed by one of the service users spoken to. However, at previous inspections it was identified that service users understood there was a curfew in place in which they were expected to return to the home by 10pm if they went out although this had not been specified within the home’s service user guide or the statement of terms and conditions. The registered manager clarified that the home did not have a curfew but that service users needed to inform staff if they were going to return later than 10pm as the front door is locked for security reasons. At this inspection it was identified the service user guide, which had been updated, had clearly addressed the home’s policy if service users went out and that there were no restrictions in place in respect to the time they had to return. Yet, on discussing this with service users they were not all clear about this issue in that apart from one they still understood there was a curfew time they were required to adhere to. Although the previous requirement in respect to this issue is deemed met it is recommended that this be addressed further with service users to ensure they are all clear about the home’s policy and what is expected of them if they intend to stay out late (See Recommendations). In respect to meals feedback from service users varied with individual service users expressing they did not like the food and also were not always happy with the quality of the food. One service user said ‘ Sometimes the food is alright and sometimes its not’. The menu was checked and this did indicate that meals provided were sufficiently varied, healthy and nutritious. The registered manager and support staff spoken to stated service users were consulted about the menu. A list was seen in the kitchen of those foods disliked by service users. There was also evidence from the house meetings DS0000025620.V343458.R01.S.doc Version 5.2 Page 15 that the menu had been discussed and suggestions from service users had been encouraged which had been included in the menu. One service user stated how they had asked for one particular meal to be removed from the menu and this had been acted upon. In respect to the quality of the food the evening meal was observed and was well presented and was balanced and healthy. The budget for food was discussed with the registered manager and this appeared to be adequate. It was also reported that various snacks including crisps, biscuits and fruit are also left out in the dining room in the evenings, which was confirmed by service users. Overall, it was evident that service users have been given opportunities to discuss the menu and their views on the meals that were provided have been taken into consideration. Consequently this standard is deemed met. However, it is recommended that the menu continues to be regularly discussed as part of house meetings so there is evidence of any changes requested by service users and that the home is continuing to try to meet individual tastes and needs as much as possible (See Recommendations). DS0000025620.V343458.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support received by service users is flexible and appropriate to their needs. Service users’ physical and emotional health needs have been met. The home’s medication policy and procedures have been updated although procedures in respect to how service users are supported with selfadministration still need to be addressed more comprehensively. EVIDENCE: Overall service users living at the home are independent and manage their own personal care although some do require prompting and monitoring that they are attending to their personal hygiene and this had been addressed in individual service users’ care plans. The home operates a key worker system to ensure consistency of support is provided. Service users spoken to were aware of who their key workers were and also confirmed they did meet with them to discuss their progress and other matters regarding their well- being and support needs. There was evidence within service users’ personal files and care plans that service users’ physical health and mental health needs have been met. Each DS0000025620.V343458.R01.S.doc Version 5.2 Page 17 service user had a health monitoring form in place that indicated that appointments had been arranged where appropriate to see the dentist, opticians, chiropodist and other health professionals depending on their individual needs. Service users have their weight monitored annually unless a need is identified for this to be carried out more regularly. In respect to service users’ mental health, there was evidence that their needs are regularly reviewed under the Care Programme Approach (CPA) although as identified at previous inspections up to date minutes of the reviews were not always available and it is recommended that the home follow this up with the mental health teams to ensure a copy of the reviews are sent to the home. Crisis plans were also in place that outlined relapse indicators for each individual service user and action to take if this occurred including contact details of the professionals involved in their care (See Recommendations). In respect to medication following the last key inspection held at the home a referral to the pharmacist inspector was made to do a general inspection of the home’s medication but also to look at the home’s system for carrying out spot checks with those service users who were being supported to self –administer. The pharmacist’s inspection identified that on the whole medication was managed well by the home including how the home was checking residents taking responsibility