Inspection on 24/01/06 for Heather Lane, 74

This inspection was carried out on 24th 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 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 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heather Lane, 74 18/09/07

Heather Lane, 74 05/12/06

Heather Lane, 74 28/10/04

Heather Lane, 74 01/07/04

Heather Lane, 74 05/11/03

Heather Lane, 74 23/05/03

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 09/07/2008.

CARE HOME ADULTS 18-65 Heather Lane, 74 Yiewsley Middlesex UB7 7AU Lead Inspector Ms Jane Collisson Unannounced Inspection 24 January 2006 14.35 th Heather Lane, 74 DS0000027090.V276976.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 Heather Lane, 74 DS0000027090.V276976.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. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heather Lane, 74 Address Yiewsley Middlesex UB7 7AU Telephone number Fax number Email address 01895 421947 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) Life Opportunities Trust Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: 74 Heather Lane is a registered home that offers support for three service users who have a learning disability. All of the service users are female and two have lived in the home since it opened in 1990. The home is managed by LOT (Life Opportunities Trust) and the building is managed and maintained by Shepherd’s Bush Housing Association. The house is in a residential area of Yiewlsey with the shopping centres of Uxbridge and West Drayton accessible by public transport. The nearest station, which is 15 minutes walk, is West Drayton main line. The ground floor has a large lounge, kitchen, one bedroom and a shower room/toilet. On the first floor are two bedrooms, a bathroom/toilet and a sleeping-in room/office. There is an attractive garden to the rear. The staff team consists of the posts of Registered Manager and three full-time Residential Workers. The rota allows for single staff cover only, with one member of staff sleeping-in at night. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 24th January 2006 from 2.35pm until 7.10pm. An unannounced visit had been made on the 17th January, but no staff or service users were at home. The Registered Manager left the service in early January, and the Registered Manager from another home has been overseeing the project, as Acting Manager, until a new appointment is made. This visit was arranged to meet with him at the home and to ensure that staff and service users would be present. One service user was present initially, with two members of staff. The two other service users were at their day services, returning home during the afternoon, so all three service users were met. There are currently only parttime three permanent staff, with vacancies for the manager and one full-time support worker. The current staff and bank staff are covering for the vacancies. The home continues to have a relaxed and pleasant atmosphere. However, there are concerns regarding two of the service users. These impact on the staffing in the home as the service users’ needs probably cannot continue to be met within the current levels. The review for one of the service users was due to be held on the 2nd February, and the other was to be arranged for the near future. The suitability of the home, or a change to the staffing, will need to be resolved as a matter of urgency. All of the service users’ records were examined, as well as the maintenance and servicing records. A tour of the home took place with the Acting Manager. For an assessment of all of the key standards, this report should be read in conjunction with the unannounced inspection report of 23rd August 2005. There were thirteen requirements made at that inspection and five of these have been met. Eight are restated and a further thirteen have been made. What the service does well: What has improved since the last inspection? The environment has been improved with the addition of new kitchen units, lounge carpet and curtains. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 6 What they could do better: Two service users have needed reviews of their support needs since before the last inspection but these have not been held. Although the meetings were being arranged, it needs to be shown that concerns are addressed as they are raised and, pending the outcome of these meetings, must be reviewed on a regular basis and appropriate action taken. The procedures for assessing, admitting and discharging service users need to be put in place to ensure that new service users are not admitted whose needs can be met. The staffing levels also need to be reviewed in the light of the changing needs of the service users to ensure that the health and safety of staff and service users are not compromised. The effect of single staff cover on service users’ activities, at evenings and weekends, needs to be fully evaluated. To ensure that the service users and their representatives are made fully aware of the terms and conditions, including the fees and other charges, they need to be provided with the contracts in respect of their support and accommodation. Because the needs of the service user who used to stay in the home alone have changed, a new risk assessment is required to be completed for the service user and kept under review. The record keeping in the home still requires improvement with all relevant records available for inspection. The health care files, in common with the care planning files, need to be streamlined, with information kept up-to-date. A number of records were not available, including the complaints log. Not all of the policies and procedures appeared to be current and the Acting Manager is to check that all of the policies being held in the home are the current ones. The complaints procedure will also require amendment if no new policy has been produced. Staff need to ensure that they take responsibility for health and safety issues. Although a breakdown in heating in one of the bedrooms had been reported it had not