Inspection on 20/02/07 for Gibraltar Crescent (36a)

This inspection was carried out on 20th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gibraltar Crescent (36a) 26/01/06

Gibraltar Crescent (36a) 08/08/05

Gibraltar Crescent (36a) 17/11/04

Gibraltar Crescent (36a) 10/06/04

Similar services:

The Royal School for Deaf Children - Westgate College

89 Hastings Avenue

39 Westway

24-26 St John`s Road

David Gresham House

Denecroft

4 Malham Drive

7 - 8 Hawthorn Way (RNIB)

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

CARE HOME ADULTS 18-65 Gibraltar Crescent (36a) 36a Gibraltar Crescent Epsom Surrey KT19 9BT Lead Inspector Susan McBriarty Unannounced Inspection 20th February 2007 09:00 Gibraltar Crescent (36a) DS0000013491.V327701.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 Gibraltar Crescent (36a) DS0000013491.V327701.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. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gibraltar Crescent (36a) Address 36a Gibraltar Crescent Epsom Surrey KT19 9BT 020 8393 0865 0208 393 8649 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) RNID Care Services South West and Wales Mrs Christine Ann Downing Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 18-65 YEARS The gender of those accommodated will be MALE and FEMALE Date of last inspection 26th January 2006 Brief Description of the Service: Gibraltar Crescent is a purpose built detached home offering accommodation for up to six people with a learning disability, who may also have a hearing impairment. Service users have individual bedrooms, one of which has an ensuite bathroom. The bedrooms are set over two floors, access to the first floor is by stairs. The home has a large rear garden with patio area. The service has its own vehicle, a people carrier. The home is situated in a quiet residential area on the outskirts of Epsom. A number of local shops are close by. Epsom town centre with a larger variety of shops and facilities is a short distance away. The area is well served by public transport. The service is managed and staffed by the Royal National Institute for the Deaf (RNID) a registered charity. The property is maintained by CDHA (Chichester Diocese Housing Association) - formerly Hyde Housing. Fees for 2006/2007 range from £891.68 to £924.14 per week. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven and three quarter hours (7.45) hours, commencing at 9.00am and ending at 4.45pm. Ms Susan McBriarty regulation inspector carried out the visit. The registered manager of the service was present throughout the inspection. The inspection took into account the pre-inspection questionnaire information and records held at the home including resident files, staff personnel files, supervision, training, medication administration and daily records. The inspector made observations of interactions between staff and residents during the visit. The people living at the home prefer to be called residents. The commission had not received comment cards from residents or other sources (such as relatives) by the time of the visit. The residents at the home would not be able to tell the inspector their views without considerable support from the staff working in the home. The manager said a meeting was taking place with residents on the 21st February to talk about the questions asked in the comment cards. Feedback was received on 28th February 2007. What the service does well: Written assessments are completed before residents move to the home. Prospective residents are also supported to make trial visits to the home ensuring their individual needs and aspirations are met. Residents can be confidant that care plans and risk assessments recognise their assessed and changing needs and enable them to make decisions and take risks as part of an independent lifestyle. The home actively encourages residents to take part in activities and to be a part of the local community. Family links are supported and maintained by the home ensuring that wherever possible members of residents’ families attend reviews, residents visit their relatives and talk to members of staff. Residents receive the care and support they need in a way they prefer and require and information is known about residents includes their likes and dislikes. The home is well run with a manager who is aware of and understands the needs of the residents and how these needs should be met. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A number of requirements and recommendations were made during the visit on the 20th February 2007. Risk assessments were generally carried out to enable residents to take risks as part of an independent life. Some improvement was needed to ensure that home had a system in place to make sure these were reviewed regularly. The health and emotional needs of residents were met by the home. Some review of the health needs of male residents could further improve how their needs are met. Further review the pharmacist’s recommendations would confirm that residents are protected by the home’s policy and procedure. The complaint policy needed some improvement to make sure that residents views were listened to and acted upon. The adult protection policy required review. This would make sure that residents are protected from abuse and neglect. The communal areas of the home needed review to make sure that residents live in a homely and comfortable environment. Members of staff received appropriate and regular training. Some improvement was needed to ensure that any gaps in training could be easily identified. Improvement was needed to ensure residents were protected by the home’s recruitment policy. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 7 Some of the policies and procedures used by the home need to be reviewed to make sure the organisation is clear about what training members of staff need. The home asks residents and their relatives about the service they receive the outcomes need to be made known to the residents and their relatives. A number of the residents had chosen to remove the window restrictors in their bedrooms. Some assessment was needed to make sure that those residents stayed safe. 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. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed and Standards 4 and 5 partly assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and aspirations of residents are assessed although further improvement to record keeping was suggested. Residents are provided with a pictorial individual statement of terms and conditions. EVIDENCE: Most of the residents had lived at the home for some time; this was confirmed by the care plans looked at during the visit. Written assessments are completed on residents before they move into the home. Records held by the home and discussion with the manager and another member of staff confirmed this. Prospective residents are offered a trial period as part of the assessment, the date and time of the visits were partly recorded in the written assessment. A policy and procedure for admissions to the home was available in hard copy on the organisations intranet service. A suggestion was made that all visits to the home are recorded further confirming that the individual needs and aspirations of residents are met. Six (6) comment cards were received from residents, four (4) made no comment about moving to the home, one said they were asked and one said they wanted to move there. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 10 Requirements had been made during the last three visits by the commission for the home to produce a statement of terms and conditions for each of the residents. These had been completed in picture and easy read format and the requirement met. This ensured that prospective residents and their representatives had the information they need about moving into the home. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 11 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): Standards 6,7 and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflected the assessed and changing needs of residents including their personal preferences ensuring their needs could be met in a way they wished. Some improvement was needed to ensure that residents could continue to be supported to take risks as part of their lifestyle. EVIDENCE: A number of care plans were sampled. The care plans were in picture format with easy read notes and signed where possible by the resident. The personal likes and dislikes of residents had been documented and recorded ensuring their views and wishes were taken into account. A checklist had been placed at the front of the care plan. The checklist required members of staff to make sure that the care plan was reviewed regularly and that goals and targets agreed with individual residents were still relevant. The document was signed and dated showing how often the care plans had been reviewed and indicating that the were reviewed in detail. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 12 The residents are encouraged to make decisions about their lives and assistance as necessary. The manager said that risk assessments were in the process of being updated. Only one of the files sampled was out of date. The risk assessments in all the files sampled varied as to when they had last been reviewed dating from February 2006 to August 2006. In discussion with the manager and another member of staff it was confirmed that a revised format for risk assessments was in place and had prompted the reviews. A recommendation is made that the home ensures risk assessments are reviewed regularly and are recorded and documented. This will ensure that service users can continue to take risks as part of their lifestyle. Gibraltar Crescent (36a) DS0000013491.V327701.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): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a range of activities, have appropriate relationships with family and friends and their rights and responsibilities are recognised in their daily lives. EVIDENCE: The residents have a learning disability and some also have a sensory impairment. All use a range of communication methods; they do not access employment. A charter of rights had been drawn up and included the right to privacy, dignity and choice. The charter included the right to communicate in a language and mode of their choice; the right to have their ethnic and cultural differences recognised and their sexual orientation respected. Training records and discussion with the management team and observations by the inspector confirmed the use of Makaton and British Sign Language Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 14 (BSL). Pictures, photographs and symbols as well as the spoken word were used. This enables the members of staff to support and communicate with residents effectively. For example photographs and easy read notes had been used to remind a resident of the day they voted in the local elections. Feedback was received from six (6) residents who said they were able to make decisions about what they do each day and the types of activity they take part in. These included visiting family, going out to dinner, going to the seaside and eating fish and chips. Transport was provided by the home. Where residents had family they were encouraged to visit the home. The manager said that relatives were also encouraged to take part in reviews and was able to discuss the outcomes of meetings where family members had taken part. All the residents have a doorbell placed outside their bedrooms and these were observed being used by staff during the course of the visit. The doorbells set off a flashing light inside the bedrooms of those with a hearing impairment to enable the resident to know when someone is calling. On returning home after spending the day at a day centre residents chose whether they wished to spend time in their bedroom, talk to staff or help out in the kitchen. Minutes from meetings provided in symbol format confirmed that residents and members of staff had chosen a signing name to be used when communicating. Picture symbols had also been used to show what activities residents took part in including church attendance and a day centre. The manager said that they were aware the records about the day centre were not accurate but had not received the information they needed. The records supplied by the day centre, which in some instances said that residents had spent the day drinking tea, confirmed this. On returning home residents were asked what they had done during the day and where able to talk about going bowling and who had won. The manager said the centre would be asked again for the information needed. One resident enjoyed craftwork and an example of completed work with a photograph of the service user had been placed on a board enabling the resident to show what they had achieved. Those care plans sampled included the life story of residents in photographs and easy read notes showing, where possible, their childhood, pictures of where they lived before and what has happened since they moved to the home. A regular newsletter using pictures and an easy read format had been produced showing what had happened within the home and the achievements of residents and members of staff. Residents were encouraged to take part in cooking in the home; photographs of one resident confirmed this. The resident was seen taking part in all aspects Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 15 of cooking from shopping for the items needed to the finished product. A picture menu was provided and the manager and other staff confirmed that a dietician had been contacted for advice about the menus provided and the managers said that the suggestions received had been acted upon. The manager also said that residents take part in the four week menu planning with support from members of staff. The menus supplied with the preinspection questionnaire showed a varied diet. Residents are able to take part in a range of activities, have appropriate relationships with family and friends and their rights and responsibilities are recognised in their daily lives . Gibraltar Crescent (36a) DS0000013491.V327701.