for their own medication. However, it did identify that in respect to current and prospective residents that self- administer that a more formal risk assessment should be completed. An example of a risk assessment form was sent to the home by the pharmacist inspector. Also, there needed to be more information within the home’s medication policy on supporting residents to manage their medication. At this inspection there was evidence that the risk assessment form had been completed with service users. In addition, a self- administration monitoring form that aims to check how service users are managing was also seen to be in place. In respect to the home’s medication policy, a previous requirement that this should be updated as it was identified that it was lacking in addressing some areas in relation to the handling of medication had been met and generally it was robust although self –administration had not been covered within the policy. Shortly, following the inspection, a revised copy of the medication policy that included some information about self -administration was sent to CSCI. However, this had still not adequately covered how service users would be supported in this area. Specifically, the policy had not addressed that all service users will have a risk assessment completed with them prior to allowing them to take their own medication, the different levels/ stages of support to be given to service users to enable them to progress towards self administration including as some service users are currently doing coming to the office unprompted to collect their medication daily, the checks that need to be carried out in the initial stages to ensure compliance and how often reviews (i.e.) the self administration monitoring form will be completed to check whether residents are managing and finally those situations when self administration may need to be stopped. There was evidence that staff had completed training in medication and in respect to the three staff that had been recruited since the DS0000025620.V343458.R01.S.doc Version 5.2 Page 18 last inspection there was evidence for one that they have previously undertaken a course in safe handling of medication whilst for the other two staff measures had been taken to book them on training. Both staff members confirmed this. A sample of medication records was checked and these were found to be accurate. However, it was noted that the individual homely remedies lists signed by the GP had not been reviewed for two service users one since January 2006 and the other April 2006. It is advised that these are re-evaluated (See Requirements & Recommendations). DS0000025620.V343458.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints policy and complaints had been logged. Measures have been taken to ensure service users are protected from abuse. EVIDENCE: The home’s complaint policy includes the stages of and timescales of the process. A copy of the complaints policy had been placed in the entrance hall of the home visible to service users, their relatives and representatives. At the last inspection it was identified that the home had not maintained a log of complaints and minor complaints had not been recorded. At this inspection the complaints log was checked and one complaint had been recorded from a service user whose room had been affected by a leak from the shower situated above their room upstairs. There had been no formal complaints made in respect to the home. The home has an appropriate adult protection policy in place that addresses the different types of abuse and procedures to follow if abuse is suspected and identified. There was evidence that the two permanent full time support staff had completed adult protection training. Since the last inspection the home had recruited three part time support staff. There was evidence that one of the staff members who had a National Vocational Qualification (NVQ) Level 2 had completed a module in adult protection as part of the course whilst the other two staff had been booked on adult protection courses to be held within the next two months. Both staff members who were spoken to also confirmed this. DS0000025620.V343458.R01.S.doc Version 5.2 Page 20 There have been no adult protection investigations undertaken in relation to the home since the last inspection. In respect to service users’ finances, one service user’s money was subject to Court of Protection with a relative taking responsibility for this whilst an application for Court of Protection was to be processed for another service user. Service users where appropriate have been encouraged to take responsibility for their own money. Where service users were being supported with managing their personal allowance records had been maintained that were seen and these had been accurately maintained. DS0000025620.V343458.R01.S.doc Version 5.2 Page 21 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, 25,26, 27 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely and well - maintained inside although some improvements are required outside at the front of the home. Service users’ bedrooms suit their needs and lifestyles and are comfortable with suitable furniture and fittings. The home has sufficient toilets and bathrooms. The home was clean and hygienic. EVIDENCE: A tour of the premises was undertaken. The home was comfortable with furnishings that were domestic in nature and overall it was found to be suitable for its stated purpose. A previous requirement that the home should address the issues of the radiators not being guarded or having low surface temperatures had been addressed within the