been repaired and supplementary heating had not been supplied. Action had not been taken to arrange for a more substantial safety system to be fitted to the front door. Because the home has only a small staff team and there are two full-time vacancies, the recruitment needs to be carried out as quickly as possible, using external advertising if necessary, rather than relying on internal advertisements. While bedrooms are pleasantly furnished, there is a lack of comfortable seating. There is no private communal area and service users should be Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 7 offered comfortable chairs to be able to use their bedrooms for relaxation and for entertaining visitors. Consultation with service users and their representatives has not been carried out as part of a review of the quality of care and this should be done on a regular basis. Some health and safety issues remain to be completed. The fire risk assessment needed to be updated to minimise any risk to service users when the fire door are left open at night. Evidence is required to be provided that the current Legionella testing has been carried out. 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. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Information is in place for prospective service users and their representatives to be aware of the services and facilities the home is able to offer. However, more suitable formats for the service users should be provided, particularly in respect of the Service Users Guide. The changing needs of two of the service users need to be reassessed urgently so that their requirements can be met. EVIDENCE: A new Statement of Purpose has been produced since the last inspection and a copy of this was provided to the Commission for Social Care Inspection at this inspection. It complies with Schedule 1 of the Care Home Regulations 2001 in most aspects but some further information should be provided on the admission procedures for considering service users for the home. The complaints procedure could also be improved to be made more accessible and informative. The Statement of Purpose will need to be updated when the new manager is appointed and it is recommended that these amendments are included at that time. The current Service Users Guide is not provided in a visual or format with symbols, which would make it accessible to the service users and it is recommended this is given consideration when the information is updated. There have been no new service users admitted since the last inspection. The procedure on that occasion was for the service user to visit the home before admission to see if the home could meet her needs. However, some Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 10 information was not clear before admission, which has contributed to the current concerns regarding staffing levels. The procedure included in the Statement of Purpose on admissions and discharge is very short and uninformative. It should be improved to meet the National Minimum Standards and Care Home Regulations 2001. This should provide for a review of the service user’s needs to be ongoing, particularly where there are concerns identified after admission. Two of the service users’ support needs are changing or are not being fully met and this needs to be addressed by reassessment. The Statement of Purpose states that service users with high care needs cannot be met and that the staffing level is minimal. The safety of the service users may be compromised by one of the service users often being awake throughout the night. There is a risk that the fire doors may be left open. Another service user, who has been able to remain alone in the home for short periods, may not be safe to do so in the future because of possible dementia. In addition, the current single staff cover cannot provide for individual outings for the service users. This was a concern during the previous summer. The manager currently overseeing the service is aware of these concerns and will ensure these are discussed at the forthcoming reviews. Both of these concerns were raised at the previous inspection in August 2005 but insufficient action appears to have been taken and these issues now must be addressed as a matter of urgency. A blank copy of the terms and conditions/contract are in place, with details of the fees and services, but were not seen to be supplied for each individual service user. These need to be provided, with the fees to be paid, and updated as required. No details of the Local Authority contract was seen and under Regulation of the Care Home Regulations 2001, this should be provided to the service users. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The care planning systems need to be improved and service users should be involved in these processes wherever possible. More frequent reviews need to take place, particularly with the changing needs of the service users. EVIDENCE: Each service user has a care plan but the information in place is in need of reviewing and simplifying. A system that involves the service users, and provides them with input into their care plan, could be introduced in the home and this should be given consideration. Staff said that a new system had been due to be introduced but this had not yet happened. The need for these reviews was highlighted at the last inspection in August 2005 but they have not been held. One was due to take place the week following this inspection. Another was to be arranged shortly, it having been two years since the last review took place. The review of the third service user was also overdue and needs to be arranged. The Acting Manager said that he would be participating in the reviews of the service users. Staff must ensure that reviews also take place regularly of the care plans, risk assessments and other documentation, particularly when concerns have been raised but are not resolved. The Acting Manager was asked to ensure that a Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 12 new risk assessment is completed for