Inspection on 20/12/07 for Gloucester Road (22)

This inspection was carried out on 20th December 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gloucester Road (22) 07/01/09

Gloucester Road (22) 08/11/05

Gloucester Road (22) 12/04/05

Gloucester Road (22) 09/11/04

Gloucester Road (22) 18/05/04

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

CARE HOME ADULTS 18-65 Gloucester Road (22) 22 Gloucester Road Kingston Upon Thames Surrey KT1 3SJ Lead Inspector David Halliwell Key Unannounced Inspection 20th December 2007 9:30 Gloucester Road (22) DS0000013392.V336778.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 Gloucester Road (22) DS0000013392.V336778.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. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gloucester Road (22) Address 22 Gloucester Road Kingston Upon Thames Surrey KT1 3SJ 020 8547 0610 020 8546 3832 pm-gloucesterroad@together-uk.org www.together-uk.org Together Working for Wellbeing 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) None at present Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2006 Brief Description of the Service: 22 Gloucester Road is a large, detached property situated on the outskirts of Kingston-upon-Thames. Town centre facilities are within easy reach and the home is conveniently situated for access to public transport networks. The property is owned by the Local Authority, the Royal Borough of Kingston but the project is managed by “Together – Working for wellbeing”. The home has a contract with a local Primary Care Trust. The local primary care trust also contributes to the funding of the project. The home offers six bedrooms on the ground floor of the property and a further ten bedrooms on the first floor. The home has a large garden to the rear, mostly laid to lawn with a range of mature trees and shrubs. Gloucester Road (22) DS0000013392.V336778.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 visit undertaken for 22, Gloucester Road. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and 4 residents. Informal interviews were conducted with 3 other residents as a part of the tour of the home. 5 requirements and 4 recommendations have been made as a result of this inspection and feedback on all these requirements and recommendations was given verbally to the Manager at the end of the inspection visit. There are some re-occurring themes appearing in the requirements and recommendations mainly to do with staff training, supervision and records. Details are explained more fully both in this report and in the section below named “What they could do better”. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. What the service does well: What has improved since the last inspection? Good progress has been made in meeting the 10 requirements and 6 recommendations that were made as a result of the home’s last key inspection that took place on 5th September 2006. Of the 10 requirements issued at that inspection 7 have now been fully met and some progress has been made on 1 other requirement. Specific progress has been made in the following areas: 1. Needs assessments, care plans and reviews and now updated and reviewed regularly and at least once every year. 2. Care plans contain the required level of detail. 3. An inventory for each resident is maintained. 4. Some works have been carried out to the property that was required. 5. Staff have now enrolled for NVQ training. 6. Staff files and resident’s files are in much better file order. 7. Supervision practices have been improved. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 6 8. The Manager has started his NVQ level 4 training in preparation of becoming the registered Manager. What they could do better: Specific areas identified in this report are as follows: 1. 2. 3. • • • • • • 4. • • • • • • 5. 6. Risks that have been identified in the risk assessments should be specifically addressed in the care plans in order to minimise the risks to the residents. All staff should receive POVA training from an outside and a recognised trainer at least once every 2 years. Certificates of staff attendance will be required. The following areas of the home need some further improvement work: In the kitchen a tile was missing that needs replacement so as to avoid a health hazard. The ground floor bathroom floor and toilet bowl needs replacement as discussed with the Manager. The rear back stairway needs redecoration as it is stained and rather tired. The toilet by bedroom no 8 needs another overhaul with special attention paid to the floor that needs to be fully sealed so as to avoid the penetration of urine that cause bad odours and potential health hazards. Replacement radiator covers are required throughout the house, the Manager told the Inspector that this is planned for 2008. In the toilet by bedroom no 15 the boxing needs replacement and the floor needs to be sealed. A review of 5 of the staffing files evidenced: That suitable application forms are completed as a part of the process but only 2 of the 5 files inspected actually had application forms in them. Usually 2 references are obtained including one from the last employer, however 4 staff files had no references. All staff files reviewed by the Inspector had proper CRB checks that had been carried out for staff employed within this home. Other official documentary evidence confirming the identification of staff either in the form of a passport, birth or marriage certificate needs to be held on file – this information was only seen on 2 of the 5 files inspected. Training certificates and other evidence of qualifications gained by the staff member should also be held on the staffing files such as that for NVQ training. Staff files should included signed and dated copies of their contracts. An annual training needs analysis is recommended for the whole staff group at Gloucester Road and maximum use made of the training provision. That some externally provided training be laid on for staff that would compliment and expand the scope and range of the existing “in house” training packages. Suggested areas are in some of the most important key areas for staff skills and knowledge including: needs assessment, Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 7 care planning, developing action plans, monitoring and review; POVA; and health and safety. 