Inspection on 14/08/06 for Green The (3)

This inspection was carried out on 14th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Green The (3) 23/08/07

Green The (3) 17/01/06

Green The (3) 11/10/05

Green The (3) 10/02/05

Green The (3) 24/06/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Green The (3) 3 The Green Sutton Surrey SM1 1QT Lead Inspector David Pennells Key Unannounced Inspection 14th August 2006 12:00p Green The (3) DS0000007140.V303419.R02.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 Green The (3) DS0000007140.V303419.R02.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. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green The (3) Address 3 The Green Sutton Surrey SM1 1QT 020 8641 9348 020 8644 5399 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) www.caremanagementgroup.com Care Management Group Limited Mr Simon Daniel Burrowes Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 17th January 2006 Brief Description of the Service: 3, The Green, Sutton is owned, managed and staffed by the Care Management Group (CMG). The home provides residential care for up to seven male adults with learning disabilities and associated challenging behaviour / mental health problems. The home is a large detached Victorian property situated just to the north of Sutton Town Centre - close to local shops, transport links and this busy town’s many social, commercial and educational amenities. The main house has six single bedrooms, and communal space comprises of a main lounge and conservatory (which is used as a smoking room), a separate dining room, and a kitchen. There are sufficient bathrooms and toilet facilities located throughout the home for the resident population. Across a courtyard there is a small laundry room, a games room - and the manager’s office is located beyond this well-used facility. Upstairs in this ‘stable’ block, there is also a bed-sitting room - which acts as a separate self-contained ‘flatlet’, used for the encouragement and development of a single service user’s independence skills. There is limited parking on site at the front and side of the house, and onstreet spaces available on ‘The Green’ itself. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The aim of this inspection visit was to review the ‘core standards’ relating to younger adults, to meet with staff and service users, and to review the requirements and recommendations from the last visit. Arriving at lunchtime, the inspector was able to meet morning shift staff before the handover time when the afternoon staffing came on duty. The afternoon provided time spent viewing documentation, assisted by the deputy manager - Jason Waddick. The home manager, Simon Burrowes, was on leave - but contributed to the inspection data both by completing a pre-inspection questionnaire, which had been previously returned to the Commission, and by his presence at a subsequent lunchtime visit to the home on 17th August. Following his time in the home on the first day, the inspector left at approximately 8.15pm, having spent some time speaking to - and engaging with - service users, a relative, and staff members. The inspector is grateful for the co-operation, the hospitality and welcome afforded to him throughout the inspection process. The inspector is particularly grateful to the deputy manager for his assistance on the first day’s visit. What the service does well: What has improved since the last inspection? The home has been provided with a new shower unit in one of the downstairs toilets - providing an excellent and well-used facility for service users. Carpeting in the hallway and lounge has been replaced. Redecoration and refurbishment continues to be a feature of the overarching plan to keep the fabric of the building at an acceptably high standard. The previous requirement that fridge and freezer temperatures be rigorously maintained had been adhered to, documentation now showing a consistent approach to this important food safety aspect. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Prospective and current service users can be assured they will have their needs assessed, recognised and appropriately recorded by the home. Quality in this outcome area is good. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: The population of seven service users at the home has been constant since November 2004; two service users have resided at the home since before the Millennium celebrations (1999 & 1996), with an arrival in 2001, one in 2002 and three in total arriving in 2004. The service user group’s age spans from late teens to late thirties; the average age being around 29. This constancy / stability of service user has been fundamental to the progress of a number of the service user’s wellbeing; their behaviour programmes being constantly implemented thanks to the stability this long-term residence brings. The organisation has a dedicated Assessment Team that ensures that all necessary information is accrued prior to an admission to the home. The judgement statement above covers the checked standard within this section; the remaining standards were not inspected at this visit; it is known, however that they were found ‘met’ in the previous inspection cycle, and there is nothing to suggest to the inspector that any of the issues have changed fundamentally at the home. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 9 Service users are in regular contact with both health and social care professionals, including GPs, Care Managers, and community based mental healthcare professionals, all of whom are able to check that assessed needs of each individual is being met. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. The home creates and maintains care plans and assessment documents designed to ensure that the needs of service users are realistically met in an individually focused way. Service users can be assured that their rights to individuality and selfexpression are protected, whilst acknowledging the community aspect of living at The Green. Service users can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. Quality in this outcome area is good. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: Care plans tracked were fully comprehensive and current in content. Care plans are reviewed and updated after the collation of a monthly review by the dedicated keyworker - this reflecting on achievements and changing needs. Care plan reviews were timetabled into a formal cycle of structured reviews. The home is very keen to encourage those service users who are willing and able, and (where appropriate) with support, to manage their own financial Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 11 affairs. The home maintains a good financial record-keeping process, with a ‘transparent’ financial auditing system being used. Risk assessments were in place for all of the service users covering various aspects of care, including personal hygiene, community presence, and specific behaviours likely to challenge the service. Each assessment identifies the risk, the likely consequences, and the action required to minimise the risk’s negative effect. Individualised guidelines (i.e. risk management strategies) for service users assessed as likely to be aggressive or to self-harm have also been drawn up, with the involvement of specialist care professionals as appropriate. Some risk assessments were noted to be slightly out of date and a review of all such documentation is recommended. Staff members support service users to take ‘responsible’ risks as part of the process of enabling them to maintain and develop their independent living skills. Potential risks and hazards are assessed (under broadly identified headings such as: Relationships / Community access / Aggressive behaviour / Electrical hazards / Fire precautions / etc), and are recorded in each individual service user’s care plan. It was very evident from the individualised care plans that - based on an assessment of acceptable risk and safety criteria - staff encourage service users to take ‘reasonable’ risks, whenever possible - and to live their lives to the full. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 & 17. Service users can expect their lifestyles at the home to be individually focused and aimed at personal development. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choice and decision-making. Activities provided and pursued ensure positive engagement within the home and especially the local community, as far as is practicable, whilst acknowledging and respecting each individual’s needs and capacities. Service users can expect to be provided with a good standard of nutritious and interesting food, whilst acknowledging the right to their own stated choice and ensuring that mealtimes are a pleasant and enjoyable time. Quality in this outcome area is good. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: The programmes of activities noted in respect of service users who files were case-tracked showed significant engagements with the ‘outside world’ - and Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 13 evidenced the home’s staff making substantial efforts to ensure that opportunities to engage with the local community - and to find rewarding occupation and recreation - are key to each individual service user. Many service users engage with local colleges and a number have occupational focuses - such as helping out on a regular basis in charity shops, etc. Two service users were expected to start attending an extensive three-year Life Skills Course at NESCOT on a five-day a week basis very soon after the inspection visit. The home is again commended for the effort they make in this regard - clearly no stone is left unturned when seeking out appropriate and stimulating activities for the service users. Arts & crafts, table tennis, pool, karaoke, books, videos and computers are the variety of opportunities pursued at home. Cinema, bowling, ice skating, attending the library, colleges and social clubs are examples of external activity – as well as other social activities such a going to the pub and out with family / friends. Family contacts are clearly vitally important to most service users. Some family contacts are local, and service users can visit independently, whereas some relatives are some distance away and visit, or even contact, the home very infrequently. The home does make positive efforts, generally, to keep in contact. One service user is married and spends times with his wife & child, and her family. Visitors to the home are enabled either to spend time in the service user’s own room, or the conservatory is made available to them. The dining room is also available for use - and lends itself to more formal / officialstyle meetings / encounters. Holidays enjoyed this year will include a trip to Malta for two service users (with two staff) and four have been to Yarmouth - accompanied by three staff members. Feedback to the CMG quality assurance questionnaire at the home showed from three interviewees - their overall happiness with the placement of ‘their’ service user. One care manager and one of the home’s general practitioners had responded to the Commission’s questionnaire and both indicated broad satisfaction with the care provided by the service. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 14 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. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s daily service input and through longer-term assessment and care planning programme. The systems adopted by the home regarding medication should ensure the safety and consistent treatment and support for each service user, provided that tight attention is paid to all relevant records. Quality in this outcome area is adequate to poor. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: The care and support provided by the home is generally appropriate and sensitive to the needs of the individual. Routines are very flexible and guidance and support is ‘second nature’ to the staff - who are able to ‘live alongside’ the service users, integrating support and assistance as appropriate. Service users clearly choose their own clothes and initiate their own day-today activities; service users are supported by staff in activities and their daily routines - and by keyworkers in particular. Each service user clearly is treated as an individual, and keyworkers are responsible for the ongoing persuasion / encouragement of engagement with fulfilling and enjoyable pursuits. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 15 All service users have access to local community health services, including local GPs for all, and other paramedical services - as appropriate and preferred (accessing two different chiropody services, for instance); local community opticians and dental surgeries are used. Service users are encouraged to take control of their healthcare needs (e.g. arranging their own appointments), in accordance with the homes philosophy of promoting privacy, dignity and independence. A number of service users are supported with psychiatric ‘visits’ on a regular basis. The home has excellent liaison contact with mental health services and those professionals associated with Learning Disability services in Sutton. Record keeping in regard to service users health care appointments is well ordered, and weight charts are maintained on a monthly basis. Concerns regarding the accuracy of ‘prn’ (‘when required’) medication details and records previously raised at the home were, after examination of actual individual ‘prn’ guidance, raised again at this visit. It became apparent that in regard to one service user, the allocated discretionary medication could have been administered in a number of different ways. In respect of a second service user, a relatively recent letter from the psychiatrist had indicated that the ‘prn’ medication still available to this person was - seemingly - no longer on their ‘approved’ list of current medication. Accuracy is absolutely essential in this regard - and the home has been previously challenged to resolve any variations in advice given. A Statutory Notice has therefore been served on the home, to emphasise the importance of rigorously clear instructions in this area of medication administration. It was also noted that during a recent shift (Sunday 13/08/06 - pm) due to the sickness absence of a senior support worker, two support workers were left to staff the building and the senior in charge that morning used a process of secondary dispensing to leave out medication for service users, rather than leave the on-call senior to come in to manage the medication. The senior had also signed (presumably before going off duty) that service users had taken their tablets -when this could not be verified by him. This practice of secondary dispensing is against all best practice advice and guidance, and so also such recording practices - which can be the route for potential mistake / error. Such practices must not be allowed at the home. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 16 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): 22 & 23. Service users and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescale. The home provides adequate support to service users to ensure that they are protected from harm, neglect and any form of abuse, though attention must be paid to ensuring that the correct documentation is held. Quality in this outcome area is generally good. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: The home’s complaints procedure is included (in symbols format) in the Statement of Purpose / Information Handbook and contains information about how a complainant can contact the Commission should they wish to do so. The procedure has clear timescales given, so that a complainant knows what to expect - and time frames for the resolution of such complaints. A record book for all concerns / complaints made about the service at the home is kept. The CMG Company’s training for staff under the title: “Dignified Management of Conflict” (Simon Burrowes is a trainer) - alongside the “Understanding Challenging Behaviour” course provided, ensures that service users are only restrained when absolutely necessary, and even then treated with respect in such challenging situations to avoid issues of possible abuse. The CMG Policy and procedure for ‘Alleged Abuse’ now refers directly to the Local Authority’s Guidelines for dealing with any incidents of Adult Abuse. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 17 It was noted that the home was still operating with the 2002 version of the London Borough of Sutton Vulnerable adult guidelines; this had been superseded in 2005 by a new version of the Multi-Agency Policy - and should have been provided by the Council to the home. The home’s manager was encouraged to contact the Borough without delay to obtain the revised version. Green The (3) DS0000007140.V303419.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30. Service users can expect to live in a generally clean, warm and comfortable environment designed to meet their needs and providing adequate communal services and domestic facilities. Service users can be assured that, once the bedrooms have been reassessed for adequate fittings and furnishings, the home will be a comfortable, safe and hygienic environment in which to live, without unnecessary risk. Quality in this outcome area is, overall, good. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: The house, a detached Victorian building, stands in its own grounds overlooking a green at the north end of Sutton town centre. This enables service users and staff to easily access a myriad of resources - leisure, shopping, transport and other facilities. The house has been generally well maintained, with the staff being able to access the ‘handyperson team’ of CMG to address general maintenance issues, or to access appropriate service engineers for the specialist equipment in the home. The garden area was noted to be much improved and pleasant - an ideal location for a recent CMG celebratory party. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 19 Although an ‘existing home’, The Green’s main building provides bedrooms of a size well in excess of the minimum national standard; the smallest bedroom is 12.3 sq metres in dimension, and the largest is 18.2 sq metres. Communal space on the ground floor is also clearly well above the minimum required but necessary to ensure that service users have sufficient space to be themselves and not to ‘overcrowd’. The Independent Living Flat measures 18.9 sq metres and has its own bathroom entirely separate to this (‘ensuite’). Carpet replacement in the main hallway and lounge has now been completed and new kitchen units and equipment have been installed - this leading to a substantial upgrade in the quality of the service user’s ground floor environment. The main lounge is spacious and comfortably furnished; the conservatory is a popular place to meet visitors and to ‘have a smoke’. The dining room is also a good size and the ‘annexe’ and garden provide space for sporting pursuits. A new shower room facility on the ground floor has also been added - and is clearly a useful new resource for the home - now providing a variety of bathing possibilities, alongside the bath upstairs. One service user’s bedroom was visited and reviewed, and the furnishing was noted to be relatively poor for a service user who has little difficulty in managing his environment; there were no handles on the chest of drawers, and a high window had no curtaining - whilst curtaining to the lower window was in poor condition. Whilst accepting that some bedrooms may well be sparsely furnished due to challenging behaviour, and / or an individual’s preference, those who do have a capacity to enjoy such facilities must be given the best opportunities to maintain a high standard of furnishing. A comprehensive review of bedroom furnishings and fittings is required. Office space (both the first floor staff office and the manager’s space) requires ongoing refurbishment - to make the environment more pleasant to sit in and more ‘office-like’ to encourage a culture of professionalism, and to make staff members feel a little more ‘valued’. An identified danger in the main building office of a shelf holding many heavy ring binders immediately above the desk at a height of six feet or so, presents as a potential health & safety danger. The home was clean and odour-free on the day of the inspection. Service user’s room cleanliness is self-managed - though staff intervention may be invoked if the situation was becoming too difficult for a service user to manage. The cleanliness of communal areas is also a joint responsibility between service users and staff. Green The (3) DS0000007140.V303419.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Service users can rely on the home providing adequate staff in sufficient numbers and being duly competent, to provide a service that strives to meet the service users’ individually identified needs. The home’s recruitment and staff support mechanisms are generally organised so as to ensure the safety, protection and wellbeing of service users, though attention must be focused on ensuring adequate induction is carried out in a timely way, that new starters are properly checked before starting work, and that the deficit in First Aid training for staff is addressed. Quality in this outcome area is poor. This judgment had been made using evidence gathered both before and during the visit to this service. EVIDENCE: Thirteen staff members currently are employed to provide the service on a basis of three staff per daytime shift with the manager in addition, and a separate waking night shift. The home was ‘down’ three full time support worker staff