home’s fire risk assessment. This specified a fire safety officer had checked the radiators and that it had been assessed that radiators covers were not necessary. Internally the home was generally well maintained. However, outside at the front of the home the pathway leading up to the home was cracked and broken with loose paving DS0000025620.V343458.R01.S.doc Version 5.2 Page 22 potentially posing a health and safety risk and therefore needs to be repaired (See Requirements). The home has two double rooms that were both being shared up till recently. At the last inspection although the home had as previously required included their policy on the sharing of rooms in the statement of terms and conditions, it was identified that despite a single room becoming available the service users that were sharing had not being given the option of moving into the vacant room and one of the service users spoken to stated they would like to move into their own room. This was discussed with the owner of the home and the registered manager who both stated they would support this. At this inspection, it was identified that the service user had moved into the room and was happy with this new arrangement. One of the service users who still shares a room confirmed they were happy to do so but would prefer not to continue to share if the other service user left the home. The home must ensure that the policy regarding sharing that this is not arranged unless both individuals make a positive decision to do so is implemented if this situation arises. Subject to a previous requirement that all broken items of furniture in service users’ rooms should be replaced was identified as having been addressed at this inspection. The majority of service users’ rooms were inspected and all had new wardrobes and bedside cabinets. Rooms seen were also suitably personalised. The home has sufficient bathrooms and toilets to meet the needs of the service users. The shower upstairs, which had a problem with leaking water affecting the bedroom below on the ground floor, was in the process of being repaired and refurbished when the inspection was being held. It was reported that this had not inconvenienced service users, as there is a shower/ bathroom on the ground floor. A previous recommendation that grab rails should be placed in the bathroom downstairs to assist where needed those service users to get in and out of the bath had been addressed. The home was clean and hygienic on the day the inspection was held with laundry facilities sited away from the preparation of food in a room upstairs. DS0000025620.V343458.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff working at the home have been supported to achieve a relevant qualification to ensure they are at a competent level to work with service users. Not all appropriate checks have been obtained for all staff working at the home. A training plan had still to be completed but the home had arranged for staff to complete training in mandatory topics and in other relevant areas. EVIDENCE: There was evidence that staff have been supported to achieve relevant qualifications with one of the two full time support workers having completed a National Vocational Qualification (NVQ) Level 3 whilst the other was in the process of doing a NVQ Level 3. Of the three part time support workers recruited since the last inspection there was evidence that one had completed a NVQ Level 2. The home also has two bank workers that regularly work at the home but their qualifications were not checked at this inspection. Yet, even including these staff the home had met the required target specified within the National Minimum Standards (NMS) that 50 of staff should be qualified. DS0000025620.V343458.R01.S.doc Version 5.2 Page 24 In respect to recruitment, the staff files of the three support staff employed by the home since the last inspection were checked and also the staff file of one of the bank workers. It was identified that the files of those recruited in recent months all included an Enhanced Criminal Record Bureau (ERCB) check but it was noted the ERCB for the bank worker who has worked at the home for some years was from a previous employer and there was no evidence that a POVA check had been done that lists those individuals identified as being unsuitable to work with vulnerable adults. The registered manager reported an ERCB had been obtained by the home but could not produce this for inspection. A copy of this must be sent to CSCI. There were the required two references in place for all staff and those staff more recently recruited had been interviewed of which evidence was sent to CSCI following the inspection and the forms used also indicated that both the registered manager and the owner had interviewed staff. However, it was identified from the application forms that gaps in employment for two staff had not been addressed. Also, an up to date photograph was not in place for two support staff (See Requirements). There was evidence that support staff had completed training in mandatory topics including a general health and safety course infection control, first aid, manual handling. Also, support staff including those more recently recruited had been booked to complete mandatory training in areas where it had been identified it was required, for example to do food hygiene. Staff had also completed or had been booked to undertake courses in areas specific to the needs of the service users ensuring their individual and collective needs are met. These included induction in mental health and mental health awareness, counselling skills, Care Programme