Inspection on 05/02/08 for Grosvenor Terrace, 52-60

This inspection was carried out on 5th February 2008.

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

Other inspections for this house

Grosvenor Terrace, 52-60 16/02/09

Grosvenor Terrace, 52-60 18/12/06

Grosvenor Terrace, 52-60 18/05/06

Grosvenor Terrace, 52-60 18/10/05

Grosvenor Terrace, 52-60 02/06/05

Grosvenor Terrace, 52-60 11/11/04

Grosvenor Terrace, 52-60 23/08/04

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 Grosvenor Terrace, 52/60 Camberwell London SE5 0NP Lead Inspector Mary Magee Unannounced Inspection 5 &13 February 2008 10:00 th th Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 52/60 Address Camberwell London SE5 0NP 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) 020 7277 1619 020 7277 1619 52grosvenor@odysseycsft.org www.odyssey-csft.org Odyssey Care Solutions for Today Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 Brief Description of the Service: 52-60 Grosvenor Terrace is a home that has single rooms for eight service users with learning disabilities. It is in a residential street just a short distance from the shopping area of Walworth Road. The home is made up of two large Victorian terraced houses that are connected with a garden and patio at the back. There is a disabled parking bay outside the home that is used for the home’s minibus. On the ground floor are 2 bedrooms that are wheelchair accessible. No 60 has a specially adapted kitchen for wheelchair users. The home is close to local shops, entertainment and public amenities. There is no lift in the home. There were no vacancies at the time of this inspection and all the current service users have been at the home for a number of years. The service user part of the fees for a place at this home are £62.35. There are contributions towards transport of £4.25 if on the lower rate of Disability Living allowance or £11.06 if on the higher rate of Disability Living Allowance. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. ‘The quality rating for this service is 1 star, This means the people who use this service experience adequate, quality outcomes. This unannounced inspection lasted over two days. A tour of the premises was made, all communal areas were seen as well as four bedrooms. The newly appointed manager was into his second day of employment when the inspection began Present during the inspection period and assisting with the process were two deputy managers. Three permanent support staff were spoken with, also three agency staff met with the inspector over this inspection period. All service users were seen over the two days, they acknowledged and communicated using signs and gestures. One service user is able to express himself verbally, he spoke freely to the inspector of life at the home. Two relatives were spoken to; comment cards were received from two service users and two staff members. A Quality Self Assurance Assessment was completed by the home and submitted prior to the inspection. What the service does well: There are a number of positive aspects of this service, • • • • • • • • • Staff find out what service users want and write this down for them in care plans. Staff help service users make decisions. Service users get to go out and do the things they want to do. Staff make sure service users go to the doctor when they need to. Staff give prescribed medication to service users at the agreed times. Staff protect service users from people who might hurt them. Service users have their own bedrooms and they are attractively decorated. The home is clean and comfortable. People living at the home feel secure and safe with a number of staff that are familiar with them. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 6 • Relatives like the fact that there are regular staff members present that know how to communicate with and respond to service users. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.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 Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate, 2 3 This judgement has been made using available evidence including a visit to this service. The staff team carries a number of vacancies. The use of agency temporary staff means that the service is not as consistent or as good as it should be. EVIDENCE: We met all eight service users, they have lived at the home for a number of years. The home was owned by the local authority (Southwark) until four years ago when it transferred to an external provider called Odyssey. Care management initially referred all current service users. Individual care plans have been developed for/with service users based on the care management assessments and the homes own assessments. The home has a number of skilled staff that have worked in the home for some years. They are familiar with service users and know how to meet their needs. However there are five staff vacancies that are filled by agency staff. This is not satisfactory as it affects continuity, a deterioration has taken place in the management of records. Some of the temporary staff engaged lack the essential experience and skills, communication skills also show shortfalls. A requirement was stated in the previous inspection of December 2006. This has not been addressed. The requirement is restated. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 9 The staff team is not fully reflecting the ethnic composition of service users, this should be addressed. A recommendation is made. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff work with service users to find out what support they need, what may harm them and what help they may need. The information is recorded in care plans and risk assessments. Staff are knowledgeable on individual support needs but there are inconsistencies in how key workers/support staff operate. Because of the inconsistencies record keeping is not always kept up to date. As a result of this shortfall there maybe service users that are not supported to do things that would make them more independent EVIDENCE: Personal care and support plans are in place for service users. Generally they have improved since the last inspection but the improvement has not been sustained in all areas. Individual member staff (permanent) spoken to demonstrate a good knowledge of service users’ needs. They were observed to work well with service users and understand their mode of communication. Service users appear at ease using the communal facilities and participate in many aspects Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 11 of life at the home. One service user spoke positively of the support he receives. The mother of another service user finds that the home delivers well the care and support her son requires, his needs have changed in the past year and staff responded appropriately to these. The mother of another service user finds that basic needs are met in the home but the service was affected in recent months by the lack of management. “Some carers are not enthusiastic or motivated unless a manager is present to direct them” was the comment received from a relative. We case tracked how two service users are supported. Key workers are allocated to support both individuals, this ensures that communication is effective. A number of service users are non verbal, it is important that regular consistent staff are available to work with individuals. Referred to in Staffing Standards. Inconsistencies are evident in the recording rather than the service delivery. this relies entirely on the member of staff responsible for the one to one support. There is evidence that care plans and risk assessments were managed well up until October 2007 when the manager moved to another service. Since then there are marked differences in the record keeping. For one service user the care plan in place is well maintained, contains clear short and long term goals, is dated accurately and was recently reviewed. Records show that action identified in the service user reviews is carried out in a timely manner. The key worker when spoken to appeared very knowledgeable and motivated. A parent spoken to also commented positively on the contribution this staff member makes to service users’ lives. The risk assessment records contain information for each service user on any risks associated with supporting the individual, including challenging behaviour and how to manage these effectively and safely. For another service user although he has a regular key worker the record keeping is not always reliable and up to date. There is evidence that the service user is supported with daily routines and is working towards achieving his goals. There is a lack of monitoring reports. The records are not reflecting that the key worker is regularly reviewing the needs or the risk assessments. Quarterly evaluations are undertaken for all service users, and sent to the local authority. However according to the records of copies held on files dates have been omitted from some of these records since November 2007. Because of the variations in record keeping a third service user’s file was viewed. This contained up to date care plans and risk assessments. It is evident that some key workers undertake fully the duties assigned and complete the necessary documentation. Overall attention is needed in how personnel records for service users are managed. According to some support workers interviewed when the key Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 12 worker is absent, the replacement worker is not completing the necessary documentation. The newly appointed manager recognises that there are performance issues, also why some records have not been completed as staff have had to manage additional workloads. He had arranged to meet with individual members of staff to discuss this. As two of the three service user files were well maintained a requirement is stated that an audit be done of all service users’ files and that any areas of shortfalls identified in care planning and risks assessment records are addressed. Staff are responding to recommendations made in regular reviews both in house and statutory. A number of statutory reviews remain outstanding. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual weekly programmes that include doing things they enjoy both in and outside of the home. The rights of service users are respected. Lack of attention is given to individual preferences and dietary needs. The home provided is not always providing meals that promote the health and well being of individuals. EVIDENCE: Service users have individual weekly programmes that include doing things in and outside of the home. Some of the information on activity plans is old and should be updated. The home has not kept up to date recently the records to demonstrate the level of participation in activity plans. A recommendation made. One service user told of attending college and learning cookery skills. The majority engage in regular community activity such as day centre or college or swimming. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 14 There also social clubs in the community for people with learning disabilities, individuals like to go to for socialising with their own age group. Service users enjoy annual holidays. Recent cutbacks were experienced in community day care activities with fewer days for day centre activities available. For some service users this means that they are at the home more frequently. One relative felt that more in house stimulation could be provided. A recommendation is made However at the time of inspection service users were out for lunch and participating in other events in the community. The home benefits from the use of a mini bus it shares with a sister home in the street. . Relatives are welcome at the home. Service users receive visitors without restriction and staff support service users to keep in touch with their families. Supper was being prepared during the first day of the inspection. Menus on display in the dining room were out of date and not service user friendly. Also displayed on the board is old guidance from the dietician. However menus in picture formats replaced these on day two of the inspection. Consideration is not given to responding to individual needs or preferences. Two agency staff members prepared the evening meal, not much thought or preparation was needed as the meals consisted of frozen chicken pies and vegetables and needed cooking in the oven for short periods. Neither staff were familiar with any particular needs or preferences and demonstrated that it was just another chore to be done. Communication issues made it difficult for both members of staff understand questions asked, (agency). All service users were served the same meal regardless of whether they liked the choice or not. Records of food consumed are not always maintained satisfactorily. The majority of food available was stored in the freezer. This indicates that a high proportion of food is not freshly prepared and the quality of frozen food is not considered. There is little emphasis on healthy eating or serving food that service users like. A requirement is stated. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Service users are supported by staff in the way that they choose and their health need are met. When service users need special treatment, meetings are held with all people involved in their care to make sure that decisions are made in their best interests. Medication procedures are safe. EVIDENCE: Health action plans are in place for service users. Records show that service users are supported to attend GP appointments and other healthcare professionals. One parent spoken to feels assured that her son receives the best care and attention, and that staff consult with the doctor when there are concerns. Issues relating to continence management are referred to appropriate bodies, however evidence is not available on records to demonstrate that this is dealt with appropriately after consultation. A recommendation is made. Also there is a lack of knowledge within the staff team on management of continence. Staff according to records are not trained in this. This needs to be included in the training and development plan for the staff team Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 16 Service users that are non verbal have written guidelines in place for staff telling how they like to have things done for them. Emotional and physical needs are monitored. Consultations take place with psychology too and recommendations made are responded to satisfactorily. For a service user that experiences frequent seizures risk management strategies are in place. The service user is not restricted by this in leading a fulfilling life, he was supported on holidays recently. Staff are trained on epilepsy and managed effectively to deal with any seizures experienced by the service user. Incident reports are made and sent to relevant bodies, copies are also held in service user’s folder. The weights of service users are monitored monthly and any changes are responded to appropriately by referring to the dietician. Foot care has not always been dealt with by chiropody due to the demand on statutory services. According to a member of staff individual staff members received training on foot care to make up for this shortfall. Medication profiles are in place for service users. The systems for receiving storing and administering medication are good. The medication procedures were examined for two service users. No shortfalls were found in the service. Service users according to records receive prescribed medication at the times prescribed. From records seen it was observed that a service user had a medication review recently and as a result prescribed medication was changed. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Complaints and concerns are taken seriously, these are investigated properly. Service users are protected form abuse by the presence of staff trained in policies and procedures around safeguarding vulnerable adults EVIDENCE: Information supplied in the completed AQQA provided information on how the views of people using the service are promoted. Weekly house meetings provide a forum for service users to discuss any issues and to say what they want for the house. Minutes of the meetings are available for viewing. Staff respond to any concerns identified on a daily basis, they take appropriate action and record any incidents and make relevant notifications. According to staff training records staff receive POVA training as part of the induction process, they also have received training on safeguarding vulnerable adults in the past two years. All three staff interviewed demonstrated a good knowledge of safeguarding adults procedures. There have been no allegations of abuse or neglect recorded for the home since the last inspection. Staff can be slow to respond to minor issues raised by service users or relatives. The complaints book until recently had not recorded all the actions taken to respond to complaints. However a copy of a letter acknowledging a complaint sent to the complainant demonstrates that the management respond appropriately to all areas of concerns or complaints raised. A relative spoken to finds that the manager is approachable and feel confident in his ability to respond appropriately to complaints raised. The home does Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 18 have an independent advocate for all service users who has worked with them for a number of y Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 27 28 29 30 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and safe throughout and the communal areas are spacious and pleasantly decorated. Bedrooms are single occupancy. EVIDENCE: The home was clean and hygienic and free from offensive odours. Recent redecoration has taken place. This has enhanced the communal areas of the home. Communal areas are comfortable and attractive with sofas and suitable seating. New furniture was on order for the second lounge, currently bean bags are used by service users. Three of the bedrooms seen were comfortable and homely, service users personalised them. There is no lift at the home. For service users that are wheelchair users their bedrooms and bathrooms are located on the ground floor. Bathrooms and toilets are located conveniently for service users. Some of the furnishings (curtains) in use in one lounge was identified as non fire retardant in a risk assessment completed in November 2007. However no Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 20 further action was taken to address this until the new manager viewed the risk assessment during the inspection, he removed the items and made the lounge it safe. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The organisation provides an extensive range of training to the in house staff team which equips them well for the role. Service users are not being offered the best support possible due to the large number of permanent staff vacancies. This impacts on the staff team, performance issues are not addressed satisfactorily through consistent supervision and support. Service users are protected by the home’s own recruitment procedures but there is no assurance that agency staff are vetted as thoroughly. EVIDENCE: The staff team includes a majority of support staff employed by the organisation and that are familiar with service users. Three of the permanent support workers were interviewed. The organisation utilises the CSCI staff schedule to record information for all organisational staff, this information is held on file at the home, this is evidence of the robust recruitment procedures for in house staff. According to training records held in house staff have received regular and relevant training that equips them with the skills needed for the service user group, these include autism, Makaton, challenging behaviour. However some issues and conditions relating to service users are not included in this training, Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 22 e.g continence management. A requirement is stated in relation to training and development Appraisals are held annually. Training needs identified at appraisals are not always responded to in training events. A recommendation is made, the registered person should ensure that training and development is linked to individual training needs identified at appraisals New staff employed in the past year received LDAF induction training and mandatory training since appointment. The majority of in house staff have completed NVQ programmes or are participating currently in this award. The service has not moved forward since the last inspection as a result of the lack of a permanent staff team. Agency staff continue to fill the five vacant posts. The home seeks to engage agency staff that are familiar with service users to avoid disruption. However the experience gained during the inspection did not confirm this. Two of the staff present on one day were preparing the evening meal, both had poor communication skills and had little knowledge of service users’ needs, another agency member of staff spoken to on the day was observed sitting with service users in the lounge. For a period of time it was observed that engagement with service users was minimal. No records relating to recruitment or training were available for the agency staff engaged. A requirement is stated. The registered person must ensure that appropriate documentation is available including confirmation of robust vetting procedures, and training and experience for all agency staff engaged. According to the newly appointed manager the recruitment is ongoing. The vacant posts need to be recruited to as matter of urgency. The requirement stated in the previous two inspections is restated. Appropriate numbers of staff were seen to be on duty, rotas viewed confirmed this too. There is evidence that the staff team are not working as effective as they could, this may reflect the absence of effective management for the past five months. There are competency issues that need to be addressed within the staff team. According to staff spoken to there are examples of support staff that are unable to carry out personal care that involves moving and handling due to medical conditions. This places an onerous burden on the other staff members on duty and needs to be addressed. A requirement is stated. Records were seen of supervision given on a one to one basis to support staff. This has been less frequent in recent months. The supervision is not addressing the shortfalls within the staff team, these shortfalls include teamwork and continuity, record keeping, codes of conduct. A Requirement is stated. The registered person must ensure that staff are supervised and supported and that any issues relating to staff performance and capability are addressed. The newly appointed manager has recognised the weakness in the staff team and commenced one to one sessions with members of staff in his second week at the home. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 23 Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 41 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although service users receive care and support that they require the service has not progressed or moved forward due to the absence of a manager. The lack of leadership and good management has impacted negatively on the service. Staff welcomes the appointment of a new manager. The staff team show commitment, this combined with good leadership demonstrate the capacity within the team to take the service forward and make it into a good service. EVIDENCE: The service has been without a registered manager since 2006. A manager was appointed in January 2007, registration with CSCI did not take place and the manager moved to another service at the start of October 2007. Staff spoken to have found a lack of leadership in the past five months and feel that Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 25 this has contributed to the home not been run as well as it should. They welcome the presence of the newly appointed manager. This was also consistent with the views of relatives spoken to. One relative said “ I have discussed my issues with a support worker but nothing has been resolved”, she said she has spoken with the newly appointed manager and looks forward to improvements in communication with the home. The newly appointed manager is experienced in managing services for this service user group. He has achieved NVQ Level 4 and the Registered Managers Award. He is enthusiastic, he demonstrates a capacity to recognise weakness in the service and to address them with relevant action plans. By day two of the inspection he met with the staff team and set up appointments to meet on a one to one basis with staff. He had received the application form to register with CSCI and plans to complete this promptly. The registered person must ensure that the new manager completes and submits the application form to register with CSCI. The home has made improvements to incorporate service user views, regular in house meetings take place, also in house reviews with service users and relatives where possible. The home does have an independent advocate for all service users who has worked with them for a number of years. The result of the quality assurance developed by the organisation Odyssey was not available to confirm the outcome of the evaluation or the progress made in the service. A recommendation is made to forward a copy of this report this to CSCI for evaluation. According to the self-assessment completed at the home for CSCI a number of polices appear