at the time of the inspection - this leading to a number of additional shifts being worked by current staff, the manager engaging more with service users ‘hands on’ - and bank staff covering a number of shifts. A reduced staffing level of two over a Sunday afternoon resulted in the morning shift senior not handing on to the senior on call the fact that staffing Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 21 would be running below the usual level - and this resulted in the ‘compromise’ of medication being inappropriately secondarily dispensed from their source containers (see narrative regarding standard 20). The inspector tracked two staff files - those of two of the most recent ‘new starters’. This exercise was purposefully undertaken, as an Immediate Requirement Notice served on the home at the last unannounced inspection visit highlighted the need to improve induction training / recording and to be vigilant in meeting the regulatory requirements concerning starting staff when a PoVAFirst rather than a full CRB check was in place. It became evident that a staff member had worked for twenty-eight days throughout June 2006 on a PoVAFirst check without the necessary extra supervisory arrangements being put in place, or the Commission being notified of this ‘extraordinary’ arrangement (under Regulation 37(e)). There was also no evidence of any induction being recorded / completed for this staff member. The other new starter had only completed their induction documentation on 09/08/06 - they had started work on 15/05/06; at least two of the documents relating to ‘mandatory’ induction were expected by the registered provider to be completed ‘within two weeks’ of the staff member starting. Due to the issues above being subject to an Immediate Requirement Notice previously, the Commission has subsequently served a Statutory Notice to the registered provider in regard of 3, The Green - relating to both recruitment checks and induction training. A requirement is also set in this report seeking notification by the manager to the Commission of any new staff commencing employment at the home, furnishing details of their employment status and details of their induction and supervision. As well as the manager being quite close to the completion of his Registered Manager’s Award at NVQ Level 4, one support worker has a Diploma in Social Work, and two further staff members are undertaking their NVQ at Level 2. It was stated that a number of staff members were keen to ‘get going’ on their NVQs – but the Company’s scheme – for historical reasons – could not take on any further trainees for the present. The care staff team will clearly not, therefore, achieve the previous inspection requirement that at least 50 of them should be qualified to minimally NVQ Level 2 by the end of 2006 (already a year later than the NMS deadline). The registered provider must address such deficits and evidence, in an action plan, intentions to meet this shortfall. First Aid training must be seen as a priority in the immediate short term; assessment of certification held at the home suggested that only one member of staff was still within their three year time window of being qualified at any level to practice as a First Aider. The home must aim to cover each shift with at least one worker so qualified. Green The (3) DS0000007140.V303419.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. The home operates management systems that should ensure that service users benefit from a well-run, competently managed and safe environment, provided the manager has sufficient time to manage the systems competently. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to policies & procedures, and the day-to-day conduct of the home. Record keeping, however, requires a stronger focus. Service users can be assured that their welfare, health and safety is, in general, safeguarded through the home’s adherence to appropriate guidance and regulatory framework concerning best safety practice. Quality in this outcome area is adequate. This judgment had been made using evidence gathered both before and during the inspection of this service. Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 23 EVIDENCE: Simon Burrowes, the registered manager Simon has more than three year’s management experience working in the home, where he has worked since February 1991. He is currently undertaking NVQ Level 4 in Management and Care; the home’s manager told the Inspector that there had been a six-month delay in the completion of his course to attain the Registered Manager Award at NVQ Level 4; the final stages were expected soon. This delay is regrettable; as such a large responsibility ‘hanging over’ a manager is not helpful especially as the home is currently short-staffed. Unannounced visits by representatives of the registered provider are clearly being carried out on a regular basis and the subsequent reports are being forwarded to the Commission. Such visits involve checking documentation, inspecting the premises and interviewing both service users and staff. Quality Assurance surveys are regularly sent out to relatives, friends and representatives / advocates of service users to encourage feedback about the quality of the service provided. The responses are received centrally and collated, prior to being sent on to the home itself. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes ‘Resident Times’ as well as the more global in-house staff magazine. The home has now received a substantial Quality Assurance file - which requires focused work and will challenge the management whilst permanent staffing is short at the home. Evidence was found on the day of the inspection that not all significant events were notified to the Commission under the home’s Regulation 37 responsibility - such as the assault of a staff member, the use of ‘Dignified Management’ (planned restraint) and the scalding of a service user whilst away on holiday. Failures of notifying such significant events are again evidence of the management not being positioned to ensure that such formal notifications / obligations have been undertaken. The manager was requested to furnish full details concerning the scalding incident - including details of the issues raised concerning the holiday venue’s response to the home’s complaint. The manager is also reminded that records of events - even when providing a service away from the home - must be made of significant issues arising, reflecting the provider’s ongoing burden and responsibility of care. As four incidents - all of which were of some significance - had not been reported, a Statutory Notice has been served on the registered providers in respect of 3, The Green - to ensure full compliance with such regulatory requirements for the future. Green The (3) DS0000007140.V303419.R02.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X 1 2 X Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) & 17 Requirement Statutory Notice Issued: Information and guidance especially relating to ‘prn’ (discretionary) medication must be rigorously maintained and immediately updated as necessary (see text above). Timescales of 18/10/05 & 21/02/06 not met. Provision of trained / qualified levels of staff must always be made to ensure that the practice of ‘secondary dispensing’ of medication is never allowed to be practiced at the home. Furniture and furnishings must be reviewed in service users’ bedrooms to ensure that there are adequate and appropriate facilities provided to each service user, according to their needs and temperaments. Furniture & furnishings in the first floor office must be improved to make the environment more pleasant DS0000007140.V303419.R02.S.doc Timescale for action 05/10/06 2. YA20 13(2) 17/08/06 3. YA26 16(2)(c) 20/10/06 4. YA28 23(3)& 12(5) 20/10/06 Green The (3) Version 5.2 Page 26 and more ‘office-like’ to encourage a culture of professionalism, and to indicate the value staff and their written / recording work are held in. Timescales of 15/12/05 & 15/02/06 not met. 5. YA32 18(1) A minimum of 50 of the care staff team must be qualified nominally to NVQ Level 2 in care as soon as practicable. An action plan must be sent to the Commission stating how this deficit will be rectified. Standard timescale of 31/12/05 now exceeded; carried forward from the previous inspection. Statutory Notice Issued: That all staff must be thoroughly checked by rigorous pre-employment checks prior to being allowed to work under a PoVAFirst check rather than the full Criminal Records Bureau Enhanced Level check. Immediate Requirement Notice previously set with timescale of 23/01/06. That when new staff members start at 3, The Green, the Commission must be formally notified of their starting date, including details of their employment status and confirming arrangements for their induction and supervision. 31/12/06 6. YA34 19 05/10/06 7. YA34 18 & 19 01/10/06 8. YA35 17 - Sch 4 & Statutory Notice Issued: 18 Induction training must be carefully monitored and completed - for all new staff starting work at the home - in line with the company’s respective stated timescales. DS0000007140.V303419.R02.S.doc 05/10/06 Green The (3) Version 5.2 Page 27 Part of Immediate Requirement Notice previously set with timescale of 23/01/06. 9. YA35 13(4) First Aid training must be provided to ensure that trained & qualified staff members at the home cover the staff rota on a continuous basis (24/7). The registered provider must ensure that the manager is provided with sufficient time & resources to ensure that managerial and statutory responsibilities are carried out effectively at the home. Statutory Notice Issued: All significant incidents which occur, affecting the welfare and or wellbeing of a service user, even if off site from the home itself, must be notified to the Commission in line with the statutory requirements of Regulation 37. Full details concerning the incident involving the scalding of a service user whilst on a holiday away from the home but under the supervision of the home’s staff - must be sent to the Commission without delay. 31/12/06 10 YA37 10(1) 30/09/06 11. YA41 37 05/10/06 12. YA42 37 01/10/06 Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 28 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 YA9 Good Practice Recommendations It is recommended that service users risk assessments should be reviewed to ensure that all are maintained as up-to-date and ‘current’ documents. The home should access a copy of the London Borough of Sutton’s current (2005) Vulnerable Adult multi-agency policy and procedure to replace the presently held out of date (2002) document. The registered manager should be qualified to NVQ Level 4 in Management and Care. Mr Burrowes is now close to completion of his course. 2. YA23 3. YA37 Green The (3) DS0000007140.V303419.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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