7. Training needs for all the staff team should be aggregated into a training matrix that may be used by the management team to plan all future training courses in the year ahead. This will serve a dual purpose in that it will easily inform the Manager what training the staff team have received and where the gaps in training exist. 8. Staff supervision: • Supervision should be on a 1:1 basis once every 2 months. • Supervision notes must be maintained regularly and kept on staff files and areas of discussion in supervision must be detailed enough to cover the monitoring of work with individual residents and the analysis of care plan outcomes, support and professional guidance, and the identification of training and development needs and • Annual appraisals need to be carried out and copies held on file. 9. 3 accidents have occurred to staff in the kitchen that may indicate the need for the Manager to review of health and safety practices in the kitchen as well as staff training. 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. Gloucester Road (22) DS0000013392.V336778.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 Gloucester Road (22) DS0000013392.V336778.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 inspected at this inspection. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective service users may be assured that their needs are assessed and that their individual aspirations and wishes are taken into account in the assessment process. EVIDENCE: Standard 2 – This standard requires the service to ensure that individual residents’ needs are assessed and that their aspirations are taken into account in the process. At the last full inspection and after a review of 5 of the residents’ files, a requirement was made concerning the residents needs assessments, risk assessments and care plans. It required that the care plans should be updated and reviewed at least once every six months and that the care plan review meetings should be held with the placing authorities annually. The Manager informed the Inspector that since the last inspection work has been carried out by his staff care team on the development and overhaul of all the residents’ care plans. A new model and format has been implemented and a blank format was shown to the Inspector. This shows a comprehensive approach to care planning and a positive improvement over the previous format. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 10 A review of 4 of the residents’ files at this inspection showed that the revised care planning format is now being used for each resident. The files that were seen demonstrated a logical progression of the processes involved from needs assessment through to care planning as well as regular monitoring and review of the care plans. The care plans seen had been signed in agreement by service users and were dated. The care plans could also be seen to be linking in with care programme approach documentation that includes the mental health clinical teams input to the overall process of care provision. It is important that this new care planning process is now used consistently for all residents at Gloucester Road. The requirement set previously has now been met. Gloucester Road (22) DS0000013392.V336778.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 & 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The individual resident’s care plans seen by the Inspector on the residents’ files does now reflect the assessed and changing needs and personal goals of the residents. They may be assured that they will be supported to make decisions about their lives with assistance as needed and that they will be supported to take risks as part of an independent lifestyle. EVIDENCE: Standards 6 – 4 resident’s files were inspected and the Inspector spoke to 4 residents over the course of this inspection. Upon inspection it could be seen that the resident’s risk assessments, needs assessments, reviews and care plans had been updated in the last 3 months using the new model and format implemented by the Manager. However the Manager must ensure that Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 12 any risks identified in the risk assessments are specifically addressed in the resident’s individual care plans so as to ensure the best protection for the resident. The link between the risk assessments and the care plans was not clear on the files inspected and this is now a requirement. The 4 residents interviewed by the Inspector confirmed that they do have a say in the care planning and review process within the home. A summary of the weekly activities has been drawn up for each resident that links in with the care plan objectives and helps to ensure they are being actioned appropriately. This means that residents can be assured that their assessed and changing needs will be reflected in their individual plans and that they have an up to date individual plan to guide the care they are provided with by staff in the home. Following the recent review and revision of residents care plans co-ordinated by the