Inspection on 08/05/07 for Hersham Road (20)

This inspection was carried out on 8th May 2007.

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

Other inspections for this house

Hersham Road (20) 20/04/06

Hersham Road (20) 10/11/05

Hersham Road (20) 07/06/05

Hersham Road (20) 13/01/05

Hersham Road (20) 15/07/04

Hersham Road (20) 12/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hersham Road (20) 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ Lead Inspector Denise Debieux Unannounced Inspection 8th May 2007 09:15 Hersham Road (20) DS0000013464.V336606.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 Hersham Road (20) DS0000013464.V336606.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. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hersham Road (20) Address 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ 01932 269171 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) Welmede Housing Association Ltd Amanda Louise Salih Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Physical disability (1), of places Physical disability over 65 years of age (1) Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: 20 Hersham Road is an adapted large house situated on a busy main road in a residential area, which is within walking distance of all community facilities of Walton On Thames. Service provision is for up to eight people with learning disabilities, some of who have physical disabilities in addition to their primary condition of a learning disability. The service affords all single bedroom accommodation on the ground and first floor with the third floor designated for staff use only. Wheelchair users are confined to the ground floor as provision of a lift is not available. There is a spacious combined lounge/dining room overlooking a furnished patio and a large, attractive well maintained enclosed garden. Residents have access to the home’s vehicle, which is equipped for transporting wheelchair users. The service is owned by Welmede Housing Association Limited and staffed by employees of the North Surrey Primary Care Trust through a support agreement between the Trust and Welmede Housing Association. Fees are £1256 per week. This fee does not include holidays, hairdressing, personal items, toiletries, outings or aromatherapy. This information was provided on 30/04/07. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection, took place over 8.5 hours and was carried out by Denise Débieux, Regulation Inspector. Ms Amanda Salih (Registered Manager) was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. Service users living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. A tour of the premises took place. On the day of this visit there were six residents living at the home, with two vacancies, one resident is at present in hospital. All five residents and four on-duty staff were spoken with during the visit. Two resident survey forms and three staff survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. Three of the residents are unable to communicate verbally and observations of the interactions between staff and these residents were also used to form the judgements reached in this report. The home had completed a pre-inspection questionnaire and resident care plans, staff recruitment and training records, health and safety check lists, menus, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector would like to thank the residents and staff for their time, assistance and hospitality during this visit and the residents, relatives and staff who participated in the surveys. What the service does well: The home have developed and implemented a comprehensive pre-admission procedure to ensure that the personal, health and social care needs of any new residents can be met. The staff are committed to making sure that all current residents are involved in the assessment process for any prospective residents that apply for admission to the home. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 6 Residents are supported and encouraged to make personal choices and decisions about their own lives and to participate in the day to day running of their home. Residents spoken with told the inspector how they were happy living at the home and that they felt safe living there. Residents benefit from the management approach at the home providing an open, positive and inclusive atmosphere. One staff member commented that the best thing about working at the home is the: ‘friendly people, challenging work and the freedom to do new things with the residents.’ One relative commented that: ‘My relative has always been very well cared for at the home and the staff are very good with the residents.’ What has improved since the last inspection? What they could do better: In order to ensure that residents are protected from the potential risk of harm or abuse, action must be taken to ensure that the home’s staff recruitment practices and staff training programmes are in line with current legislation and best practice guidelines. Requirements regarding staff recruitment and training were made at a previous inspection, were not met and must now be actioned in full and without delay. The home must also take steps to ensure that all required policies and procedures are in place and have been reviewed. This requirement was originally made in November 2005 and has yet to be actioned. Requirements have been made that each resident be provided with an individual contract and an individual plan of care that includes risk assessments and sets out actions that staff need to follow to meet each resident’s personal, health and social care needs in the way they prefer. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 7 An effective method for assessing the home’s success in meeting the aims, goals and aspirations of the residents must be developed and implemented. Recommendations have been made that the manager contact the funding authorities for each resident and arrange a formal care review; that the staff document in more detail monies spent for or on behalf of residents where an official receipt is not obtainable and that the manager complete her plan to document the home’s emergency contingency plan and make it available to all staff. 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. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose now provides prospective residents with the information they need to make an informed decision about admission to the home. The procedures at the home ensure that resident’s needs and aspirations are fully assessed prior to admission to make sure that their needs can be met. The written contracts (license agreements) need to be completed for each resident to ensure that all relevant information is available to them and/or their representative. EVIDENCE: At the previous inspection a requirement was made that the home’s statement of purpose be updated. During this visit the statement of purpose was inspected. This document has been updated and produced in picture format and was seen to contain all required information and reflected the current situation at the home. The previous requirement has been met. All current residents have lived at the home for a number of years. Their preadmission assessments had been archived and were not available during this visit. However, as the home has two vacancies, they are currently beginning the assessment process with one prospective resident and this procedure was described to the inspector. The manager explained that, following the initial enquiry, a member of staff went to visit the prospective resident and staff at Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 10 the day centre she attends. Following this visit the prospective resident will be invited for a number of visits to spend time at the home and to meet with the other residents. These will initially be short visits, e.g. for tea and a tour, gradually increasing in time to include a meal and eventually a weekend stay. The manager also wants to arrange for staff to visit the resident at her current home and talk with any other involved health and social care professionals in order that they can build up a clear picture of the needs of the prospective resident. Once the manager has completed a thorough assessment, a meeting will be arranged to include the prospective resident, her relative or representative, her care manager and staff from the home in order to discuss and agree a plan of care to be offered. The manager described how she wants to make sure that the home is the right place for the resident and that the views of the current residents will be sought prior to anyone being offered a placement at the home. One resident told the inspector that she had been involved in deciding to move to the home. She also told the inspector that the new prospective resident is a friend of hers and she was excited that she may be moving to the home. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Each file sampled contained a blank ‘license agreement’ (contract) which had been produced in plain English and picture format. However, the home now needs to individualise and complete these agreements for each resident and then go over the agreements with the resident, their representative and/or independent advocate to ensure, as far as possible, that they are understood. The manager is aware that these agreements will need to include a full breakdown of the total fee payable, in line with recent legislation. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to review their current care planning system to ensure that each residents’ assessed and changing needs and personal goals are reflected in their individual plan. The home needs to ensure that all residents have an up to date, individual care plan that details the care required to fully meet all aspects of their health, personal and social care needs in the way they prefer. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Prior to this visit, relatives were sent survey forms, three forms were returned and were all positive regarding the care their relative received at the home. One relative commented: ‘My relative has always been very well cared for at the home and the staff are very good with the residents.’ During this visit three care plans were sampled. They consisted of a ‘wishes/needs/strengths’ assessment sheet, staff action sheets, daily life risk assessments and progress notes. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 12 The wishes/needs/strengths assessments were detailed, included resident’s preferences and also included some, but not all, actions staff needed to take to meet the identified need. In each file these assessments had been routinely reviewed every three to six months. The staff actions sheets were not as detailed and did not cover all the identified needs, they also were not reviewed as often as the wish/needs/strengths sheets. The daily life risk assessments (e.g. road safety etc.) had all been drawn up but were not routinely reviewed with the care plan, with some seen not having been reviewed since 2005. The staff record in the progress notes any changes or new needs, together with anything that is out of the ordinary. On occasions there were no entries for one to two weeks. When sampling the files it was noted in the progress notes that one resident had returned from holiday and had some blisters, the manager described how the staff are dealing with this concern and the resident told the inspector that the blisters were improving. However, this new concern had not been added to the care plan and there were no documented guidelines or