the service user who remains, for short periods, alone in the home. She had previously opened the door, whilst alone, to a Commission for Social Care Inspection inspector she did not know. Staff said that they reinforce to her that she must not open the door whilst alone, but her possible diagnosis of dementia must be taken into account for the risk assessment. Whilst service users are offered choice about the day-today running of the home, the single staff cover does not always allow for the service users to have a choice about individual pursuits that they wish to undertake. As the service users do not all enjoy the same activities, such as walking, choices may be limited during evenings and weekends. All three service users are now at home most weekends and spontaneous outings may be curtailed. This situation needs to be kept under review. Because the home is small, all of the service users can be consulted quite easily on the day-to-day decisions about the home. However, there is no evidence of any formal consultation and it needs to be demonstrated that service users are given every opportunity to participate fully in the running of the home. Policies, procedures and other documentation is not produced in user-friendly formats which could assist the service users to have a better understanding of them. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15, 16, 17 The service users, because of their attendance at day services, a work placement and weekend and evening clubs, are able to enjoy a variety of activities. However, the staffing cover limits the number of individual activities that can be enjoyed outside of these times. EVIDENCE: The service users’ diaries provide evidence of the daily events in the service users’ lives, including any assistance they give around the home and comments on health, mood and any concerns. Service users were seen to be encouraged to carry out small tasks, and remain independent, by making drinks and keeping the home in good order. Because the home is small, service users need to respect other service users’ space and no concerns were raised during this short visit. One service user was seen to be very independent, being able to make a decision about when to have a shower and to prepare for it. There was a good rapport noted between the staff member on duty and the service users. All three of the service users now attend day centres, one for five days a week, one for four days and one for two days. All attend different services. One Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 14 service user has a part-time job, and is continuing to access this independently. However, the travel arrangements must be kept under constant review because of the changing health needs of the service user. One service user continues to attend a cookery course and the service users had the dish she had prepared for their evening meal. It was noted at the previous inspection in August that one service user may have to attend a day centre rather than remain in the home on her own. Although not the centre originally chosen, the service users said that she is now enjoying her two days a week at the centre. It is important that service users are seen to have a choice of activity that suits their needs and these are not made only because of the staffing levels in the home. One service user particularly enjoys the ballet and her key worker has arranged tickets for a performance in March. None of the service users had a holiday this year arranged by the home, but one service user had been on a holiday with a club she attends. Staff use their own cars for taking service users out as the home has no transport of its own. There are public transport links, used by one of the service users, close by. A visitors’ policy is included in the Statement of Purpose and there are no restrictions except for visits in the late evening. Family contacts are maintained wherever possible by visits and by letter. One service user makes regular visits to her family at weekends but with less frequency than in the past. The evening meal is cooked by the staff member on duty and a weekly menu is provided. The service users assist with their packed lunches for their visits to the day services. Meals taken by the service users are recorded and were seen to be varied. The evening meal on the day of the inspection was a pasta dish that one of the service users had prepared at college, with meat cooked by the member of staff. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Although it appears that the health and medical needs of the service users are being met, there is some inconsistency in the way in which individual service users’ records have been maintained. Improvements to the record keeping are required. EVIDENCE: The service users are supported by staff with their personal care in accordance with their individual needs. Each has a wash hand basin in their bedrooms, and there are two bathrooms, one with a shower and toilet on the ground floor, and one with a bath and toilet, on the first floor. With the exception of the Acting Manager, all of the support staff are female so same gender care is always provided. Although times for getting up and going to bed are flexible, these are restricted by the need for service users to be ready for their day services in the morning. Staff complete their duties at 11pm in the evening and commence at 6.30am on weekdays, 7am at weekends. One service user does get up during the night and, as mentioned elsewhere in this report, this concern needs to be addressed, particularly as there are no waking night staff and sleeping-in staff may be disturbed. The service user has also been found asleep in the shower-room and the effect on her health and welfare must be taken into consideration. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 16 In all of the files examined, details were seen of recent visits to health care professionals, although outcomes of the visits are not consistently recorded. The system of assessing the service users’ health care needs, the “Health Action Plans” had not been recently updated and not all of the files are maintained to the same standard. The health care files, in common with the care planning files, files need to be streamlined, with information kept up-todate. Professional support with speech therapy and the assessment of a service user’s possible dementia have been accessed, and the latter is ongoing. An agreement was reached with the Commission for Social Care Inspection pharmacy inspector regarding the storage of the medication, which is kept in a locked filing cabinet in the lounge, due to a lack of suitable storage space elsewhere in the home. There were concerns that the high temperatures reached occasionally in the lounge would affect the medication and it was planned to store all of the medication in refrigerators. The Pharmacy Inspector advised against this. The medication is supplied, from a local pharmacy, in weekly sealed containers. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 It must be ensured that the complaints procedures are in accordance with the Care Home Regulations 2001 and it can be established if any complaints have been made by the maintenance of records that are available for inspection. EVIDENCE: No complaints file was located on this inspection so it could not be ascertained fully if any complaints had been made. However, none has been recorded on the recent Regulation 26 visits, which had been carried out by the current Acting Manager in his capacity as the Registered Provider’s representative. Although there is a visual and simplified complaints procedure contained in the Statement of Purpose, for the use of the service users, the full complaints procedure does not fully explain the role of the Commission for Social Care Inspection and this should be clarified. Staff have received training in the procedures for safeguarding adults and there have been no adult protection issues raised in the home. No changes appear to have been made to the financial procedure, dated December 2004, which does not refer to the appointeeship for service users. This has been a requirement twice and is restated. It was not ascertained if the policies and procedures had been updated and, as stated elsewhere in this report under National Minimum Standard 41, the Acting Manager is to check to see if the policies and procedures available in the home are the latest. If the financial policies and procedures have been amended, then these need to be added to the file of policies and procedures and staff made aware of the changes. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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, 25, 30 The home is comfortable and pleasantly furnished and provides a relaxed environment for the service users to enjoy. However, service users should be offered the opportunity to make further use of their bedrooms, by the addition of a comfortable chair or chairs, in view of the lack of a private communal space. When there is a breakdown of equipment, such as the heating in one of the bedrooms, staff must take action to ensure the home remains warm. EVIDENCE: The house is comfortable, homely and well-maintained. New carpets and curtains have been provided in the lounge. A new kitchen has also been installed and the home was found to be very orderly and clean. Photographs of the service users enjoying holidays and other activities are around the home. The lounge is also used for dining and there is a table sufficient for three service users and a staff member. As required at the last inspection, a visit was made by a London Fire and Emergency Planning Authority officer to examine the fire precautions for the home. While the officer found the precautions satisfactory, this was with the understanding that the ground floor fire doors are closed at night. One service user is frequently up and about at night and doors have been found to be left open. It was required previously that the former Registered Manager Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 19 contacted the relevant Social Services department to advise them of the risks. Potentially hazardous items, such as the kettle and microwave, are disconnected or removed at night so they cannot be used by the service user. The Acting Manager said that these risks will now be discussed at the review due shortly to be held. Action must now be taken to ensure that any risk to the service users and staff is minimised. Following the possibility of front door being opened at night by the service user, the London Fire and Emergency Planning Authority officer advised that either the front door or the porch door should have a security lock which could be easily unlocked in the event of fire. This had not been actioned but the Acting Manager is now aware of the need for this to be fitted. Although all of the bedrooms are pleasantly decorated and personalised, it was a requirement at the last inspection that service users should be offered the choice of furniture contained in National Minimum Standards and the home’s own terms and conditions, including comfortable seating. As there is only one communal space, the provision of at least one comfortable chair should be made available to support the service users to relax in their bedrooms and for entertaining visitors. One of the service user’s bedrooms was found to be very cold. Although the broken radiator had been reported, it had not yet been repaired. The Acting Manager provided a small heater, on the day of the inspection, until the radiator is repaired. The home’s staff must be aware that they need to take action to provide suitable heating is available in the event of a breakdown. Two bathrooms are provided for the three service users and staff, one being a ground floor shower room. Both rooms have toilets and each of the service users’ bedrooms has a wash hand basin. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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): 31, 32, 33, 34, 35 The home’s staffing levels are no longer sufficient to meet the needs of the current service users and action must be taken to address the concerns. Although basic training courses have been undertaken and NVQs commenced, specialist training also needs to be offered to meet the needs of service users with learning disabilities, particularly those who are older. EVIDENCE: As there is only single staff cover for most of the time, staff take on all of the responsibilities for the home whilst they are on duty. There is no deputy manager or senior support worker to cover when no manager is in post. Staff had not carried through the advice of the London Fire and Emergency Planning Authority regarding the front door lock. It needs to be demonstrated that staff are aware of their responsibilities, in the absence of the Manager, in order to ensure that urgent tasks are carried out as required. Alternatively, consideration should be given to a senior post being created so that there is line management responsibility during absences. Whilst the staff receive updated training on the basic training needs, there has been no training in understanding learning disabilities. The Acting Manager said that new staff will now undertake Learning Disability Framework Award training when commencing work. Two of the three staff have commenced National Vocational Qualification training, one at Level 2 and one at Level 3. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 21 No details were available of any medication competency training and the Acting Manager was asked to look at this being provided. Because of the changing needs of one of the service users and the needs of the newest service user, the single staff and sleeping-in cover are no longer sufficient to meet the needs of the service users. Staff who are sleeping in may have their sleep disturbed and then continue to work a part, or full, shift. It was discussed with the Acting Manager, who was in agreement, that staff must record instances of disturbance during the night to evidence the effect on the service users and the staff. The staffing level also cannot always provide for service users to undertake individual activities outside the home, unless it is a group activity, at least one of the service users is away or with an activity not involving the home’s staff. The current staff team, who are all part-time, are long-term members of staff and there is one bank staff. They are currently working additional hours to cover for the vacant Manager’s post and the full time support worker vacancy to provide continuity for the service users. It was a requirement at the last inspection that the recruitment practices are improved. There have been no new staff employed and the staff member whose file was not available is no longer working in the home. The documentation for one agency staff being used was not available, including information on the Criminal Records Bureau disclosure. The Acting Manager said that he would obtain this information. The home must have information on all of the staff who work in the home, in accordance with Schedules 2 and 4 of the Care Home Regulations 2001. Because of the absence of a permanent manager, the supervision records were not checked on this inspection. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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): 38, 39, 40, 41, 42 The home relies on good team management because of the single staff working and infrequency with which staff meet. The Acting Manager is familiar with the home, service users and staff, which should help over the period while the new manager and support worker are being recruited. Because of the concerns with two of the service users, the recruitment process needs to be carried out as quickly as possible. Some of the administrative procedures need to be improved. EVIDENCE: The Acting Manager said that an internal advertisement would be placed initially, throughout the organisation, for the position of Registered Manager. The full-time vacancy for a support worker also needs to be filled and the Acting Manager said that this might be offered, on a short-term contract, to a bank worker. Because staff work alone, and there is limited contact between them on some days, the Acting Manager prefers not to use agency staff. The Registered Providers must ensure that every effort is made to fill the vacancy positions, by external advertising if necessary, and within the shortest possible timescale. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 23 There are currently no systems in place to fulfil Regulation 24 of the Care Home Regulations 2001, with regard to providing a review of the quality of care and to show how improvements to the service will be made. This review needs to take into account the views of the service users and their representatives. When complete, a report of the review needs to be given to the service users and to the Commission for Social Care Inspection. The regular Regulation 26 visits have been made, on behalf of the Registered Providers, and submitted to the Commission for Social Care Inspection. Because the Acting Manager has conducted some of these reports, and has overseen the home during the previous absences of the former Registered Manager, he has an awareness of the home and knows the service users and staff. Some of the records, including the complaints log, could not be located on this inspection and there needs to be an improvement in the record-keeping generally. All of the service users’ files were examined and there is a lack of consistency in the way in which the information is maintained. The policies and procedures available in the home may not be the most up-todate copies provided by the organisation. This was a requirement at the last inspection as a number of them appeared to be out-of-date and had not been reviewed and revised for some time. The Acting Manager undertook to obtain a full list of current policies and procedures and to ensure they are placed in the home. He will need to make certain that the staff are fully aware of any changes. A sample of the maintenance records showed that the small electrical appliance testing was carried out in March 2005, the Landlord’s Gas check took place in June 2005, and the fire alarm system was serviced in November 2005. The Environmental Health Officer last visited the home in 2003. The Legionella testing did not appear to be current and evidence that this has been carried out must be provided. The fire risk assessment is also required to be updated. Although risks have been identified, it needs to be shown how the risks are being minimised, particularly in relation to the possible opening of the fire doors at night. Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 3 2 2 3 1 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 2 2 2 2 X 2 X ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000027090.V276976.R01.S.doc LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heather Lane, 74 Score 3 2 3 X X 2 2 2 2 2 X Version 5.1 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 YA2YA6 Regulation 12 (1) 14 (2)(b) Requirement The needs of the service users must be kept under review and appropriate action taken to ensure that their needs are being met. (Previous timescale of 31/10/05 not met). The procedures for assessing, admitting and discharging service users must meet the National Minimum Standards and Care Home Regulations 2001 in order to ensure the health and welfare of both new and existing service users. The terms and conditions must be completed for new service users to ensure that they are fully aware of the fees and other charges, and the facilities and services provided. (Previous timescale of 31/10/05 not fully met). Where the Local Authority has made arrangements for the provision of accommodation and personal care, a copy of the contract must be provided to the service user. It must be demonstrated that service users are offered DS0000027090.V276976.R01.S.doc Timescale for action 28/02/06 2 YA3YA4 12 (1)(a) & (b) 31/03/06 3 YA5 5 (1)(b) 31/03/06 4 YA5 5 (3) 31/03/06 5 YA7 12 (2) 16 (2) 28/02/06 Heather Lane, 74 Version 5.1 Page 26 (m)(n) 6 YA9 13 (4)(b) (c) 7 YA19 15 (2)(b) 8 YA22 22 9 YA23 13 (6) 10 YA25 23 (2)(c) 23 (2)(p) 11 YA25 16 (2)(c) 12 YA31 13(4c) 23(4c)(iii) opportunities to make decisions, with the assistance of suitable information and support. Staff must ensure that any lack of opportunity to fulfil the service users’ individual choices, particularly with regard to activities, are recorded. A new risk assessment must be completed for the service user who current remains alone in the home for short periods. A copy must be supplied to the Commission for Social Care Inspection. The health care files, in common with the care planning files, must be streamlined, with information kept up-to-date. The complaints procedure must meet Regulation 22 of the Care Homes Regulations 2001 and be provided to service users. (Previous timescale of 31/10/05 not met). The Registered Person must ensure that service users are safeguarded from financial abuse in accordance with a written policy. (Previous timescales of 29/11/04 and 31/10/05 were not met) The home’s staff must be aware that they need to take action to provide suitable heating is available in the event of a breakdown of equipment. The service users must be seen to be offered sufficient furniture to meet their individual needs. (Previous timescale of 31/10/05 not met). Staff must take action where the London Fire and Emergency Planning Authority have given advice to minimise the risk to service users and staff. 15/02/06 31/03/06 30/04/06 30/04/06 31/01/06 31/03/06 28/02/06 Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 27 13 YA32 YA35 18 (1) (c) (i) 18 (1) (a) 14 YA24YA33 15 YA34 17 (2) 19 (1) 16 YA38 18 (1) (a) 17 YA39 24 (1) (2) & (3) 17 18 YA40 19 YA41 17 (1) (3) (a)(b) 20 21 YA42 YA42 13 (4)(a) 23 (4)(c)(v) Staff must receive the training required to meet the needs of the service users and the work undertaken in the home. The staffing levels must be reviewed in the light of the changing needs of the service users to ensure that the health and safety of staff and service users are not compromised. All of the recruitment records required under Schedules 2 and 4 of the Care Homes Regulations 2001 must be available for inspection. (Previous timescale of 31/10/05 not met). The Registered Providers must make every effort to recruit a full staff team, including the post of Manager, as soon as possible. A regular review of the quality of care must be undertaken. (Previous timescale of 30/11/05 not met). Up-to-date policies and procedures must be available in the home to enable the records required under Schedules 1, 3 and 4 of the Care Homes Regulations 2001 to be maintained in accordance with current legislation. (Previous timescale of 30/11/05 not met) The record keeping in the home must be improved and maintained in order to ensure that all of the records required by the Commission for Social Care Inspection are available for inspection. Evidence must be provided that current Legionella testing has been carried out. The fire risk assessment must be updated to show how the identified risks are being minimised, particularly in relation to the possible opening DS0000027090.V276976.R01.S.doc 31/03/06 28/02/06 28/02/06 28/02/06 30/04/06 31/03/06 31/03/06 28/02/06 28/02/06 Heather Lane, 74 Version 5.1 Page 28 of the fire doors at night. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Amendments to the Statement of Purpose, in respect of the admissions and complaints procedure, should be made when the new Manager is appointed and the document is revised. The current Service Users Guide should be provided in a visual format or format with symbols, which will make it accessible to the service users. It is recommended this is given consideration when the information is updated to include details of the new Manager. 2 YA1 Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Heather Lane, 74 DS0000027090.V276976.R01.S.doc Version 5.1 Page 30 - 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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