outdated. A recommendation is made. Record keeping is not as good as it should. Inconsistencies are seen throughout and reflect the lack of continuity in the staff team. The office is badly organised with a number of old files and information that needs to be archived. Staff generally are doing a good job and are supporting service users to lead meaningful lives, but paper trails are not always available to evidence the good work done. A requirement is stated. While case tracking management of service users’ money was observed. Service users’ money was checked and all systems for accounting and monitoring for the money are mostly robust and effective. Two staff sign for transactions. Statements are present of bank transactions. This is audited at monthly RI visits. It is not possible to share with each relative copies of the service users bank statements for reasons of confidentiality. Records of Regulation 26 visit reports were not seen. A recommendation is made that copies of Regulation 26 visit reports are forwarded to the inspector. According to records seen of maintenance and service checks equipment is serviced regularly and kept in good condition. Fire fighting equipment is checked and in maintained in good working order. Fire evacuation procedures take place in accordance with fire risk assessments. Health and safety risk Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 26 assessments take place. Fridge and freezer temperatures are recorded, hot water temperatures are tested regularly. It was not possible to verify if the assessor was suitably trained for the role. There were indicators present that verified otherwise. The last risk assessment for the premises identified that the lounge curtains were not fire retardant, yet no action was taken at the time to take the appropriate action. The newly appointed manager recognised that sensor lights were attached to the curtains and could pose a risk, he took immediate action. A requirement is stated in relation to health and safety risk management. The registered person must ensure that persons responsible for health and safety risk management are trained and competent for the role. Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 2 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 3 26 x 27 3 28 x 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 2 3 3 2 2 X Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 28 YES 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 YA6 YA9 Regulation 13 (4) (a) & (c) Requirement The registered person must ensure that an audit be done of service users’ files and that any areas of shortfalls identified in individual service users’ files regarding care planning and risks assessment records are addressed. The Registered Individuals must ensure that the current staff vacancies are recruited to as a priority. Previous requirement: Unmet timescales 28/02/06 30/09/06, 30/03/07. The registered person must ensure that service users are offered choices in relation to meals served, they must be served wholesome nourishing food at appropriate times. The registered person must ensure that appropriate documentation is sought and available for all agency staff engaged. The registered person must ensure that support workers employed in the staff team are competent, capable and fit for DS0000060236.V341900.R01.S.doc Timescale for action 30/04/08 2 YA33 YA3 18 (1) (a) 30/04/08 3 YA17 16 (i) 30/04/08 4 YA32 YA34 7,9 19 Schedule 2 (6) Schedule 2 31/03/08 5 YA32 YA31 31/03/08 Grosvenor Terrace, 52/60 Version 5.2 Page 29 6 YA35 18 (1) c 7 YA36 18 (2) 8 YA37 YA38 S11 Care Standards Act carrying out the roles and duties expected. The registered person must ensure that training and development programme provides for subjects relevant in the service user group, including continence management The registered person must ensure that staff are effectively supervised and that any shortfalls in practice are addressed The Registered person must ensure that the new manager completes and submits an application to be registered as manager to CSCI: The registered person must ensure that record keeping is improved and that a clear paper trail is maintained. The registered person must ensure that persons responsible for health and safety risk management are trained and competent for the role. 31/03/08 30/03/08 31/03/08 9 YA41 17 (1) (2) (3) 13 (4) c 31/03/08 10 YA42 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA3 YA6 Good Practice Recommendations The registered person should ensure endeavour to have a balanced staff team both culturally and ethnically that reflects the composition of service users. The Registered Manager should ensure that all service users needs, including needs around culture, ethnicity, religion and gender are considered and addressed in the care plan. The registered person should ensure that all service DS0000060236.V341900.R01.S.doc Version 5.2 Page 30 3 YA6 Grosvenor Terrace, 52/60 4. YA7 records are maintained up to date, signed and dated appropriately The registered person should ensure that staff research agencies and individuals who can advocate or offer peer support for service users and who share some of the same culture, heritage and disabilities. The registered person should endeavour to respond to cutbacks in local services and provide more opportunity for service users to engage inappropriate stimulation within the service The registered person should ensure that records are consistently maintained to demonstrate level of stimulation and participation in activity plans The registered person should ensure that training and development is linked to individual training needs identified at appraisals and supervision The registered person should ensure that the results of the quality assurance process are submitted to CSCI for evaluation. The registered person should ensure that policies are reviewed and updated to reflect current legislation The Registered Manager should archive any old and unnecessary information and improve filing systems throughout the home. The registered person should ensure that copies of Regulation 26 visit reports are forwarded to the inspector. 5 YA14 6 7 8 9 10 YA18 YA35 YA39 YA40 YA41 11 YA41 Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grosvenor Terrace, 52/60 DS0000060236.V341900.R01.S.doc Version 5.2 Page 32 - 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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