Approach (CPA) and care planning, risk assessment/safety at work. Those staff recruited since the last inspection had received a basic induction and it was evident from records they had been issued with the Skills for Care induction booklet but none had completed this. In addition, a previous requirement that a detailed training plan had to be drawn up that outlines individual and collective training needs of staff was not available for inspection although an individual training form that outlined identified training needs and courses that had subsequently been booked for one staff member was sent to CSCI following the inspection. However, this information needs to be put in place and made available to be inspected for all staff working at the home The requirement in this area has now been outstanding for three inspections. Continued non- compliance will lead to enforcement action being taken (See Requirements). Subject to a previous requirement that staff should have an annual appraisal, there was some evidence that this process had been started with appraisal forms having been issued to the two full time permanent support workers for them to initially complete. The other support workers who had been recruited in recent months would not require an appraisal. In respect to supervision, records indicated that although support staff had received some supervision DS0000025620.V343458.R01.S.doc Version 5.2 Page 25 this was not sufficient to ensure all staff would receive a minimum of six sessions annually as specified within the NMS (See Requirements). DS0000025620.V343458.R01.S.doc Version 5.2 Page 26 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced and holds appropriate qualifications to ensure that service users benefit from a home that overall is well run. There still needs to be improvements in the way the home addresses quality assurance so that effective self- monitoring takes place. The health, safety and welfare of service users have not been always been fully promoted and protected. EVIDENCE: The registered manager is very experienced having worked for nearly thirty years within the mental health field. She has held various different posts within hospital settings and has previously managed three care homes. She has also completed the NVQ Level 4 in management. It was evident from the inspection that overall the home is well run. However, the home does not have a computer and it is advised to support the registered manager and support staff DS0000025620.V343458.R01.S.doc Version 5.2 Page 27 to complete administrative tasks more efficiently that consideration is strongly given by the registered provider to purchase a computer for the home (See Recommendations). In respect to quality assurance there was evidence at the last inspection that service users had been issued with customer satisfaction surveys for this year. However, subject to a previous requirement there was still no evidence available that the views of relatives or professionals involved in the home had been sought. A copy of a survey that indicated it was for completion by relatives as well as service users was sent to CSCI following the inspection although the questions were focused more towards residents and it is advised separate surveys are drawn up for relatives and professionals to complete. Also, subject to a previous requirement a report detailing the results of surveys completed by service users could not be identified and there was no evidence available that an annual development plan had been drawn up. This should be based on the results of the surveys and should reflect aims and outcomes for service users. Requirements in this area have now been outstanding for three inspections. Continued non- compliance will lead to enforcement action being taken. In addition, a previous requirement that monthly provider visits should be carried out and copies of the reports sent to CSCI had not been addressed. However, evidence of a completed self audit document that covered areas specified by the National Minimum Standards (NMS) was sent to CSCI following the inspection to be reviewed annually (See Requirements). A previous requirement that the home must ensure an up to date fire risk assessment is completed, was addressed. The fire risk assessment, which was comprehensive, had been reviewed. There was evidence that fire alarm call points had been tested weekly and fire equipment had been maintained. The LFPEA had carried out an inspection of the premises in June 2007 and found all to be satisfactory with regards to fire safety. An up to date gas safety record was in place although subject to a previous requirement an up to date electrical wiring certificate could not be identified neither could a legionella certificate. Also, there was no evidence that water temperatures had been recorded to prevent scalding. This needs to be completed or if it is considered that service users are not at risk of scalding as they are able to test water temperatures themselves this needs to be addressed in a risk assessment. Finally, it was noted that there had been an incident where a service user had fallen in their room and was taken to hospital for a check up. This should have been reported to CSCI under regulation 37 and attention to this is required (See Requirements). DS0000025620.V343458.R01.S.doc Version 5.2 Page 28 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 HOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X DS0000025620.V343458.