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): Standards 18,19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care in the way they prefer and their physical and emotional needs are met although some improvement would further benefit male residents. Further review was needed to confirm that residents are fully protected by the home’s policy and procedure for the administration of medication. EVIDENCE: Feedback was received from six (6) residents. All indicated that they liked the members of staff who always treat them well. Overall comments made told the commission about the things they like to do or the people they like to be with. For example food shopping, ‘my home day’, a football club and meetings. The care plans sampled confirmed that resident’s personal preferences and wishes about their personal care needs had been recorded. All members of the permanent care staff team were female and it was not clear how male residents felt about not being able to choose a male to assist with their personal intimate needs. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 17 The care plans also confirmed access to the dentist, doctor and health specialists such as audiologist and chiropody. The dates and times the residents attended had been recorded. The manager discussed the chiropody needs of service users and said that the doctor had been asked to refer their service users through the National Health Service. The home felt the residents had a right to free foot care due to their disabilities. Records and documents sampled showed that residents were weighed each month. Residents had also received information about consent relating to health care. For example female residents had been given information about and encouraged to attend for smear tests. It is recommended that the home confirm that male residents receive the same opportunity to attend health checks for example testicular checks. This would further confirm that the health and emotional needs of residents are fully met. The manager and another member of staff said that the home had requested a visit by a pharmacist and this had taken place on the 21st January 2007. A number of recommendations were made including recording when and how much medication was received on the medication administration record. The recommendations were due to be implemented from the beginning of March 2007. On sampling the medication administration some gaps on the medication administration record were found. The gaps could not confirm that medication was given when needed although the blister pack was checked and the corresponding date was empty. Olive oil had been put into small bottles for use and the name of the resident was on the bottle. No instructions were on the bottle for their use. Members of staff had identified the initials they would use when completing the medication administration record but not the signature. In one instance the signature used did not match the initials the member of staff said they use. This might cause some confusion. Photographs of residents were held separately from the medication administration records. A book was in use that identified when and what medication was received into the home and sent for disposal. A policy and procedure was in place to make clear what members of staff should and should not do and that they ‘should be’ trained before they are allowed to administer any medication. Training certificates were seen that confirmed care staff had received training. The doctor has signed a record of the homely remedies in use for each service user for example painkillers confirming which would be safe to use. A recommendation is made for a further review to take place once the recommendations of the pharmacist have been put in place for the home to review the administration, storage, handling and disposal of medications in order to ensure that any identified gaps remaining are acted upon. This would further ensure that residents are protected by the homes’ policy and procedure for the administration of medication. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 18 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): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some improvement was needed to ensure that residents were confident that their views were listened to and acted upon and that they were protected from abuse and neglect. EVIDENCE: The home had a copy of the complaint procedure on DVD and picture format. A policy and procedure was in place to enable residents and their relatives to make a complaint. The procedure did not offer a time frame for complaints made verbally. The policy required all members of staff to receive training in dealing with complaints as part of their induction and thereafter annually. Training in dealing with complaints was not provided by the organisation. The manager said that no complaints had been received since the last visit by the commission. The complaints and compliments book was sampled and a number of cards and letters were viewed thanking the staff for the care and support they had provided to the residents. The requirement made during the last visit by the commission on the 26th January 2006 to include the details of the commission had been met. A requirement is made to ensure that the views of residents are listened and acted upon. A policy and procedure is in place to safeguard adults. The policy and procedure required review. For example the policy stated that if the abused person does not want the matter to go further then their wishes should be respected unless other circumstances apply. The policy also stated that Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 19 members of staff must receive alerters’ training and staff responsible for investigating should also receive appropriate training. The training required by the policy was not provided. A copy of the local authority multi-agency guidelines was available in the home and the manager was able to state clearly what action they would take should an allegation of abuse be made. Training records, discussion with the manager and another member of staff confirmed that awareness raising training had been attended. The manager had not been aware of the managers’ tool kit training provided by the local authority for managers of registered services. Training for the majority of staff had taken place in 2004. Requirements are made to ensure that residents are protected from abuse and neglect. The policy and procedure for safeguarding adults must be reviewed and confirm support of the local authority guidelines. In addition members of staff including the management team must receive appropriate training and or refresher training in the safeguarding of adults taking into account the requirements made by the organisation in the policy and procedure. Please also see Standard 40. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 20 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): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvement was needed to ensure that the home provided a homely and comfortable environment. The home was fresh and hygienic throughout. EVIDENCE: A full tour of the home was carried out. The resident’s bedrooms had been personalised, reflected their interests and had been decorated in colours they had chosen with support from the care staff. The manager said that the communal areas of the home had been decorated once in the ten years since the home first opened. The inspector noted that the communal areas required some work. A number of the walls were stained and doors and doorframes showed signs of wear and tear. Replacement window furniture had been provided however the repairs to the original sites were poor and in some areas showed signs of coming away. Some of the windows do not fit snugly against the window frame. The visit was carried out on a cold day and the draft could be felt through the window frame. The manager said that application was being made to replace the stained carpets Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 21 in the kitchen and conservatory but would not be able to confirm agreement until the budget for 2007/2008 had been agreed. A requirement is made to review the decoration and repairs of the home to ensure that residents are provided with a homely and comfortable place to live. The home was fresh and hygienic throughout. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 22 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): Standards 32, 34, 35 and 36 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement is needed to make sure that residents are supported and protected by the home’s recruitment policy and procedures. Training, development and supervision records and documents would benefit from the provision of a monitoring system to ensure that residents continued to have their joint and individual needs met and benefit from a well supported and supervised care staff team. EVIDENCE: A number of staff personnel files were sampled. A requirement had been made during the inspection of the 26th January 2006 for all members of staff to have a contract. The manager and files sampled confirmed the requirement had been met. The pre-inspection questionnaire and discussion with the manager confirmed that four (4) members of staff had completed a National Vocational Qualification (NVQ) to level 2 or above and a further four had been enrolled on the same course. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 23 Criminal record bureau (CRB) checks and or copies of CRB applications forms were found in all of the care staff files. The manager said that the organisations human resources department had been contacted and they were waiting for a response to confirm that they could dispose of the information. Not all of the references necessary were available on the file; the manager said that the human resources department probably held these. The home kept a central record of the name of the member of staff and the disclosure number. The applications forms seen including one completed in November 2006 do not require applicants to provide all their employment history and reasons for any gaps. Requirements are made that the application forms be updated to include the information necessary and that the files contain all the information required. This will ensure that residents are supported and protected by the home’s recruitment policy. The requirement that the files contain all the information necessary has been brought forward from the inspection of 26th January 2006. Discussion with the manager, another member of staff and training records confirmed that training had been completed by members of staff for example Makaton, British Sign Language, health and safety, medication, fire safety and food hygiene. Deaf and disability awareness training had also been completed and was a requirement of the organisation. The organisation had an equal opportunities policy and procedure. The policy stated that managers and others would be trained and supported to meet the requirements of the policy. None of the staff had received equal opportunities training. The training schedule for 2007/2008 was checked on the organisations intranet and it was found that equal opportunities training was not on the list to be provided. A requirement was made to review the implementation of the organisation’s equal opportunities policy to ensure that residents and members of staff could benefit from a clear introduction of the policy. Please see Standard 40. The management team had devised a central training record. In discussion with the management team it was considered that putting dates of completion could make some improvement and when training was next due on the document rather than an N or a Y to indicate completion. Records for completed training were held in more than one area increasing the work needed to confirm care staff training needs. Evidence was available to show that care staff received supervision and the manager said that appraisals were due to be carried out. The home would benefit from having a central record showing who had been supervised and when clearly confirming supervision had taken place. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 24 A recommendation is made that the training plan and supervision records and documents be reviewed in order to ensure residents continue to be supported by well trained staff who benefit from support and supervision. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 25 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): Standards 37, 39 and 42 were assessed, Standard 40 was partly assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well run home. Some improvement would further confirm that residents’ views underpin all self-monitoring, review and development of the home. Policies and procedures would benefit from improvement to ensure the residents’ rights and best interests are safeguarded. The health, safety and well being of residents is promoted and protected by the home. EVIDENCE: Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 26 The manager is registered with the commission and had completed the qualifying training needed to support and inform the role of home manager. Evidence was seen of further training taking place to maintain their skills and knowledge. The manager confirmed that the petty cash system has been reviewed since the last visit on the 26th January 2006. The home had provided written confirmation to the commission of completion and this was not assessed during this visit. Discussion with the manager and minutes of meetings and completed questionnaires from relatives and others confirmed that a quality assurance process was being used by the home. The information received had not been brought together to identify what the home does well and areas for development. A recommendation is made that the outcomes been recorded and made available to residents and their relatives. This would ensure that residents’ views underpin all self monitoring and review. As noted earlier in this report it was found that a number of policies and procedures provided by the organisation required members of staff to complete specific training. The manager was not aware of such training being available and checks were made during the visit on the organisations intranet confirming training was not available. A requirement is made that the organisation review policies and procedures and ensure they are able to meet the training requirement they have made for their staff team. This would further confirm that residents are supported by a staff team who are able to meet their joint and individual needs. A number of policies and procedures relating to health and safety in the home were viewed these included manual handling, fire safety, lone working, and health and safety. The organisation had a named person responsible for health and safety matters. The manager said that residents were involved in making checks in the home for example water temperatures. A symbol format checklist had been devised and was seen by the inspector and was used regularly by residents with care staff support. The pre-inspection questionnaire received by the commission set out the dates that health and safety checks had been carried out within the home. These included checks regarding the emergency lighting system, the date of the last fire drill and fire equipment checks. The health, safety and well being of residents is promoted and protected by the home. The manager and the tour of the home confirmed that resident’s bedrooms had been provided with window restrictors and in that some instances the residents had removed them. A recommendation is made that the provision of window restrictors be risk assessed to ensure residents’ decisions about not using them Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 27 was recorded and documented to ensure their health, safety and welfare is further promoted and protected. Gibraltar Crescent (36a) DS0000013491.V327701.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 CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 2 X X X Gibraltar Crescent (36a) DS0000013491.V327701.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 YA22 Regulation 22 Requirement Timescale for action 30/04/07 2. YA23 13(6) 3. YA23 13(6) 4. YA24 23(b)(c) The complaint procedure must be reviewed to ensure that time scales are given and made clear however the complaint is made. This will ensure that residents’ views are listened to and acted on. The protection of adults’ 30/04/07 procedure must be reviewed to ensure that it supports the local authority multi-agency guidelines for safeguarding adults. This will ensure that residents are protected from abuse and neglect. Training in adult protection for 30/03/07 the management team of the home must be reviewed to ensure that it is adequate to protect residents from abuse and neglect. A review of the décor and repairs 30/03/07 completed at the home must take place including: decoration of the communal areas, repairs completed to the window frames and the displaced windows and action taken as required. This will ensure that resident live in a homely and comfortable DS0000013491.V327701.R01.S.doc Version 5.2 Gibraltar Crescent (36a) Page 30 environment. 5. YA34 19 Schedule 2 The documents required in schedule 2 must be held on the file of each member of staff to ensure residents are protected by the home’s policy for the recruitment of staff. 30/03/07 6. YA34 19, Schedule 2 (6) 7. YA40 12(1)(a) This requirement has been brought forward from the inspection of the 26th January 2006. Application forms must be 30/03/07 updated to include a full employment history and a reason for any gaps in employment. This will ensure that residents are supported and protected by the home’s recruitment policy. The policies and procedures 30/04/07 provided by the organisation must be reviewed particularly where additional training is required by the organisation and not provided including: complaints, protection of adults and equal opportunities. This will ensure that residents’ safety and well being is promoted and protected. 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 YA9 YA19 Good Practice Recommendations It is recommended that a system for reviewing risk assessments is put in place to ensure that residents can continue to take risks as part of an independent lifestyle. It is recommended that specialist health monitoring checks for example testicular checks take place for male residents in order to further confirm that residents’ physical and DS0000013491.V327701.R01.S.doc Version 5.2 Page 31 Gibraltar Crescent (36a) 3. YA20 4. YA35 5. YA36 6. YA39 7. YA42 emotional health needs are met. It is recommended that a further review of the receipt, storage, handing and disposal of medication into the home take place once the pharmacist recommendations have been acted upon. This will further confirm that residents are protected by the home’s policy for the administration of medication. It is recommended the systems for recording care staff training be reviewed in order that any gaps can be readily identified. This will ensure that service users individual and joint needs continue to be met by appropriately trained staff. It is recommended that a system for monitoring the provision of supervision be implemented to identify any gaps. This will ensure that service users continue to benefit from well supported and supervised staff. It is recommended that the outcomes of the quality assurance information are documented and made known to residents and relatives. This will confirm that residents can be confident that their views underpin self-monitoring, review and development of the service. It is recommended that where residents choose to remove window restrictors that a risk assessment is carried out and documented. This will ensure that the health and safety of residents is promoted and protected. Gibraltar Crescent (36a) DS0000013491.V327701.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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