Manager, much more of the data specified in schedule 3 under Standard 6 has now been included in the resident’s files which are also now in much improved order with information clearly identified in chronologically ordered sections. There is now a photograph on file of the resident; the needs and goals of the service user have been stated on those care plans seen and there was evidence of the resident having been involved in the drawing up of the plan. These details are very important parts of the plan and are necessary so that both key workers and residents are clear about how care is to be provided to them. A previous requirement has therefore now been met. Residents did confirm verbally with the Inspector that they had been involved with their care plans and their reviews when these had been held. The Manager informed the Inspector that there have been no new residents placed at Gloucester Road since the last inspection. Therefore a recommendation made at the last inspection could not be reviewed here. It was that links between the resident’s care plan and the referring care manager’s assessment and care plan should be clearly defined in the resident’s care plans. The Manager is reminded about this here. All residents confirmed that they do have a key worker and that they are able to communicate with their key workers appropriately. The Manager and staff also confirmed that all residents have a key worker who they receive support from on a regular basis. Standard 7 – Residents interviewed by the Inspector confirmed that the staff at Gloucester Road do respect their rights to make their own decisions where appropriate. Care staff also made it clear that they involve the residents wherever possible in making their own decisions in order to assist in supporting a positive move towards independence. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 13 The Manager told the Inspector about the daily meetings and the community meetings that are held in the unit which involve the residents as much as is possible, to make decisions about different aspects of their lives. This includes menu planning and daily activities as well as planning the routine maintenance tasks that have to be undertaken every day and which involves the residents. Residents confirmed with the Inspector that they attend the daily meetings and the community meetings together with staff. Minutes of the community meetings were shown to the Inspector. Standard 9 – The Manager informed the Inspector that risk assessments are undertaken for each resident to assist in their taking responsible risks. Inspection of the files confirmed that these risk assessments had been undertaken. Care support staff also confirmed that they are involved with their residents in completing these risk assessments in order to support residents to lead as independent a lifestyle as possible. Reference to the link between these risk assessments and the care plans is made under Standard 6 in this report. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 14 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): Standard 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are able to take part in appropriate activities and are to a reasonable extent involved in local activities. Residents have appropriate relationships and their rights and responsibilities in their daily lives are recognised and respected by the staff in the unit. Residents are offered a healthy diet and they are assisted in learning cooking and food preparation skills. EVIDENCE: Standard 12 – The Inspector found evidence that care support staff appropriately encourage the maintenance of resident’s relationships with family and friends if residents also wish to do so. The Manager told the Inspector that visitors to the home are encouraged and that they use the visitor’s book to sign in. The visitor’s book was seen in the front entrance hall was evidently in regular use. The Manager also said that residents are enabled to take part in appropriate activities by the care staff. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 15 Most of the current residents living at Gloucester Road moved there directly from the Netherne Hospital where their previous activities are not recorded on the files now held at Gloucester Road. Interviews with 4 residents and 3 of the staff including the Manager said that now more outside services and activities are being used. 1 resident goes to a community centre where they join in physical exercises. That resident told the Inspector how much they enjoy doing so and said that they go twice a week. Another resident said that they go to a local church each weekend. Some residents interviewed told the Inspector that they do not wish to use other local community services “because we are well looked after here”. The Manager told the Inspector that information is being provided by staff at the home about local activities that residents say they are interested in. Standard 13 - Interviews with residents demonstrated that they do attend some local community events although their wishes for an active community social life are somewhat limited. Information is made available and staff do encourage residents to be involved as much as possible in local activities. Some residents told the Inspector that they like to go to the shops. Residents make full use of local public transport facilities in order to get out and about and to see friends and family. 