actions for staff to follow. Apart from the initial entry in the progress notes, there had been no further recording that related to the blisters or evidenced that the blisters were improving. None of the care plans had been signed by residents or their representatives to evidence their involvement in drawing up the plans. The manager and deputy manager stated that they had recently attended two training courses, one on person centred planning and one on health action planning. The inspector was advised that, following these courses, the staff have just begun reviewing the care planning system and hope to develop a more integrated system. A requirement has been made to this effect. A recommendation has also been made that that the manager contact the funding authorities for each resident and arrange a formal review. Risks assessments relating to healthcare are discussed in the ‘Personal and Healthcare Support’ section of this report. Two resident survey forms were completed, with assistance from staff, both residents stated that they chose what to do during the day, the evening and at weekends. One resident told the inspector how she had chosen her holiday and also described how she had been helped to choose the colours when decorating her new bedroom. On the day of this visit residents were seen to be choosing what they did and where they went within the home, where they indicated that they wanted assistance from staff this was quickly understood by the staff and the assistance provided. Hersham Road (20) DS0000013464.V336606.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that residents’ rights are respected. Meals are well-balanced and varied. EVIDENCE: The daily routines at the home reflect the requirement to promote independence, individual choice and freedom of movement. Residents confirmed they could choose what to do, when they wanted. This was also confirmed by observations made by the inspector on the day of this visit. Each resident has a weekly activity schedule that is based on his or her known interests and hobbies. The activity schedules sampled were seen to be varied Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 14 and included activities both within and outside the home in the local community. One resident described her work at the local day centre and said how much she enjoyed going every day. Another resident said how much she enjoyed making cakes at the home. One relative spoken with, prior to this visit, described how staff from the home are sometimes able to provide transport so she can visit the home when there are problems with public transport. The menu for the week of this visit was seen to be varied and well-balanced, advice is sought from a local dietician, for individual residents, as and when needed. The inspector was advised that residents plan their meals, usually on a daily basis, with assistance and guidance from the staff where needed. The home have worked hard and developed photograph cards of different foods, these cards are used to enable residents, who have difficulty communicating, participate in and make choices when planning meals. The lunchtime meal was taking place during this visit, the food was presented in an appetising manner, staff were sitting with the residents in the dining room and there was a relaxed family atmosphere. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance was seen to be provided, where needed, in a respectful and sensitive manner. However, the home needs to ensure that all identified needs are included in the care plans and that assessments to identify any risks to a resident’s health are carried out and routinely reviewed. Sound policies and practices are in place for the administration and management of medications. EVIDENCE: During this visit three care plans were sampled. Some, but not all, identified health care needs were incorporated into the care plans. Newly identified needs were mentioned in the progress notes but had not been incorporated into the care plan. This has been discussed earlier in this report and a requirement has been made. The care plans included daily life risk assessments but the home have no formalised risk assessment methods for specific health related risks. For example: one resident is at increased risk of skin breakdown and should have a skin risk assessment carried out, preventative measures documented and Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 16 regularly reviewed. It was also discussed that the home should request a referral to the local district nurse/tissue viability nurse to ensure that the preventative measures they have put in place are the most suitable for the resident concerned. Although this resident is currently in hospital, the manager stated that she will be consulting the local district nurse when the resident’s discharge date is known. Two residents have been referred to a dietician due to concerns regarding their weight, no nutritional risk assessments have been carried out; the staff need to use a hoist when transferring one resident, although the manager assured the inspector that a moving and handling assessment had been carried out, this could not be located on the day of this visit; one resident has been provided with an electric bed with integral bed rails, no risk assessment has been carried out for the use of these bed rails. On reviewing the files it was noted that, where risks had been identified it was not clear how the staff had established that a risk was present or the level of risk indicated. A requirement has been made that these health related risk assessments should be carried out as a matter of some urgency. The risk assessments should be part of the resident’s care plan, routinely reviewed and updated and risk reduction measures clearly documented and available at all times for staff