Inspection on 25/09/08 for Gonville Road (33)

This inspection was carried out on 25th September 2008.

CSCI found this care home to be providing an Adequate service.

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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gonville Road (33) 27/09/07

Gonville Road (33) 07/09/06

Gonville Road (33) 15/11/05

Gonville Road (33) 13/05/05

Gonville Road (33) 24/11/04

Gonville Road (33) 13/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOME ADULTS 18-65 Gonville Road (33) Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE Lead Inspector Claire Taylor Key Unannounced Inspection 25 & 30 September 2008 10:00 th th Gonville Road (33) DS0000028514.V372041.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 Gonville Road (33) DS0000028514.V372041.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. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gonville Road (33) Address Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE 020 8683 4802 T/F 020 8683 4802 wilfredbovell@yahoo.co.uk 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) Wilfred Bovell Barbara Elaine Bovell Mr W Bovell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2007 Brief Description of the Service: Bovells Lodge is a small care home for up to three adults who have a learning disability. The home is situated in a residential area of Thornton Heath with good access to local transport links and amenities. There are three good- sized single bedrooms on the first floor, communal lounge, open plan dining / kitchen area, laundry and office. There is a garden to the rear of the home with paved area. The registered owner is also the manager and is very involved with the day to day running of the service. The weekly fees for a place at the home start at £1084.00 and were correct at the time of this inspection. Additional charges are payable for holidays, some activities and personal items such as toiletries. Any extras would be discussed prior to admission. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. There have been no changes in the ownership, management or service registration in the last twelve months. We spent a day and a half at the home. On our first unannounced visit, the person living in the home was due to go out for the afternoon so we completed our inspection on a second pre arranged day. Various records were looked at in relation to people’s care, staffing and the way the home was being run. One person was living in the home at the time of our visit and we were informed that two other people had started to use the service for short term or respite care breaks. We also had a look around the home and the manager/owner Mr Bovell assisted us with the inspection. We did not receive any comment cards back on this occasion but we spoke with the person who lives in the home and the part time staff to ask for their views about the service. Prior to the visit, the home returned its Annual Quality Assurance Assessment (AQAA) when we asked for it. This is a self-assessment that the provider must complete every year and is used to tell us about the services provided, how the home makes sure of good outcomes for the people using it and any planned developments. Some details from the AQAA are included in this report. What the service does well: What has improved since the last inspection? Most areas that needed attention from our last inspection had been addressed. The care plan and risk assessments had been reviewed for the person who lives permanently in the home. The manager has completed training on safeguarding vulnerable adults run by the local authority and there were plans for one staff to attend the same course. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 6 The induction programme for new staff is now based upon the Skills for Care standards which is designed to help ensure that all new staff starting in the care industry undergo a minimum level of initial training. The manager had ensured that CRB checks were completed before making a decision to recruit. Health and safety practices have improved in some areas. Fire alarms, equipment and hot water temperatures were being checked regularly to ensure safe operation. Replacement flooring has been laid in the hall and there are plans to extend it through to the dining room. What they could do better: Some progress has been made to improve the outcomes for people living at the home, but further work is required to ensure good outcomes. Two people were using the service for short-term stays, which means the home was offering respite care arrangements. This must be reflected in the Statement of Purpose and improvements are needed concerning the home’s admission process. Before admitting anyone to the home, the manager must ensure that each person’s care and support needs are fully assessed. Failure to do so means that both they and the care home cannot be assured that their needs will be met. Up to date information concerning the provision of care must be available to ensure that the staff are fully aware of each person’s assessed needs and any changes. Any person using the service must have an up to date plan of care so that staff have clear guidance on how to meet their care needs effectively and promote their health and welfare. Each person must have an up to date and relevant contract so that they have accurate information about how much they will pay and what the home provides for the money. We found that significant improvements are needed with the home’s standard of record keeping. This also applies to some aspects of record keeping required by law. We acknowledge that this is a small service, however, improvements will ensure that the rights and best interests of people living in the home are more fully safeguarded. The correct records must be held in the home for all people who use the service and this applies to individuals who stay for shortterm care. All staff now need to update training in key health and safety areas. This will ensure that people’s needs can be fully met and health and safety practices are correctly followed. One issue remains outstanding from our last inspection in that staff had not updated their fire safety training. We therefore sent a warning letter to advise that we will take enforcement action if there is another failure to comply. Staff must update their knowledge and skills in a timely manner to ensure that all people living and working in the home are kept safe. The manager needs to develop and maintain a planned supervision programme for the small staff team. Arrangements for monitoring the quality of care need improvement so that people who use the service have influence over the home’s operation and development. We need to be kept informed of any events that affect the well being of people living in the home. This is so we can track incidents and monitor whether the home has made the correct choices when dealing with events that could have put people at risk from harm. Management must therefore ensure that both they and all staff are familiar with the required guidance under regulation 37. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 7 As well as the Regulations and National Minimum Standards for Care Homes for Younger Adults, attention is drawn to various guidance and information documents that are available to service providers on our website. (www.csci.org.uk). 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. Gonville Road (33) DS0000028514.V372041.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 Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to use the service cannot be assured that their needs will be met. The absence of important information, including written needs assessments means that their care needs may not be met. Up to date contracts are also needed so that people know how much they will pay and what the home provides for the money. EVIDENCE: Since our last inspection, two people have started using the service for shortterm stays ranging from a few nights to full weeks at a time. The third person has lived at the home for many years. The home’s Statement of Purpose and Service Users Guide generally provides good information about the services on offer. The document needs amendments however so that it accurately reflects the respite care facility that the home was offering. This will ensure that people who wish to use the service are fully informed. We saw a needs assessment for the two people who stay on a respite care basis that was completed by the placing local authority of Lambeth. Both were out of date however and in need of review. The manager therefore needs to contact the placing local authority and obtain a copy of the most up to date information. Prior to admission, the home had not carried out its own needs assessment for either person. This Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 10 means that the home may admit someone without ensuring that it has the capacity and resources to meet the individual’s specific care needs. The manager must carry out a full needs assessment from the point of admission which takes into account the care the person requires, their needs, strengths and abilities. Information gained from a full assessment would enable the staff team to identify and plan for supporting the person’s needs when they came to stay at the home. The manager explained that the two people visited the home with their respective families before they started using the service. Again there were no records to reflect this. Following any new admission, the home should arrange a review meeting to check that the person is happy in the home and that it is suitable to meet their individual needs. We looked at the contract for the person who lives permanently in the home but it had not been updated since 2003. There were also no contracts for the two people who stay on a short-term basis. The contract must specify what the person is expected to pay and include accurate information about the facilities and services that people can expect to receive. Any arrangements for charging ‘additional costs’ that are not covered by the basic price of each person’s placement must also be fully reflected in their terms and conditions. Gonville Road (33) DS0000028514.V372041.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): 6, 7 and 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning and risk management process needs improvement, as it does not give assurance that people’s needs are being fully met. People are able to make decisions about their life, with support if they need it. This is because the staff promote their rights and choices. EVIDENCE: As already mentioned in the report, we saw very limited information about the two people who use the service on a short-term basis. A care plan had not been developed to guide staff in providing the most appropriate and agreed care and support for meeting each individual’s assessed needs. In addition there were no risk assessments for either person. There were some daily records but these were basic and did not give an indication of each person’s experience of their day. In response to our last inspection, a care plan review had taken place for the third person in the home in April of this year. The plan included basic information necessary to deliver the person’s care but lacked Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 12 detail and did not address any needs identified in a person centred way. We saw an old person centred plan that had not been reviewed since 2004. Each person in the home needs a care plan that is an up to date working tool used by the individual and all involved staff. A more person centred planning approach would ensure that people are offered improved opportunities to make their wishes known regarding their care and lives. We think that staff would benefit from further training in person centred care planning so that they can update their knowledge and skills and apply it to their work. We also suggest that any historical records be archived so that only relevant and up to date information is held on each person’s file. For what the home could do better the AQAA stated “we could care plan on a monthly basis.” We saw up to date risk assessments for the person who lives permanently in the home. These assessments aim to support the person to take acceptable risks whilst sustaining their independence wherever possible. E.g. safety around the home and going out in the local community. Risk plans must now be developed for the other two people who use the service to fully safeguard individuals from potential harm. Through discussion, we recognised that the owner and staff clearly know how to support the needs of each person but record keeping must improve to reflect the good provision of care. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are part of their local community and are supported to follow their personal interests and activities. Relationships with family and friends are well supported and daily routines ensure that people’s individual rights’ and responsibilities are recognised. People who use the service are offered a healthy diet and enjoy their meals at times that suit them. EVIDENCE: We looked at records related to one person’s lifestyle. These showed that they are very involved in the planning of their lifestyle and are supported to follow their chosen interests and hobbies. The person living permanently in the home goes to a day care placement two days a week and on other days, regularly attends a weekly pottery class, karate club, judo session and visit to church. The person said he likes his activities and also enjoyed a recent holiday to Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 14 Torquay. Other community activities include shopping, eating out and meeting friends at a weekly social club. During the summer, outings included trips to Plymouth and Exeter. During both visits, the one person we met appeared relaxed and comfortable in their home. Staff spoke respectfully with the person and supported them with their daily routine. The manager advised that the other two people who come to stay attend a day care centre in Lambeth during weekdays. During our second visit, the person was supported to help clean and tidy their bedroom. Care records included details about the person’s social network and who is important in their lives. Again however, similar records must be kept for the two people who stay short term. Due to the small size of the home, there were no specific menus although records are kept for all the meals provided. These showed that people are offered a varied and balanced diet that also takes into account individual choice and any cultural preferences. Meals are home cooked and the person we spoke to confirmed that they liked the food. We saw that people can eat at flexible times which fit in with their daily routines and lifestyles. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive appropriate support so that dignity and choice are maintained. Promotion of health is generally well observed although record keeping must improve so that people’s healthcare needs can be fully met. The home’s medication practices are generally well managed although some improvements will ensure better safety and consistent treatment for each person. EVIDENCE: Discussion and observations showed that staff respect people’s choices and know their preferred routines. Times for getting up and going to bed are flexible, as are mealtimes. Based on the written records we saw for the one person living permanently in the home, people generally receive appropriate support to access the health services they require. Healthcare needs including any specialist requirements, such as epilepsy, were recorded in the person’s care plan. We saw records for all medical appointments attended, with the outcomes and any follow up action required. The person sees health professionals on a regular basis to monitor and promote their well-being such Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 16 as the dentist, optician and consultant. The lack of important information for the two people who stay short term means that their healthcare needs may not be met however. Records must be kept so that staff have written guidance about the specific health and personal care support each individual requires. We suggest that the home develops health action plan books for all people using the service. These will provide a more person centred profile of an individual’s healthcare needs and detail how they will be met. We did see a health action plan for the person who lives at the home but it was dated 2004 and therefore in need of review to reflect their current needs. We saw that medication was stored correctly with records kept for its receipt and disposal. Administration charts were signed and accounted for. One person had a written profile about their medication and the reasons for its use. Medication was being reviewed at regular intervals in consultation with an appropriate healthcare professional. This is to ensure that the individual gets the correct medication regime or treatment where necessary. The manager stated that the two people who stayed for respite care brought their medication with them and that one individual was prescribed supplementary drinks to fortify their diet. As discussed throughout the report, the required records must be held in the home which includes medication records. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for complaints and protection from abuse are managed appropriately so that people who use the service feel listened to and safe. EVIDENCE: We saw a complaints policy that provides clear details of how concerns would be listened to and acted upon. We also saw one copy with symbols and pictures to make it more accessible to individuals with communication difficulties. Due to the home’s small size, informal concerns raised by individuals are addressed through discussion with staff on a day- to- day basis. There have been no complaints about this service since the last inspection. The person we spoke to knew who to talk to if they were unhappy or wanted to complain. We saw policies and procedures in place regarding the protection of vulnerable adults. The manager completed training on safeguarding vulnerable adults in July of this year and the part time staff was booked to attend the same course run by the Croydon local authority. The one person living in the home needs full support with their finances and the manager is the designated appointee. Appropriate documentation was in place with regard to income/expenditure made on their behalf as well as policies to safeguard their personal interests. We saw that accurate records are kept of all financial transactions and regular checks are made to ensure that these are correct. The manager stated that the placing local authority also undertake a check as part of the review process. These systems therefore help to ensure that people’s financial interests are safeguarded. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with safe, comfortable and homely surroundings in a house that is kept clean and well maintained. Bedrooms are designed and furnished to reflect the person’s individuality and meet their needs. EVIDENCE: The manager discussed some home improvements since our last inspection. Replacement flooring has been laid in the hall and there are plans to extend it through to the dining room. We had a look around the house which is furnished and maintained to a good standard. We viewed one person’s bedroom with their permission. The room reflected their needs, individuality and leisure interests. They had their own TV, music system and new laptop as well as other possessions that were meaningful to them. The person said they were happy with their room and liked to watch programmes on ‘Sky’ on their television. During our visit, the home was clean and tidy with good hygiene Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 19 practices in place. People living in the home are supported to join in with housekeeping tasks and the owner / manager carries out any essential repairs when needed. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment practices aim to safeguard people from unsuitable staff although some additional checks are needed to ensure that people using the service are fully protected. Some improvements with staff training have meant that people’s needs are more fully met although further training updates are needed. Improvements are still needed with staff supervision arrangements to ensure that people benefit fully from a well-supported staff team. EVIDENCE: Both the owners, Mr and Mrs. Bovell, live in the home and provide most of the care and support in a family type setting. There is one other employee who works part time and had started the required NVQ level 2 qualification in care. Observations showed that staff respect people’s individuality and support them to make daily choices. The one staff we spoke to had a good understanding of each person’s specific needs and their preferred lifestyle. The person we spoke to confirmed that they were treated well and liked going out with the staff. The other employee has left since our last inspection and the manager said he was Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 21 in the process of recruiting one more staff. Since our last inspection, recruitment practices have improved although further work is needed to ensure that people are fully protected from unsuitable staff. There are appropriate procedures to ensure that staff are vetted correctly before they begin work and we saw that the manager has ensured that CRB checks are completed before making a decision to recruit. We looked at records for the one staff employed; most of the required legal checks and documentation had been completed although there was no application form and only one reference. The correct recruitment checks must be carried out on all employees to ensure that people are fully protected. Training certificates showed that staff had refreshed their knowledge and skills in some areas although none of the team have updated their fire safety training since 2005. This was required at the last inspection and the manager must therefore arrange for both he and the staff to complete fire training as a priority. We also saw that an external auditor carried out a fire risk assessment on the premises in June 2007. The findings identified an action for staff to update their training, including the use of fire fighting equipment. Staff must update their knowledge and skills to ensure that all people living and working in the home are kept safe. We saw that the one staff employed had undertaken training in medication in December 2007 and also an induction programme based upon the Skills for Care standards in February of this year. For what the home could do better the AQAA stated “More training.” Although this is a small home and staff reported that they feel supported by the manager, formal staff supervision sessions had not been consistent or regular. The manager needs to ensure these take place regularly, focus on quality and care issues and consider any practice and development issues for the staff. Formal supervision also ensures that a worker’s job performance is regularly monitored and that staff receive support to do their jobs effectively and meet people’s needs. Following this inspection, we were sent some supervision records but the manager now needs to develop and maintain a planned supervision programme for the small staff team. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager, also one of the homeowners, has good experience and professional qualifications to run the home. Arrangements for monitoring the quality of care provided need improvement so that people who use the service have influence over the home’s operation and development. Record keeping must improve to ensure that the rights and best interests of people using the service are fully safeguarded. Some health and safety practices have improved meaning that people live in a safer environment. Staff need to update their training however in key health and safety areas. EVIDENCE: Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 23 The manger / owner Mr Bovell has been running the home since it first registered in 2003. He has achieved a relevant management qualification and an NVQ level 4 qualification in management and care. Since our last inspection, he has updated his training on safeguarding. We saw a quality assurance plan for the home but it included information about the National Minimum Standards and did not reflect the home’s specific systems for monitoring service quality. The plan should identify strengths and weaknesses in the service so that the staff team can make improvements where needed and ensure it is run in the best interests of the people who live there. Each year, the manager should seek the views of the people living there, their families/ representatives and other interested parties. Satisfaction questionnaires need to be offered and any results from these surveys should form part of the quality assurance plan. The AQAA stated, “Self audit needs to improve and we will concentrate on this in the next year.” Appropriate policies, procedures and records required for legislation are in place although they were randomly filed around the office and the owner spent unnecessary time locating some of them. We have suggested better organisation at the last two inspections and now require that the administration and record keeping systems be improved upon. This will ensure that people’s rights and best interests are safeguarded and enable easier access to the necessary files and records for staff and other relevant professionals. Information provided in the AQAA gave a reasonable picture of the current situation within the service. There were some inconsistencies however concerning the evidence to support the comments. We checked some of the servicing and maintenance records for the home. As required at our last inspection, the fire alarms, equipment and hot water temperatures were being checked regularly to ensure safe operation. Gas and electrical safety checks were carried out in April of this year. Training certificates showed that the two care staff had not updated key health and safety training since 2006. The manager explained that he plans to access further training through the local authority on courses such as moving and handling and infection control. We suggest that the manager develops a planned programme of training and development to show where refresher training is due. This will help ensure that staff update their skills and knowledge at the required intervals. Appropriate records are kept for accident and incident reporting although we must be informed of all significant events that affect a person’s well being. This is so we can track incidents and monitor whether the home has made the correct choices when dealing with events that could have put people at risk from harm. This relates to a recent event where the person living in the home went missing and we were not notified. The manager/ owner must therefore ensure that all staff are aware of the relevant guidance and tell us about any reportable events. Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 24 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 2 2 1 3 X 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 2 X 2 2 X Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES- 1 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 YA1 Regulation 4(1)(c) Requirement The Statement of Purpose must be updated to reflect the current situation in the home and explain how the needs of those who live there will be met. This is so that people who may wish to use the service can understand exactly how they will be cared for and supported. A copy of the revised Statement of Purpose must be sent to the Commission on completion. 2 YA2 14 Prior to admission, the home 30/11/08 must carry out a full needs assessment for each person. This is so that both they and their representatives can be assured that the home is capable of meeting their needs and that living in the home will suit them. Following a trial stay or settling in period, a review meeting is held to ensure that the person is happy in the home and that it is suitable to meet their individual needs. 31/12/08 Timescale for action 31/12/08 3 YA4 12(2) 14(1)(d) Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 26 4 YA5 5 (1)(c) (3) Each person needs an up to date and completed contract so that they or their representative are given full information about the services that are being arranged and what the home provides for the money. The two people who stay in the home on a respite basis must have a written plan of care and support. This is to ensure that staff have clear guidance on how to meet their care needs effectively and promote their health and welfare. Risk assessments must be written for the two people who stay in the home on a respite basis. This is to ensure that staff have clear guidance on what action to take to support their needs and promote their safety and independence. Any healthcare needs must be assessed and recorded for the two people who stay in the home on a respite basis. This is so that staff have clear guidance on how to meet and support their physical and emotional health needs. Medication administration records must be held for the two people who stay in the home on a respite basis. This is to ensure that individuals receive the correct medication they are prescribed. To ensure that individual’s welfare is safeguarded, all care staff must have received training in the Protection of Vulnerable Adults. 31/01/09 5 YA6 15 30/11/08 6 YA9 13(4b)(5) 30/11/08 7 YA19 12(1) 30/11/08 8 YA20 13(2) 30/11/08 9 YA23 13 (6) 31/01/09 Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 27 Partially met, timescale extended. 18(1)(c i) 19(5)(b) One staff still requires training in Safeguarding issues. This is to refresh their knowledge and skill in reporting and detecting abusive situations. All of the required information and vetting checks must be obtained prior to staff beginning work. Full employment histories with an explanation of any gaps must be explored and recorded. This makes sure that all people who work at the home are safe to do so. To make sure that staff are appropriately trained, all staff must have training in Fire Safety and the use of the fire fighting equipment kept at the home. This will ensure the safety of the people using the service. Previous timescale of 31/01/08 not met, warning letter sent. 12 YA36 18(2) A planned supervision and appraisal programme for staff is needed. Regular recorded supervision must be provided to guide the way staff work, to reflect on their work practices and assess their learning and development needs. Questionnaires need to be offered to people who use the service; their family/ representatives and other interested parties to assess whether the home is meeting its aims, objectives and stated purpose. DS0000028514.V372041.R01.S.doc 10 YA34 19 (1)(b) Sch 2 (6) 30/11/08 11 YA35 18 (1)(c)(i) 31/01/09 31/10/08 13 YA39 24(5) 31/01/09 Gonville Road (33) Version 5.2 Page 28 14 YA39 24(1) A suitable system is needed for 31/10/09 monitoring the quality of services provided. This needs to identify strengths and weaknesses in the service so that the staff team can make improvements where needed and ensure it is run in the best interests of the people who live there. The correct records for all people who use the service must be held by the home so that their rights and best interests are more fully safeguarded. 01/03/09 15 YA41 17(2, 3 & 4) Schedules 3&4 17(1)(a) Sch.3 (j) 16 YA42 The Commission must be notified 31/10/08 of all significant events that affect a person’s well being. This is so we can track that appropriate action has been taken and people are safe. The manager must ensure that all staff are familiar with the reporting of incidents and accidents under Regulation 37 of the Care Standards Act. All staff must update key health and safety training to ensure that people’s needs can be fully met and health and safety practices are correctly followed. 01/03/09 17 YA42 17(2) 18(1)(a) 19(5)(b) Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 29 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. Refer to Standard YA1 Good Practice Recommendations The user guide for the home should be made available in other formats such as large print or pictures. Repeated from last inspection in September 2007 2. YA2 The home contacts the relevant local authority of Lambeth and obtains up to date needs assessments for the two people who stay in the home on a respite care basis. Person centred plans should be developed with each person using the service and all staff should complete training in person centred care. This will enhance people’s involvement and contribution to their plan of care and enable staff to update their knowledge and skills. familiar with current good practice and developments. The job application form for staff is revised to include a request for a Full employment history and written explanation of any gaps. That the manager develops a planned programme of training and development to show where refresher training is due. This will help ensure that staff update their skills and knowledge at the required intervals. That the manager familiarises himself with the KLORA (Key Lines of Regulatory Assessment) guidance on meeting outcomes for people who use the service. 4. YA6 5. YA34 6. YA35 7. YA37 Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gonville Road (33) DS0000028514.V372041.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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