Inspection on 19/01/06 for Green Lane (626)

This inspection was carried out on 19th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Green Lane (626) 26/10/06

Green Lane (626) 02/03/05

Green Lane (626) 11/01/05

Green Lane (626) 25/03/04

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

CARE HOME ADULTS 18-65 Green Lane (626) 626 Green Lane Goodmayes Ilford Essex IG3 9SD Lead Inspector Stanley Phipps Unannounced Inspection 19th January 2006 10:40 Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 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 Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 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. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Green Lane (626) Address 626 Green Lane Goodmayes Ilford Essex IG3 9SD 020 8503 8392 020 8503 8392 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) Redbridge Community Housing Limited [RCHL] Ms Joycelyn Springer Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named person over 65 years of age. Date of last inspection 6th May 2005 Brief Description of the Service: 626 Green Lane is a residential home for six adults with a mental health condition and is managed and run by Redbridge Community Housing Limited. The home is situated on a main road on the outskirts of Goodmayes, and has easy access to pubs, shops and other local amenities. There are good transport links both to central London and within the local area. The home was opened in 1991, and is supported by staff on a twenty–four hour basis. Most of the current service users have lived at the home for a considerable period and as such, are growing beyond the original age criteria of the home. However, the registered persons have been employed strategies to enable them to continue to live in the home. They included occupational therapy assesments to determine the suitability of the environment in meeting the needs of individual service users as well as the provision of training for staff in diseases associated with the elderly. A key objective of the service at 626 Green Lane is working with all service users to maintain their independence whilst living in the home. Staff therefore work closely with them in ensuring that their personal, social, spiritual, psychological, mental health and general healthcare needs are met. An on-call system is in place to support staff beyond the normal working hours, including the weekends. There are bedrooms on both floors of the building, with a set of stairs allowing access to them. There is no lift facility in the building and this would have implications for service users as they grow older and become more frail. There are also toilets and bathrooms on both floors and the building also contains separate dining and lounging facilities. There is also a kitchen adequately sized and equipped to allow service users opportunities to maintain their culinary skills. A well-maintained rear garden is easily accessible to all individuals living at 626 Green Lane. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in approximately four hours and was timed to coincide with meeting service users, assessing the progress made from the last inspection including the observation of lunch. At the time of the visit the registered manager was on long-term leave and arrangements were in place to find a temporary replacement. The deputy manager assisted with the inspection process and his contribution was indeed valuable. An assessment of menus, medication charts, training records for staff, service user plans, policies and procedures and the environment was undertaken. Discussions were held with three service users, the deputy manager, along with an interview with one of the care (bank) staff. The environment assessment included the communal areas and the bedrooms of three service users. The inspection found that overall, there have been some improvements since the last inspection and service users spoken to, shared the same view. There were however further improvements that are needed to ensure full compliance with the national minimum standards for the service user group. Despite the improvements there were a number of repeated requirements i.e. little or no action has been taken by the registered providers to achieve compliance. They are repeated in this report indicating the deadline given previously. As part of enhancing the quality of the service at 626 Green Lane, it is imperative that all outstanding requirements are addressed as a matter of urgency. There were a couple of requirements around recruitment and records held on staff, that has been restated and the organisation is working with the Commission to progress them. They are considered separately, as the organisation has been outlining actions taken to date, to improve in those areas. This report covers all the national minimum standards that were not assessed at the first visit along with those standards that were not satisfied during that visit. What the service does well: The registered manager and staff continue to maintain a safe environment for service users - one that is relaxed and calm. This enables service users to interact in manner that is not pressured, as they go about their daily routines and objectives. Evidence could be drawn from the fact that despite the range of needs amongst the service user group, it was clear that they enjoyed sound periods of stability. Service users are encouraged to make positive contributions to life in the home and they found great value in, however little or great that might be e.g. washing up some dishes or helping out with the food shopping. Although their Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 6 individuality is promoted, there is a sense of family living at 626 Green Lane. They had lost within the six months – one of their colleagues and they spoke vividly of their memory of the individual. They also spoke positively of their contribution in saying goodbye to that individual and this is a credit to the management and staff of the home. The organisation is also actively seeking to involve service users in their staff recruitment process. There are plans to support service users with training, so at some stage in the future they would sit on staff recruitment panels. However service users at 626 Green Lane make their contribution to the recruitment process by meeting prospective candidates during the recruitment process, following which feedback is given to staff based on observation and non-contact interaction with candidates. This