2 residents interviewed said, “the local transport facilities are good and we can catch the bus just down the road here”. All residents living at 22, Gloucester Road are registered to vote in elections and are supported by staff to do so if they wish. The Inspector saw that some information is made available within the home about local activities for residents to take up if they wish. Standard 15 – Some of the residents interviewed by the Inspector told him that they do keep in regular contact with their families and friends. Staff were seen to encourage the residents to keep and maintain contacts with family and friends so that they benefit from having appropriate relationships. Standard 16 – The resident’s daily meetings with staff help considerably in identifying and respecting service users rights and responsibilities in their daily lives. Residents confirmed with the Inspector that the home’s policy on privacy is upheld appropriately within the home. Residents have keys to their own rooms and to the front door, they are able to see their GP when they need to and to choose their GPs. Staff were seen by the Inspector to knock on residents doors before entering and service users were seen to have the opportunity to spend time in their own company as and when they wish. Some residents participate in household chores and those interviewed told the Inspector that they enjoyed these responsibilities and were all very clear as to Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 16 when and what they have to do. Service users can be assured that their rights and responsibilities are respected in their daily lives. Standard 17 – The Manager informed the Inspector that there is in place a 6week menu. He told the Inspector that some consideration is now being given to changing the current arrangements whereby the unit has a professional cook. Under consideration is a plan where the staff might undertake the cooking of meals sometimes together with residents. This raises some concerns about whether staff would have sufficient training to ensure that the residents continue to be provided with a varied, healthy and nutritious diet and whether they would have the time given their existing busy care and support work with residents to be able to do so. Under present arrangements residents are enabled to make choices at the menu planning stage and special needs are catered for. 4 service users interviewed said that they have been asked about what food they would like to see on the menu and thereby confirmed this with the Inspector. The daily meetings held each morning with the residents also offers each resident a chance to make different choices about what they wish to eat on that day. Menus that were seen by the Inspector were varied and nutritious in the food being provided. The 4 service users confirmed to the Inspector that they all enjoy the food they receive at Gloucester Road. The cultural needs and wishes of the residents are also taken into account with the provision of appropriate foods, which meets their stated needs. Residents can therefore be assured that they will be offered a healthy diet and that they should enjoy their meals and mealtimes. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 17 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 & 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Personal and healthcare is provided according to service users individual needs. Clinical support for specific health care is provided by General Practitioners, District Nurses and by the psychiatric multi disciplinary teams as well as other specialist services such as chiropody, sight and hearing services thus ensuring that residents do have a good quality of life. EVIDENCE: Standards 18 and 19 – Residents interviewed said that they receive their care in the way they prefer. They said that they are able to decide themselves about their daily routines and this was also confirmed by care staff interviewed by the Inspector. Residents told the Inspector that they keep in regular contact with their General Practitioner and with their psychiatric team. The Manager informed the Inspector that all the residents are registered with dentists, opticians, chiropodists and community nurses in order to maintain their all round good health. Residents interviewed also told the Inspector that this is the case. Evidence was seen on the resident’s case files by the recording of Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 18 their contact with these services. It was confirmed that annual healthcare checks are routinely carried out by GPs. Standard 20 – The Manager told the Inspector that one of the senior care support workers is now responsible for the medication practices carried out within the home. He also said that all care staff are allowed to administer medication to the residents but that this has to be carried out under the supervision of a senior. The home’s policies and procedures manual was inspected and seen to contain appropriate policies for the control of medication. The Inspector reviewed the records for the administration of medication to residents and these were seen to be appropriately completed and in line with the home’s policies and procedures. A stock take check was carried out by the Inspector together with that senior member of staff responsible for medication and the levels of medication held within the home appropriately matched the MAR sheet records. The Inspector was also told that the Boots Pharmacy do an inspection every 6 months and that their reports are satisfactory. Training in medication for staff is a part of the overall agencies training plan and staff training records showed that all staff received this training in 2006. Staff interviewed confirmed that they had received this training. Residents vary in their ability to administer their own medication. The home actively supports those who wish to self medicate and trained staff organise the ordering, the storing and the administration of medication with service users. The Manager is advised that following recent changes in the legislation, an appropriate medication cabinet will be required for controlled drugs. Gloucester Road (22) DS0000013392.V336778.