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1) (c) Requirement Timescale for action 29/02/08 2. YA5 5(1) (b) 3 YA6 15(1)&(2) 4. YA9 13 4(c) The registered manager must ensure that all service users read and sign the statement of terms and conditions to indicate their understanding and agreement with its content and are issued a copy as well as one being retained on their personal files. (Previous timescale of 31/07/07 partially met) The registered manager must 29/02/08 ensure that the statement of terms and conditions clearly specifies by whom fees are payable and also the room number occupied by service users to make them fully aware of their individual rights. The registered manager must 31/03/08 ensure that a care plan is drawn up with service users detailing their personal and social support and health care needs as soon as possible after their admission and this reviewed six monthly to ensure all their individual needs are fully met and this is monitored for changes in need. The registered manager must 31/03/08 ensure that where risks have DS0000025620.V343458.R01.S.doc Version 5.2 Page 30 5. YA20 13(2) 6. YA24 23(2)(b) 7. YA34 19(1)& Sched 2 8. YA35 18 (1) (c) been identified a plan to manage the risks is in place. (Previous timescales of 31/03/06 & 01/01/07 not met. Timescale of 31/05/07 partially met) Continued non compliance with this requirement will lead to enforcement action being taken The registered manager must ensure that the home’s medication policy addresses in more detail the home’s procedures in respect to self administration specifically those points that are included within the report so that service users health, welfare and safety is maintained. The registered provider must ensure that the paving at the front of the home is redone repairing any loose paving maintaining the home in a good state of repair for service users. The registered manager must ensure that staff are not permitted to work in the home unless all the necessary checks and information required by regulation have been obtained; specifically that a full Enhanced Criminal Record Bureau check has been obtained, employment gaps are addressed. Also, for all staff an up to date photograph is placed on staff records. This is to ensure service users are protected. The registered provider must ensure that the home has a training plan to ensure that a proactive is adopted towards training and that it is based on the assessed needs of staff and service users. (Previous timescale of DS0000025620.V343458.R01.S.doc 31/03/08 31/05/08 30/11/07 31/03/08 Version 5.2 Page 31 9. YA36 18 (2) 10. YA36 18(2) 11. YA39 24 12. YA39 24(1b) 13. YA39 26 30/04/06 01/01/07 not met. Timescale of 31/07/07 partially met) Continued non compliance with this requirement will lead to enforcement action being taken The registered manager must ensure that all staff working at the home have an annual appraisal carried out with them. (Previous timescale of 31/03/07 not met. Timescale of 31/07/07 partially met) The registered manager must ensure that all staff receives at least six supervision sessions annually. The registered provider must ensure that results of quality assurance surveys are summarised and made available to service users and other interested parties including CSCI. (Previous timescales of 31/01/06, 01/01/07 & 31/07/07 not met) Continued non- compliance with this requirement will lead to enforcement action being taken The registered provider must produce an annual development plan, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users (Previous timescales of 31/01/06, 01/01/07 & 31/07/07 not met). Continued non- compliance with this requirement will lead to enforcement action being taken The registered provider must ensure that copies of monthly provider reports are sent to DS0000025620.V343458.R01.S.doc 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 Version 5.2 Page 32 14. YA42 23 (2) (c)& (4) 15. YA42 37 CSCI. (Previous timescale of 31/07/07 not met) The registered manager must ensure that: -Regular checks of water temperatures are carried out to prevent risks of scalding or it is addressed in a risk assessment that this is not required for service users living at the home. -There is evidence of checks for Legionella being carried out. - An up to date certificate is in place for electrical wiring. This is an updated requirement. (Previous timescale of 31/05/07 not met) The registered manager must ensure that CSCI and are relevant professionals are notified of incidents as specified within regulation 37 31/03/08 31/03/08 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. Refer to Standard YA16 YA17 Good Practice Recommendations The registered manager should try to ensure all service users are clear about the home’s policy on service users staying out late. The registered manager should try to ensure that the menu continues to be regularly discussed as part of house meetings as a means of getting service users’ feedback on meals and to try to ensure individual tastes and preferences are met. The registered manager should try to ensure that minutes of Care Programme Approach (CPA) Review meetings are obtained. The registered manager should try to ensure that individual service users’ homely remedy lists are reviewed DS0000025620.V343458.R01.S.doc Version 5.2 Page 33 3. 4. YA19 YA20 5. YA37 by the GP. The registered provider should give strong consideration to purchasing a computer for the home to allow for the registered manager and support staff to complete tasks with greater efficiency. DS0000025620.V343458.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000025620.V343458.R01.S.doc Version 5.2 Page 35 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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