is positive. From speaking to service users it was made clear that staff were supportive of and respected the choices they made with regard to their life. This was evidenced by the fact that one service user did not see great value in continuing regular attendance to a day centre. Whilst every opportunity was given to support the individual to continue with this activity it was clear that the service user’s wishes were respected. All service users spoken to were generally pleased with the quality of food that is provided by the home. They indicated that the meals provided represented their choices as well as their nutritional requirements. Service users also described that staff were flexible in that any changes in previously agreed menus were accommodated to their satisfaction. This is positive. What has improved since the last inspection? There was as an improvement in the handling of medication in the home, in that, no unsatisfactory issues were identified at this visit. None of the service users were self-medicating at the time of the inspection and all medication charts were appropriately monitored and recorded. This ensures that service users remain safe while supported with their medicines. In discussion with the deputy manager, he advised that a review of the staffing levels did take place and it was determined that the current staffing levels were adequate and this included the staffing on night duty. He described that one of the service users who presented major concerns at night in the past, no longer provided the same levels of challenge and hence the individual was now more manageable. One service user was in hospital at the time of the visit and hence, staffing levels were deemed adequate. The registered persons did provide information regarding the actions they took in relation to how they would safeguard funds that are allocated for service users leisure. This not only indicated their awareness of issues that occurred in the past, but also that their intention to develop and safeguard the financial interests and welfare of all service users living at 626 Green Lane. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 7 In discussion with the assistant director of operations after the inspection, verification had been sought with the Learning Skills Council regarding the registered manager’s current qualifications. It was reported that some of the elements apply to achieving the NVQ Level 4, but that she would have to complete the Registered Manager’s Award component to achieve the overall NVQ Level 4 in Management and Care Award. The manager is to pursue the award in September 2006 and this would have a positive impact not only in the manager’s development, but also the service at 626 Green Lane. What they could do better: The registered persons could ensure that information regarding the service at 626 Green Lane is kept updated for benefit of both current and prospective service users. A requirement regarding this was made at the last inspection and there was no evidence that this had been complied with. The home’s statement of purpose did not reflect the current service user group, made reference to the NCSC and was dated 14/3/03. This must be improved to reflect the current position and as such needs to be reviewed. On assessing the service user plans of some service users, there were several weaknesses that were glaring in that the specific needs i.e. issues regarding an individuals mental health needs, were not recorded in the plan. Issues regarding the changing needs of another were also not recorded in the plan and in some cases forms for e.g. needs assessments were unsigned. It is not clear how the needs of each and every service user in the home, were met and as such, this needs to improve. During a tour of the environment, it was generally found in a good condition. However decorative works needs to be undertaken to the entrance area and stairwell in the home. Whilst two of the three bedrooms seen were in a satisfactory state, there was one that was really unsatisfactory and in need of repair and redecoration. This was discussed in detail with the deputy manager who explained the mitigating circumstances and while they may be so, action needs to be taken to ensure that the bedroom under discussion is redecorated at the soonest opportunity. While there is no doubt that staff work well in promoting the health, safety and welfare of service at 626 Green Lane, questions could be asked about consistency and effectiveness in doing so. Evidence at the time of the inspection indicated that service users could not go on holiday due to staffing problems. These problems ranged from staff sickness, which had an impact on the use of relief staff, to the personal circumstances of others. This is unsatisfactory and needs to improve. It was noted that whilst the organisation has developed a training plan (January to March 2006) for staff across its services, that the relief (bank) staff on duty did not receive training from the organisation. This also needs to improve. At the time of the inspection, meetings were held with the registered providers, regarding their recruitment process of staff. The Commission has Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 8 gained some confidence in the new systems in place to ensure that staff are robustly screened during the organisation’s recruitment process. The organisation presented an outline of what records they hold on staff for the protection of service users and this has also brought some reassurance to the Commission. However none of the systems has been tested and arrangements to so do have been made for later in March. As such areas marked these areas would be repeated for improvement in this report. From an assessment of the policies and procedures file, there was no evidence that improvements were made as required at the last inspection. Policies identified at the last visit still needed reviewing. Service users rights and best interests are therefore inadequately safeguarded as a result of this failing. As stated earlier the same argument would be retained with regard to the records held for the protection of service users, until a further assessment is made (Scheduled for March 2006). It was noted at the inspection visit that a risk assessment had not been undertaken in relation to the ageing population to ensure the health, safety and welfare of service users and staff. This was despite this being requirement that was made at the last inspection visit. Also and with regard to health and safety, it was observed that fire drills were carried out sporadically in the home e.g. three-monthly, four-monthly and fie-monthly with no clear pattern or rationale. This is unacceptable and does not promote the safety of service users and staff in the home. Improvements are therefore required in the areas outlined above. During a meeting held with the registered providers after the inspection, they made the Commission aware that their business plan was being developed and is earmarked for release later in March 2006. Until then, the Commission is unable to determine the financial viability of the service. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 9 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. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 10 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 Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2,4,5) Service users still require updated information about the services provided at 626 Green Lane. Despite this, their needs are thoroughly assessed, they have an opportunity to visit the home prior to admission and they benefit from having a statement of their terms and conditions issued to them, once admitted to the service. EVIDENCE: Although there is a statement of purpose available to all service users as required by regulation, this document still requires updating to be of benefit either to current or prospective service users. This document carries an implementation date of the 14/3/03, makes reference to the NCSC, makes no reference to the fact that services are provided to individuals over the age of sixty-five. It is also provided in a font size that did not take into consideration individuals who are growing older. This now needs improving as a matter of urgency. There were no new admissions since the last inspection and evidence gathered at the last inspection indicated that the needs of the service user were thoroughly assessed and informed the service user plan. This forms an integral part of the admissions process to the home and is complimented by enabling prospective service users to visit the home to have a first hand view as to how what happens there. Service users spoken to on previous visits did indicate their satisfaction with the arrangement. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 12 Once admitted, arrangements are put in place for a statement of terms and conditions to be issued to the service user. This is an important document as it sets out the rights of the service user and obligations of the provider. As confirmation of acceptance both parties sign the document with a copy place on file of the service user. This is in line with the national minimum standards and its associated regulations. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,10) The needs of service users are in most cases well documented in their individual service user plans, which are reviewed as changes occur. However the specific and changing needs of all service users must be pertinently recorded to ensure that they are followed up and provided for. Service users are involved in negotiating their daily routines and objectives. As a matter of course, they benefit from being able to contribute to all aspects of life in the home and are assured that information is held on them is handled sensitively and in their best interests. EVIDENCE: From assessing a random sample of service user plans it was observed that some contained more satisfactory recording than others. This was particularly in relation to signing off needs assessment forms, reflecting the changing needs of service users and recording the specific needs of service users e.g. their mental health needs. There was evidence good practice in the home whereby one service user was reviewed and this was a six-monthly review involving individuals from the multi-disciplinary team e.g. the consultant, social worker, the service user and an advocate. However this same service user had a completed needs assessment form that was not signed, and a result one could not ascertain who was responsible for completing and/or acting upon the information contained therein. This needs to improve. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 14 Another service user had a review in November 2005 and in this review, no reference was made to the individuals mental health needs-not even to indicate that she was either; more stable or unstable. It is therefore difficult to see how the staff could effectively support this service user in a service that is set up to provide care and support to individuals with mental health problems. There was also the case in which one service user had lost confidence in attending a social club and there was little documented evidence as to how this change in need was managed. Whilst it is fair to say that from observing service users and acquiring positive feedback from them – that there are elements of good care practice in the home, key pieces of information was not in place to substantiate this. It was evident from talking to service users, assessing minutes from their service user meetings and notes from their reviews that they were supported to make decisions in their daily lives. This is enhanced by visits once per month from an advocate who comes in and checks with them as to whether they have issues they would like assistance with. Decisions made varied from individual to individual and involved which club or day centre they attend and/or whether they pursue a religious path. The examples were not exhaustive and staff played a pivotal role in enabling them to make these decisions. There was evidence of service users being consulted as a routine part of living in the home. From assessing the minutes of service users meetings, it was found that apart from being regular, it is one of the main forums for eliciting the views of service users e.g. where they would like to holiday, how they spend their leisure time internally and out in the community, what’s acceptable behaviour in the home and the types of meals they enjoy. Two service users were able to meet with prospective applicants previous to the inspection, as part of the recruitment process and this is positive. Service users ideas are also elicited during key-work meetings and on the day of the visit, it was clear that their involvement gave them a sense of belonging at 626 Green Lane. From the interviews held with the staff on duty as well as with the deputy manager, it was clear that there was a sound awareness of how information held on service users should be safely handled for their protection. This awareness was in line with the home’s policy on confidentiality and the sharing of information with other agencies. The files of service users are securely maintained in a locked cabinet in the promotion of confidentiality. They could be accessed in line with the organisation’s access to information policy. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (11,14,15,16,17) Service users at 626 Green Lane have opportunities for personal development and participate in leisure activities of their choice. This gives them something invaluable to look forward to and helps to reinforce their rights. Meals provided are consistently of a good standard and all service users are quite pleased with them. EVIDENCE: Each service user has an individual programme of activity that reflects their choice and/or interests. In assessing their participation it was clear that individuals were at different stages of their life as levels of motivation varied from individual to individual. However it must be said that the staffing input and their strategies for motivating service users were quite good and there are bits of successes in enabling individuals to achieve their goals. It must be noted that the current service user group, as they grow older are choosing to do less and in this respect they tend to engage it activities that are the most meaningful to them. Invariably there was evidence of one service user opting out of for example, a Thursday Club last year, but preferring to go out on a shopping trip to Romford or Ilford. Service users also enjoy meals out and were out to celebrate the birthday of one of their mates just prior to the Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 16 inspection. They also benefit from coach trips for example to, Southend and Clacton–on -Sea and days out were planned for up until September 2006. Records of participation are noted in individual case files and the deputy manager indicated that a new form has been developed for this purpose. It was unfortunate that the service users were unable to have a holiday during the last year and this is covered in more detail under staffing. Where possible the relatives and friends of service users are encouraged to visit and maintain contact with their loved ones. Not many have active family involvement and as such the ethos of the home gives a sense of family living, whilst recognising individual preferences. This is crucially important as it reinforces that sense of belonging-referred to earlier. One service user maintains contact with his sister through post cards and for the service user concerned - this means a lot to him. During the inspection it was clear that the rights of service users were respected throughout most aspects of their lives. Service users were called by their preferred names, asked whether it was okay to access their rooms and most importantly had their wishes carried out. There is advocacy input available to all service users and in some cases this is take up and this is beneficial to ensuring that their rights are represented. On the day of the visit lunch comprised of cod, mash and green peas with fruit custard and cream for dessert. This was a favourite in the home and service users spoke fondly of it. They also expressed their extreme satisfaction with the meals provided and make their contributions through menu planning, assisting with the shopping, washing up and some of the preparations. Meals eaten are recorded and there was flexibility both in the meals provided and the times of serving. It was accepted that the dietary needs of the service user group were met and that this was a strong area of the home’s operations. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) Satisfactory arrangements are in place for providing personal support for service users at 626 Green Lane. Key work sessions and effective links with multi-professionals ensure that the psychological and emotional needs of service users are also met. Improvements in handling medication make it safer for all service users receiving support with their medication. EVIDENCE: During discussions with service users, they expressed their satisfaction with the quality of staff support in the home. It was acknowledged that service users needs were varied and as such the level of input was higher in some when compared to others e.g. in key areas such as personal care and dealing with more complex issues such as continuing attendance to a day centre. Service users’ records bore evidence of interventions made with them individually and it was positive that their individual preferences were taken into account. All service users were registered with a local GP and there were records on file of all appointments. This included the chiropodist, dentists and opticians. Service users have access to specialist health professionals as required e.g. the consultant psychiatrist and/or a community psychiatric nurse to provide for issues regarding their mental health. Staff work closely with them to ensure that appointments are kept and that effective links are made with these professionals to enable the service users to get the best possible care. Service Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 18 users are able to see visiting health professionals in private either in their rooms or in the staff office on the first floor and this gives them confidence that their privacy is maintained. There were improvements observed in supporting service users with medication as charts were appropriately recorded and the storage of drugs was safe. At the time of the visit none of the service users were self-medicating and as such the concern raised at the last visit is no longer there. The positive side to the handling of medication was that all drugs could be accounted for and as such medication practice and service users were safer at the home. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (23) Satisfactory arrangements are in place to ensure that service users are protected from abuse and are safe whilst living at 626 Green Lane. EVIDENCE: A satisfactory adult protection procedure is in place at the home and is accessible to all staff. The home also has a copy of the local authority’s adult protection protocol and staff spoken to was aware of this. During interviews with staff it was clear that they knew what to do if the suspected or became aware of an allegation of abuse. They were also clear on the importance of whistle blowing and how this protects service users. The organisation has training in place with regard to abuse for all staff, although the relief staff on duty informed that she had no training from the organisation. This is dealt with fuller under staffing (NMS33). Adult protection awareness is introduced as early as induction with more detailed training that follows. There was no evidence of adult protection issues in the home. As such service users remain safe at 626 Green Lane. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (24,25,27) At 626 Green Lane, service users enjoy a clean, safe and homely environment, one that they are generally comfortable with. This includes adequate and wellmaintained toilets and bathrooms. By prioritising re-decorative works to the entrance area and at least one bedroom on the first floor, the overall condition and comfort of the home could be enhanced. EVIDENCE: On the day of the visit the home was clean, homely and comfortable. However, the entrance area of the home and the walls along the stairwell appeared dull and in need of redecoration. All service users spoken to were generally pleased with their accommodation at Green Lane. An examination of three bedrooms was undertaken and two of them were satisfactory with one of them awaiting, the relaying of carpets, which the service user reportedly chose. Two service users present during the assessment of their bedrooms, which were personalised and they were extremely pleased with them. The other however was temporarily empty as the service user was in hospital and the condition of this bedroom was to say the least, unsatisfactory. This included the décor, the net curtains and the carpet. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 21 In discussion with the deputy manager, he informed that they had difficulty in acquiring the service user’s co-operation to adequately maintain his private space and that this was due to his mental state. Whilst his explanation was taken on board, the room represented a health and safety hazard and the deputy manager was advised that action needed to be taken sooner. This room must be redecorated as a matter of priority with the management exploring interventions to reduce the risk of it, returning to such an unacceptable state in the future. Toilets and bathrooms were also assessed and found to be satisfactory and maintained in line with adequately meeting the needs of the current service user group. They promoted both the independence and privacy of service users who were happy with them. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (33,34) At 626 Green Lane staff work towards meeting the needs of service users, however it is clear that at times, support for service users could be more effective. The Commission for Social Care Inspection whilst learning of improvement plans with regard to staffing recruitment is still not quite confident that service users are supported and protected by the organisation’s recruitment practice, including the recruitment of bank and agency staff. EVIDENCE: As required by the last inspection there was a review of staffing levels to ensure that the welfare and safety of service users and staff is protected and safeguarded. The outcome of this review did not result in a change in the staffing levels or their deployment and concluded that the current levels were satisfactory. There is still one individual on night duty and this was deemed adequate since the needs of one of the service users previously concerned with had become more manageable. Despite this, there were a number of concerns regarding the effectiveness of the staff team and this was highlighted based on evidence gathered from the inspection. One of the key indicators was the high usage of relief staff for reasons such as sickness. Of more concern was the finding that while service users could not go on a holiday last year, initially due to the high cost of going to Dublin, when a holiday in England was identified – problems again related to staff sickness levels and to some extent staff having personal problems prevented service users from benefiting. Further recorded evidence indicated that another holiday was outlined and this could not be fulfilled because of Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 23 staffing levels. This is unsatisfactory and whilst the reasons identified may be understandable, it for the registered persons to ensure that appropriate arrangements are made to have an effective staff team in place. To add to the concern of the effectiveness of staff, it was disclosed during a staff interview that despite the individual being on the bank for a long time and employed by the agency-that no training had been provided for her. The non-provision of training in this case included that of adult protection. This must be addressed with some urgency. As a result of previous failings by the organisation in relation to the recruitment and selection of staff, the Commission has been following up at an organisational level the progress to date in this and other areas. It has been accepted that the newly employed strategies adopted by the organisation would enhance their recruitment process, meet the national minimum standards and therefore offer greater safeguards for service users. However, this has not been tested and plans have been set towards the middle of March 2006 to so do. Until such time the requirements relating to staffing recruitment would be retained in this report. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (37,40,41,42,43) There remain good management systems in place to provide a quality service at 626 Green Lane. However, acting expeditiously on outstanding requirements, including the review of policies and procedures, undertaking risk assessments with regard to the ageing population of the home would go a long way into enhancing the overall service provision in the home. EVIDENCE: Team meetings, handovers, supervision and informal one to ones have continued at 626 Green Lane and so the key foundations remain in place to provide good support to staff which would in turn have a positive impact on service users living there. The registered persons have acted upon a recommendation from the last report and have made arrangements for the registered manager to pursue the qualification of the Registered Managers Award in September 2006. This is positive. It was noted that the registered manager is on a six-month period away from work and arrangements had been made to temporarily fill