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): Standards 22 & 23 - Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may be assured that their views will be listened to and acted upon appropriately. They may also be assured that they will be protected from abuse, neglect and self-harm. EVIDENCE: Standard 22 – Residents told the Inspector that they feel their views are listened to and acted upon. They also all said that if they had a complaint they know the procedure to be followed and would do so if they needed to. Staff interviewed confirmed to the Inspector that the residents were all aware of the complaints process and that the whole staff group took any issues raised by residents seriously. The complaints record was reviewed by the Inspector, no complaints had been made since the last inspection visit. Standard 23 - The home has an adult protection policy (POVA) and the Manager informed the Inspector since the last inspection some of the staff group had received POVA training. Actually after review of the training records only 3 of the 7 staff group were seen to have received this training in 2006 and evidence of this was seen in the files held in the main office. However it is a requirement that all staff receive POVA training from an outside recognised trainer at least once every 2 years. Certificates of staff attendance will be required. Regular training in this area should mean that Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 20 staff are better aware of what abuse is and the safeguards in place for the protection of the residents should they need them. The Inspector saw the allegation of abuse record and 1 allegation had been made on 1st June 2007 since the last inspection. Evidence was seen by the Inspector that the correct procedures were followed. The appropriate authorities were informed and an action plan implemented. A vulnerable adults conference was held on 18th June with the appropriate parties including the referring local authority. All the agreed actions were taken appropriately except that the Commission was not informed of the event. The Inspector told the Manager that in future the Commission for Social Care Inspection should be informed and the Manager confirmed to the Inspector that this would be done. The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and staff are asked to sign to say that they have read and understood the policies and procedures. A review of staffing records held on staff files by the Inspector confirmed that all staff had signed such an agreement. The Manager informed the Inspector that training in this area is offered to staff. The home does look after residents’ money and the Inspector reviewed the financial records for these transactions that all were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. At the last inspection it was recommended that an inventory for residents valuable belongings be drawn up and maintained and kept up to date by key workers for all residents’ belongings that are kept in their bedrooms. Evidence that this has since been carried out was seen by the Inspector. Inventories had been signed and dated by the residents concerned in agreement to the contents. This should add to the measures already in place to ensure the protection of the resident’s property. Gloucester Road (22) DS0000013392.V336778.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): Standards 24 & 30 - Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users do live in safe and comfortable surroundings and said that they are happy living in this environment. Service users may be assured that the home is clean and hygienic. EVIDENCE: Standards 24 & 30 – Together with the Manager, the Inspector reviewed all areas of the home to assess the quality of the environment and décor. The Manager explained that a number of measures had been taken to improve areas identified at the last inspection as well as those arising from the fire that occurred at the home on 15th March 2007. The Manager said that an agency cleaner is now employed for one day every week in order to supplement the unit’s existing cleaning resource. This additional resource has made a considerable difference to the levels of cleanliness being experienced at Gloucester Road and evidence of this was seen by the Inspector at this inspection. This improvement is to be commended. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 22 Generally the home was found to be clean and hygienic although there are still some areas that do need to be refurbished and are rather tired from considerable use - specifically the bathrooms and toilets. However the Manager told the Inspector that a plan is in place for early 2008 for them all to be refurbished and redecorated as required. 4 resident’s bedrooms were inspected with the permission of those residents. They all told the Inspector that they are happy with their rooms. It is required that the following items are addressed, areas of the home that were found to need some further improvement work: 1. In the kitchen a tile was missing that needs replacement so as to avoid a health hazard. 2. The ground floor bathroom floor and toilet bowl needs replacement as discussed with the Manager. 3. The rear back stairway needs redecoration as it is stained and the paintwork needs renewal. 4. The toilet by bedroom no 8 needs another overhaul with special attention to be paid to the floor. This needs to be fully sealed so as to avoid the penetration of urine is causing bad odours and a potential health hazard. 