to refer to when providing care to the residents. The administration of some medications was observed and the medication administration records (MAR), medication storage, policies and procedures were all sampled and found to be in good order. The manager described to the inspector how the staff check that all medications have been given at each shift handover. The home are hoping that the local chemist will soon be providing pre-printed MAR sheets and blister packed medication. A requirement was made at the last inspection that keys were removed from the safe storage containers in residents’ bedrooms if there were valuables inside, during the tour of the home it was noted that this requirement had been met. During the tour of the home staff were observed to always knock before entering the residents’ bedrooms and all interactions observed between staff and residents were seen to be caring and respectful. Relatives who returned survey forms all stated that they felt the home always provided the care their relative needed and that they were always kept up to date with important issues. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that residents feel their views will be listened to. Policies are in place to protect residents from abuse and neglect but current staff recruitment practices are placing them at possible risk of harm and abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all residents, has been individualised to the home and is in an easy read, picture format. No complaints have been made to the home and no complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. Training in safeguarding adults is included in the home’s staff induction and all staff surveyed confirmed that they had received the training and were aware of the procedures to follow. The records of monies spent and receipts were sampled during this visit and seen to tally. Where money has been spent and the staff have not been able to obtain an official receipt (i.e. ice creams or drinks when out) the staff will fill in a receipt slip at the home. One receipt was seen and said ‘refreshments £7.50’, it has been recommended that the staff document, in more detail, Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 18 monies spent for or on behalf of residents where an official receipt is not obtainable. Residents surveyed and spoken with said that they knew who to speak to if they were not happy and that they felt safe at the home with one resident adding ‘they (the staff) make me smile’. Concerns related to staff recruitment are addressed in the ‘Staffing’ section later in this report. Hersham Road (20) DS0000013464.V336606.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained. The home was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: 20 Hersham Road is an adapted large house situated on a busy main road in a residential area, which is within walking distance of all community facilities of Walton On Thames. Residents spoken with expressed their satisfaction with the accommodation provided at the home. Residents surveyed all said that the home was always fresh and clean. The home was toured during this visit. The furniture and furnishings were seen to be of a good quality and specialist equipment is provided as needed by the residents. Personal bedrooms were all seen to be highly personalised to the individual resident’s wishes. Since the last inspection the home have made Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 20 a number of improvements to the communal and individual areas of the home. These improvements included the redecoration of two bedrooms, one having a replacement carpet and the lounge looked fresh and bright with new curtains and furniture. Requirements made at the last inspection that related to the environment have all been met. There is a private and well-maintained garden at the back of the house. One resident said how much she liked the garden and one relative described how her relative enjoys working in the garden and helping the staff with gardening tasks. The manager described how the home plans to change the front garden (which is secluded from the road) into a sensory garden in the near future. Laundry facilities are sited on the ground floor with washing machines suitable for the needs of the residents at the home. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. Hersham Road (20) DS0000013464.V336606.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): 32, 33, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home are working towards having 50 of staff qualified to NVQ level 2 in care but comprehensive training needs assessments of individual staff members, and the staff group as a whole, need to be carried out to ensure that residents are supported by competent and qualified staff. Arrangements for staff recruitment are not satisfactory and are placing residents at possible risk of harm or abuse. EVIDENCE: Of the nine care staff, two hold a National Vocational Qualification (NVQ) level 2 or above in care, with a further three currently undertaking or registered to begin NVQ level 2 or above. Once this training has been completed the home will have exceeded the expected minimum of 50 of qualified staff. The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the residents at the home. The morning shift is covered by three care workers, two to three care workers cover the afternoon/evening shift and the night staff consists of one waking care worker and one sleeping on the premises and available if needed. A previous recommendation that staff designations be included on the staff rota has been met. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 22 Of the two residents surveyed, one stated that they felt staff always listened and acted on what they said and one answered ‘usually’. On the day of this visit staff were observed to respond promptly to requests for help and to have a good understanding of the various communication methods used by the residents. During this visit the recruitment files for the three latest members of staff were identified for sampling. One file was not available at the home for inspection. Of the remaining two, both application forms had gaps in employment with no written explanation and neither had written confirmation of reasons for leaving previous employment working with vulnerable adults. There was no evidence to show that criminal records bureau (CRB) certificates had been obtained or that checks had been made of the protection of vulnerable adults (POVA) list for any of the members of staff. There were photocopies of CRB certificates from previous employers for two of the staff members, in both cases the CRBs had been obtained for positions in care of vulnerable adults but were not mentioned on the person’s list of employment. One of these CRBs showed that a check of the POVA register had not been requested. These three staff members work unsupervised with residents and are also shown on the rota as being the only waking staff member on duty on some night shifts. Immediate requirements relating to staff recruitment were made and left at the home on the day of this visit. Following a telephone conversation with the manager the day after this visit, it is positive to note that the home has taken prompt action towards meeting the requirements made and have put measures in place to protect the safety of residents in the interim period. The manager stated that all staff have been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice, thereby meeting a requirement made at the last inspection. Staff training records were sampled. The manager is in the process of reviewing and collating all training records for the staff at the home. A new form has been devised that, when fully completed for all staff will give ‘at a glance’ information regarding the training the staff have already received and the dates the next updates are due. This work is not yet completed and the training records at the home are incomplete. For this reason it was not possible to fully assess the training provision at the home on this visit. The inspector was advised that all staff receive induction training and that mandatory safe working practice training is included in this induction. The inspector was advised that staff keep their own induction training records and induction records are not kept at the home. However, in discussion with the Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 23 manager it was ascertained that the induction training provided to staff is not currently compliant with the Learning Disability Awards Framework (LDAF) induction or the new Skills for Care mandatory common induction standards. The home must develop and implement a comprehensive induction and ongoing training programme that complies with all current legislation and best practice guidelines and that is specifically designed to ensure that staff are able to meet the individual and joint needs of the residents living at the home. Complete records of all training undertaken, including induction training, must be kept at the home. Requirements were made at the last inspection relating to staff recruitment and training and have not been met. These concerns must now be addressed without delay. When asked if the care staff have the right skills and experience to look after people properly, all three relatives surveyed answered ‘always’. One relative commented that: ‘I can’t fault their care’ and another that: ‘I have no complaints whatsoever, the staff are lovely.’ Hersham Road (20) DS0000013464.V336606.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, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home does not have an effective quality assurance and monitoring system in place. Action needs to be taken to ensure that all required policies and procedures are put in place that safeguard the residents’ rights and best interests. Not all records were available to evidence that staff have received training to ensure that the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager holds a Registered Manager’s Award and has been working in care for over twenty years. She has worked for Welmede Housing Association Ltd since 1993 and has been the manager at 20 Hersham Road for the past two years. Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 25 The manager stated that residents’ meetings were normally once a month but there had not been one held since last December, the home plans to recommence these meetings soon. One resident likes to attend the monthly staff meetings, this is encouraged by the staff unless there is confidential information to be discussed. The resident confirmed this and told the inspector she enjoys being involved in the staff meetings. The manager explained that the views of visiting professionals and visitors are sought on an informal basis. However, at present, there is no formal system in place for effective quality assurance or monitoring that is based on seeking the views of residents. It is important that the home establish a method for assessing their success in meeting the aims, goals and aspirations of the residents and a requirement has been made. During this visit a selection of health and safety checklists were sampled. Fridge, freezer and hot food temperatures are measured daily and the records were up to date and well maintained. A fire risk assessment was carried out in January of this year, in compliance with the Regulatory Reform (Fire Safety) Order 2005. That report and a copy of the home’s Legionella certificate were available on the day of this visit and evidenced that requirements made at the last inspection had been met. As mentioned earlier in this report, the staff induction training does not meet the Skills for Care common induction standards and other records of staff training in safe working practices were not available for inspection. However, staff were observed to be following appropriate health and safety practices as they went about their work. All interactions observed between the staff and residents were inclusive, caring and respectful. Relatives who returned comment cards stated that they were always kept up to date with important issues affecting their relatives and that they felt the home meets the different needs of the residents. One relative commented: ‘Hersham Rd is one of the best care homes my relative has been in to be looked after.’ Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 3 X 1 1 X 2 X Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 27 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 YA5 Regulation 5B Requirement Each service user must be provided with an individual contract containing a breakdown of the fees payable by or on their behalf. Where a service user does not have an involved relative or representative, the services of an independent advocate should be sought to ensure that every effort is made to help the service user understand the terms of their contract. In order that service users consistently receive the care they require, in the way they prefer, all care plans must be reviewed to ensure that each service user has an individual plan of care that includes the following: • Details of all individual needs identified, • Goal/objective for each need or identified potential risk; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; • Progress notes to evidence DS0000013464.V336606.R01.S.doc Timescale for action 08/08/07 2 YA6 YA18 YA19 15(1)(2) 08/08/07 Hersham Road (20) Version 5.2 Page 28 3 YA19 13(4)(c) 4 YA34 19(1)(b) Schedule 2 that identified needs and goals are being met and that service users are receiving care in the way they prefer; • Newly identified needs or problems must be promptly added to the care plan; • Signature or other evidence to show that the service user/representative were involved in the drawing up of, and agreement with, their care plan; • Regular reviews of all sections of the care plan. In order to ensure that any 08/06/07 potential risks relating to a service user’s health and welfare are identified, risk assessments must be carried out and documented, must be regularly reviewed and staff actions necessary to reduce the risk must be incorporated into the service users’ individual care plans. (With particular reference to skin risk assessments, moving and handling risk assessment, nutritional risk assessments and a risk assessment for the use of bed rails for the service users identified on the day of this visit.) In order to ensure that service 10/05/07 users are protected from the risk of harm or abuse, all staff files must be checked and arrangements made to obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff DS0000013464.V336606.R01.S.doc Version 5.2 Page 29 Hersham Road (20) 5 YA34 6 YA35 7 YA35 8 YA39 employed since 26th July 2004. (Timescale of 21/06/06 not met) 18(2)(a) Any staff that do not have all the required checks and documentation in place, must not work unsupervised and must not be left in charge of the home until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 18(1)(c)(i) Comprehensive training needs assessments of individual staff members, and the staff group as a whole, must be carried out and an induction and ongoing training programme must be developed and implemented. The training programme must be specifically designed to ensure that staff are able to meet the individual and joint needs of the service users living at the home. (e.g. Mandatory health and safety training and updates, Learning Disability Awards Framework (LDAF) induction, care of people with epilepsy etc). (This requirement incorporates requirements 10 and 11 from the last inspection, timescale of 07/07/06 not met.) 17(2) An up to date record of all staff 17(3)(a-b) training, including induction Schedule training, must be kept at the 4 home and available for inspection at any time. (Reference: The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) 24(1) An effective method for assessing the home’s success in meeting the aims, goals and aspirations of the service users must be developed and DS0000013464.V336606.R01.S.doc 08/05/07 08/08/07 08/06/07 08/09/07 Hersham Road (20) Version 5.2 Page 30 implemented. 9 YA40 17 In order to ensure that service user’s rights and best interests are safeguarded, the home’s policies and procedures must be reviewed and certain policies should be individualised to 20 Hersham Road. (E.g. complaints, staff training, referral and admission etc.) (Reference Appendix 2 of the National Minimum Standards for Younger Adults.) (Timescales of 09/12/05 and 26/05/06 not met) 08/09/07 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 YA6 Good Practice Recommendations It is recommended that the manager contact the funding authorities for each service user and arrange a formal care review. Arrangements should be made for any service users who have no family or representative to be supported by an independent advocate. It is recommended that the staff document in more detail monies spent for or on behalf of service users where an official receipt is not obtainable. It is recommended that the manager complete her plan to document the home’s emergency contingency plan and make it available to all staff. 2 3 YA23 YA40 Hersham Road (20) DS0000013464.V336606.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Hersham Road (20) DS0000013464.V336606.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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