her position and this was also positive. However from evidence gathered at this inspection it was clear that several of the management requirements have not yet been fully complied with. One Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 25 example of this is the failure to review of policies and procedures that were identified in the last report e.g. Disability Employment (2001), Induction (2000) and Training (1998). As stated in the previous report one of the benefits of policy review ensures that service users and staff gain from changes in legislation that may impact on their health, welfare and/or their rights. Action must be therefore taken to improve in this area. All restated requirements are indicated in the requirements section of this report. As stated under the staffing section of this report the organisation has indicated how they are progressing to ensure that their record keeping fully protects service users and it has been accepted by the Commission that it is a step in the right direction. However this is due to be tested towards the middle of March with a visit to the organisations head office and as such, the previous requirement is retained in this report. In general the health and safety of service users and staff are promoted at 626 Green Lane. This is an area that is monitored by the assistant director of operations during her monthly provider monitoring visits to the home. However at the time of the visit, fire drills were undertaken sporadically and without any clear rationale for so doing. In some cases they were undertaken threemonthly, four-monthly and even five-monthly. The requirement is threemonthly. This practice is unsafe, puts service users and staff at risks and must be improved. A requirement made at the last inspection i.e. to conduct a risk assessment on the ageing population to ensure the health, safety and welfare had not been carried out. In discussion with the assistant director of operations following the inspection, she advised that the organisations draft guidelines on caring for the elderly had been circulated and this would set the stage for staff working with the increasingly ageing population - as in the case of Green Lane. She also advised that the manager, who is temporarily covering the home is due to carry out the assessments. This needs to be expedited in the interests of all concerned. Finally a business plan was still unavailable for inspection at the time of the visit. The registered persons advised that this should be published and sent to each of its services around the 17/3/06. The registered persons had responded to a recommendation made at the last inspection, in relation to how they planned to safeguard monies in the home for the benefit of service users and this was noted. However, the Commission is still unable to comment on the financial viability of the service and needs to have sighting of the relevant information. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 26 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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 3 28 X 29 X 30 x STAFFING Standard No Score 31 X 32 X 33 2 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X X 2 2 2 2 Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered persons must ensure that the statement of purpose is reviewed to accurately reflect the current service provision, and to produce an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions in relation to the care of the ageing service user group. This document must also contain updated details of the Commission. (Previous timescale of 31/7/05 - not met). The registered persons are required to ensure that (i) needs assessments for all service users are signed and dated (ii) service user reviews take into consideration their specialist needs i.e. mental health with duly recorded actions and (iii) all service user plans reflect their changing needs. The registered persons are required to redecorate the entrance area of the home with specific reference to the walls DS0000025902.V278614.R01.S.doc Timescale for action 15/05/06 2 YA6 12,13 31/05/06 3 YA24 23 15/06/06 Green Lane (626) Version 5.1 Page 28 4 YA25 23 from the ground floor entry, rising up into the stairwell. The registered persons are required to redecorate and replace carpets, net curtains and, other soft furnishings as necessary in the service user’s (PD) bedroom. The registered persons are required to (i) keep the staffing in the home under review to ensure that the needs of service users (including their social) are adequately met at all times and (ii) Provide training for relief staff in line with the homes training plan. (The latter must be prioritised for those staff, most frequently used). The registered persons are required to ensure that two references are obtained for all staff prior to commencing work. They are also required to ensure that their recruitment procedure is robust and in line with regulation. (This is a restated requirement). The registered persons are required to review their policies and procedures as identified in standard (40) of this report, in line with regulation. (Previous timescale of 30/7/05 - not met). The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For new staff, before appointment. For existing staff, See next Column. (This is a restated requirement). The registered persons must DS0000025902.V278614.R01.S.doc 31/05/06 5 YA33 19 31/05/06 6 YA34 19 30/04/06 7 YA40 12 30/04/06 8 YA41 19 30/04/06 9 YA42 13 15/05/06 Version 5.1 Page 29 Green Lane (626) undertake risk assessments in relation to the ageing population, to ensure the health, safety and welfare of service users and staff. (Previous timescale of 30/06/05 – not met). 10 YA42 13 The registered persons are required to ensure that fire drills are routinely carried out at three-monthly intervals with appropriate records kept. The registered persons are required to have a business plan for the service that is available for inspection. (Previous timescale of 30/06/05 – not met). 15/05/06 11 YA43 25 30/04/06 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 YA25 Good Practice Recommendations The registered persons should develop a system that reduces the risk of the private spaces of individuals (who may be challenging) from becoming a health and safety hazard. Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Green Lane (626) DS0000025902.V278614.R01.S.doc Version 5.1 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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