5. Replacement radiator covers are required throughout the house; the Manager told the Inspector that this is planned for 2008. 6. In the toilet by bedroom no 15 the boxing needs replacement and the floor needs to be fully sealed. The fire safety officer from the LFEPA visited in April 2007 and the Manager told the Inspector that the 1 requirement to do with the fire door between the hall and the kitchen has since been met. The last environmental health officers’ report was also seen and all the recommendations have been met. The Manager showed the Inspector evidence that the electrical wiring safety check was carried out successfully in February 2006 and this is understood to be valid for 5 years. The Inspector asked to see the records for checks on water temperatures and the Manager provided the homes records for this. They revealed that these tests have been carried out each week as is required. Tests carried out all indicated that the hot water temperatures were within the prescribed limits. Gloucester Road (22) DS0000013392.V336778.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): Standards 32, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users do benefit from clarity of staff roles and responsibilities but service users cannot be fully assured that they are supported by a competent and qualified staff team given the lack of documentary evidence on staff files. An appropriate recruitment policy and induction process helps protects residents and ensure that they are supported appropriately. However until regular and formal 1:1 supervision is provided to all staff, service users cannot be assured that they will benefit from well-supported and supervised staff. EVIDENCE: Standard 32 - The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. Evidence of this was seen by the Inspector on staff files and from discussions with staff interviewed. Staff have copies of the General Social Care Standards / Code of Conduct. Volunteers are not used within the home. The Manager told the Inspector that there is a training programme underway to ensure that all staff will be NVQ qualified by the end of the year. The Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 24 Manager said that all of the 7 staff have now either completed their NVQ level 2 training or are doing the NVQ at level 3. The Manager said that he is hoping to complete his NVQ level 4 and RMA Managers award in the nest 6 months. Staff interviewed confirmed with the Inspector that they are completing their NVQ training and some evidence of NVQ training certificates was seen in the office records. Staff files should include certificated evidence for all training undertaken by staff. Standard 34 - The Manager told the Inspector that the home does have a recruitment policy and procedure and that all staffing posts are filled by application and interview. Evidence of these processes being used was seen by the Inspector on the staffing files. A review of 5 of the staffing files evidenced: 1. That suitable application forms are completed as a part of the process but only 2 of the 5 files inspected actually had application forms in them. 2. Usually 2 references are obtained including one from the last employer, however 4 staff files had no references. 3. All staff files reviewed by the Inspector had proper CRB checks that had been carried out for staff employed within this home. 4. Other official documentary evidence confirming the identification of staff either in the form of a passport, birth or marriage certificate needs to be held on file – this information was only seen on 2 of the 5 files inspected. 5. Training certificates and other evidence of qualifications gained by the staff member should also be held on the staffing files such as that for NVQ training. 6. Staff files should included signed and dated copies of their contracts. It is therefore now a requirement that documentary evidence required under Standard 34 of the National Minimum Standards be gathered for all the staff members at Gloucester Road and be held on the staff files for review and inspection. This will help to ensure that recruitment practices meet the required standards. Staff interviewed confirmed that all have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home. However no evidence of these contracts was found on the staff files. Standard 35 – The Manager informed the Inspector that a structured induction programme is offered to new staff. Documentary evidence of this was seen by the Inspector and staff at interview said that it had been helpful to them to better understand their roles and functions at Gloucester Road. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 25 “Together” do offer a comprehensive training plan for staff that covers the essential and priority training needs for staff working in their homes. The Manager informed the Inspector that staff may attend as many internally provided training courses as they are assessed to need in order to carry out their job appropriately. It is recommended that as a part of the new managers role an annual training needs analysis is undertaken of the whole staff group at Gloucester Road and maximum use made of the training provision. Recent “in house” training for staff has included: • Boundary setting • Fire safety • POVA • 1st Aid • Infection control • Medication • Food hygiene It is recommended however that some externally provided training be laid on for staff that would compliment and expand the scope and range of the existing “in house” training packages. Suggested areas are in some of the most important key areas for staff skills and knowledge including: • Needs assessment, care planning, developing action plans, monitoring and review. • POVA • Health and safety. Training needs for all the staff team should be aggregated into a training matrix that may be used by the management team to plan all future training courses in the year ahead. This will serve a dual purpose in that it will easily inform the Manager what training the staff team have received and where the gaps in training exist. Standard 36 - From discussions with the Manager and from interviews with 2 staff it is clear that at present staff receive ongoing supervision and support in the work they undertake and a supervision record is maintained that is signed by both parties. However the record made of key areas of discussion or of all the decisions and agreements made still falls short of what is required. The Manager agreed with the Inspector that there is still work to be done in continuing to improve the quality of staff supervision in the home. It is essential for instance that there is discussion in supervision with staff about how to implement in practice the home’s philosophy and aims when working with individual residents. Equally it is essential for the successful delivery of Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 26 care to residents as well as providing job satisfaction for staff, that supervisors help them to monitor their work with individual service users and analyse the success or not of care plan outcomes in meeting their residents’ needs. A requirement is therefore made that: 1. Supervision should be on a 1:1 basis once every 2 months. 2. Supervision notes must be maintained regularly and kept on staff files and areas of discussion in supervision must be detailed enough to cover the monitoring of work with individual residents and the analysis of care plan outcomes, support and professional guidance, and the identification of training and development needs and 3. Annual appraisals need to be carried out and copies held on file. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 27 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 & 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be confident that they benefit from a well run home. With the developing quality assurance system they may be confident that their views underpin monitoring and review of the homes developments. Service users may also be confident that their rights and best interests are safeguarded by the home’s record keeping policies and procedures. EVIDENCE: Standard 37 – The Manager told the Inspector that he is due to complete his NVQ level 4 within the next 6 months after which he will apply to the CSCI to become the Registered Manager at 22, Gloucester Road. He has had nearly 2 years of experience working at Gloucester Road as the Manager and it is important now that he does complete the level 4 NVQ training this year. A requirement was set at the last inspection for the Manager to begin NVQ training and this is now partially met. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 28 The Inspector was shown by the Manager his job description that covers all the requirements set out under the Standard 37.3. Standard 39 – The Manager told the Inspector that since the last inspection the quality assurance process has been expanded. He said that it now includes feedback information from carers, referrers and funding agencies, staff and residents. Although the Manager said that none of the feedback questionnaires sent out to referring agencies have been returned and so there is no feedback from these teams. The Manager also explained that he organised an annual review day on 19th December 2007 at 22, Gloucester Road to which all the key stakeholders including the residents, their relatives and carers, staff, referrers and other professionals were all invited. He explained that this was to provide an additional opportunity to build on their quality assurance process by looking at key development themes that had been identified and to address any other issues that were brought up on the day. The Manager showed the Inspector an annual review paper for 2007 that summarises the feedback information and he explained that this information would be used to improve the way services are provided at Gloucester Road. The Manager also explained that the monthly management reviews carried out by “Together’s” senior managers and with him, continues and that he completes a monthly management report that covers a wide range of aspects to do with the services provided at Gloucester Road. He told the Inspector that a discussion takes place between himself as the Manager and the Area Manager and an action plan is drawn up and agreed for the required developments and improvements that have been identified. Standard 42 – The Inspector was shown information to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. The Manager explained that health and safety and maintenance checks are carried out on a daily and weekly basis and paperwork supporting this was seen by the Inspector. Records indicated that the last weekly check was carried out on 15th December 2007 and on 19th December 2007 for the last daily check. This means that needs are identified quickly and residents are therefore better supported and protected within the home. The fire risk assessment document was dated 28th March 2007 and evidence was seen that had been approved of by the LFEPA. The Manager explained that all the fire fighting equipment in the building is new since 17.9.07 including fire extinguishers and smoke detectors; and new emergency lighting was installed in February 2007. The Inspector saw evidence of this. Other records were inspected to check the regularity of fire drills (last fire drill was held on 14.12.07), break glass testing and emergency lighting tests. The Manager Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 29 explained that all furniture within the home now meets the B.S fire proof standards. The Manager informed the Inspector that all staff receive training in fire safety, first aid, food hygiene, and infection control. This was supported by staff interviewed that confirmed that they had received training in these areas. Satisfactory certificates were seen by the Inspector for: Boiler – 19.9.07 Gas – 19.9.07 Fire alarms –17.9.07 Fire extinguishers – 17.9.07 Water / legionnaires tests – 1.06 All food was seen to be stored appropriately and properly labelled with dates of opening and expiry. Fridge and freezer temperatures records were checked and records indicate that they came within the acceptable ranges. Accident records were checked and the policy and the procedures for dealing with accidents were seen to be recorded correctly. The following records were seen for accidents that have occurred since the last inspection: 2.7.07 – staff accident / burn to arm in kitchen 10.08.07 – staff accident / cut to thumb in kitchen 17.08.07 – resident accident / cut to foot in bedroom 20.08.07 – resident fall in office 30.09.07 – staff accident / burn to arm in kitchen 3 accidents have occurred to staff in the kitchen that may indicate a need for a review of health and safety practices in the kitchen as well as staff training. It is recommended that the Manager look at these areas so as to improve staff safety and reduce accidents. Hot water temperatures were checked and records indicated that they came within the acceptable range. The last water temperature test recorded was for 15th November 2007. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. The Manager showed the Inspector a recently completed risk assessment for the building and for the communal areas. This is welcomed as it should assist in the prevention of accidents and will inform the maintenance programme for the building. Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 30 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 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 31 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 YA6 Regulation 14 Timescale for action Risks that have been identified in 01/03/08 the risk assessments should be specifically addressed in the care plans in order to minimise the risks to the residents. All staff should receive POVA training from an outside recognised trainer at least once every 2 years. Certificates of staff attendance will be required. The following areas of the home need some further improvement work: • In the kitchen a tile was missing that needs replacement so as to avoid a health hazard. • The ground floor bathroom floor and toilet bowl needs replacement as discussed with the Manager. • The rear back stairway needs redecoration as it is stained and rather tired. • The toilet by bedroom no 8 needs another overhaul with special attention paid to the floor that needs to DS0000013392.V336778.R01.S.doc Requirement 2. YA23 18 01/04/08 3. YA24 23 01/04/08 Gloucester Road (22) Version 5.2 Page 32 • • be fully sealed so as to avoid the penetration of urine that cause bad odours and potential health hazards. Replacement radiator covers are required throughout the house, the Manager told the Inspector that this is planned for 2008. In the toilet by bedroom no 15 the boxing needs replacement and the floor needs to be sealed. 4. YA34 19 That documentary evidence 01/02/08 required under Standard 34 of the National Minimum Standards be gathered for all the staff members at Gloucester Road and be held on the staff files for review and inspection. This will help to ensure that recruitment practices meet the required standards. Supervision: • Supervision should be on a 1:1 basis once every 2 months. • Supervision notes must be maintained regularly and kept on staff files and areas of discussion in supervision must be detailed enough to cover the monitoring of work with individual residents and the analysis of care plan outcomes, support and professional guidance, and the identification of training and development needs and • Annual appraisals need to be carried out and copies held on file. DS0000013392.V336778.R01.S.doc 5. YA36 18 01/03/08 Gloucester Road (22) Version 5.2 Page 33 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 YA35 YA35 Good Practice Recommendations That an annual training needs analysis is undertaken of the whole staff group at Gloucester Road and maximum use be made of the training provision. That some externally provided training be laid on for staff that would compliment and expand the scope and range of the existing “in house” training packages. Suggested areas are in some of the most important key areas for staff skills and knowledge including: needs assessment, care planning, developing action plans, monitoring and review; POVA; and health and safety. Training needs for all the staff team should be aggregated into a training matrix that may be used by the management team to plan all future training courses in the year ahead. This will serve a dual purpose in that it will easily inform the Manager what training the staff team have received and where the gaps in training exist. 3 accidents have occurred to staff in the kitchen that may indicate a need for a review of health and safety practices in the kitchen as well as staff training. It is recommended that the Manager look at these areas so as to improve staff safety and reduce accidents. 3. YA35 4. YA42 Gloucester Road (22) DS0000013392.V336778.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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