Inspection on 18/05/06 for Holmbury Dene

This inspection was carried out on 18th May 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmbury Dene 08/08/08

Holmbury Dene 08/10/07

Holmbury Dene 08/12/05

Holmbury Dene 29/04/05

Holmbury Dene 22/12/04

Holmbury Dene 02/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Holmbury Dene 2 Lawrie Park Road Sydenham London SE26 6DN Lead Inspector Ornella Cavuoto Unannounced Inspection 17 &18th May 2006 10:00 th Holmbury Dene DS0000025625.V294274.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 Holmbury Dene DS0000025625.V294274.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. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holmbury Dene Address 2 Lawrie Park Road Sydenham London SE26 6DN 0208 7787700 0208 7789437 ask.providenceproject.org.uk 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) Providence Project Mrs Juliette Anne Hagan Care Home 10 Category(ies) of Learning disability (0) registration, with number of places Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 10 persons with a learning disability of whom up to 3 may also have a physical disability 8th December 2005 Date of last inspection Brief Description of the Service: Holmbury Dene provides care for up to 10 people with learning disabilities, up to three of who may have a physical disability. The support offered includes mental health and management of challenging needs. The home is staffed on a 24-hour basis, consisting of a manager, an assistant manager and full and part time support workers. Staff levels can vary depending on the number of service users staying at the home at any one time and the level of their support needs. The home provides respite care for service users who live in the community with carers and for service users awaiting a more permanent placement. The home is also the emergency placement and assessment centre for people with learning disabilities in Lewisham. It is a large, two and a half storey building close to Sydenham train station and local shops and services. The area is also well serviced by buses to central and south London. There is accessible off road car parking space for up to seven cars to the front and side of the building. The garden is accessible from the dining room. The ground floor is wheelchair accessible consisting of four single bedrooms, a reasonably sized kitchen, a mid -sized dining room, a large lounge looking onto the front of the building, one fully accessible shower room/toilet, one fully accessible bathroom and the staff sleepover room. The first floor contains three single bedrooms, two bathrooms /toilets, a lounge area and the staff room. There is also a self-contained flat on the first floor currently not used for accommodation. The second floor has a room used for volunteers. There were four service user vacancies at the time of the inspection. The service is block funded by Lewisham Partnership and so cannot provide information with regards to monthly fees. Prospective service users are given information about the service via a Service User/Carer pack. CSCI reports are made available to prospective service users in the Service User/Carer pack. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over a day and half. The registered manager was present for the duration of the inspection process. The inspection involved speaking to two staff members and two service users. Other inspection methods included inspection of care records and a full tour of the premises. What the service does well: What has improved since the last inspection? The home has begun to establish a key worker system so the individual needs of service users can be more effectively met. The home is taking measures to look at ways service users can become more involved in the decisions and day to day running of the home. The majority of staff have received training in adult protection to ensure that service users are safeguarded from harm or to take prompt action if a situation arises where abuse may be suspected. The home has introduced a formally recognised quality assurance system to ensure that standards within the home are maintained. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s statement of purpose has been revised to ensure all the information included is correct. The individual needs of prospective service users are assessed prior to admission. Prospective service users know the home will meet their individual needs. Not all service users have been issued with a statement of terms and conditions with the home. EVIDENCE: The statement of purpose was inspected and has been all the information included is accurate. The statement format that service users can understand. However, the been produced in an accessible format for service users graphics. altered to ensure that of purpose is not in a service user guide has using “Widget” picture The day prior to the inspection taking place the home had an emergency admission for which there was evidence that a core assessment had been obtained from the local authority prior to the service user being admitted. The information contained in the assessment was not completely up to date which is an issue that needs to be addressed by the home in future admissions of service users. However, a risk assessment meeting was held the following day Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 9 with other agencies involved to further discuss the individual needs of the service user and how these were to be met by the home. Other service user plans that were looked at all contained a copy of the core assessment (See Recommendations) There was evidence that the home does have the capacity to meet the assessed needs of individuals admitted to the home. Service user plans demonstrate that specialist services such as mental health services, specialist behavioural services, speech and language therapy, district nurses amongst others are accessed to ensure service users needs are met. Furthermore, the service has a balanced team that ensures that the needs and preferences of specific minority ethnic communities are catered for and met. Finally, although not all staff are NVQ qualified as required within the national minimum standards (See details regarding Standard 32) there was evidence from discussions with staff and records indicating they have received other relevant training that they do individually and collectively have the skills and experience to deliver the services and care which the home offers to provide. Apart from one service user who lives at the home on a permanent basis and has been issued a statement of the terms and conditions of their stay within the home, the home has not developed a statement of terms and conditions for other service users who stay at the home on a respite basis or as part of an interim placement. This needs to be addressed. It is important that the format used is also one which is accessible to service users (See Requirements). Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 &9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Information contained in service user plans is still in need of being updated to ensure that they clearly reflect service users’ changing needs and personal goals. There was limited evidence available that service users are given assistance with making decisions about their lives. Although efforts are made to consult and enable service users to participate in all aspects of life in the home, more could still be done to ensure opportunities are given to service users. There have been slight improvements around the assessment of risks of service users but this is an area that still needs to be more comprehensively addressed. EVIDENCE: At the last inspection it was identified that although service user plans were based on information from the core assessments obtained from the local authority, that they contained a lot of detailed information about the personal, health and social care needs of individual service users and included Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 11 interventions and individualised procedures to address aggressive and other forms of challenging behaviour, a lot of this information had not been updated or regularly reviewed to ensure that the changing needs and personal goals of service users are clearly reflected. At this inspection four service user plans were looked at and from this it was evident that previous requirements made in respect to service user plans have not been addressed although the timescales to undertake these issues had not fully expired at the time the inspection was held. For example, evidence that service user plans are being reviewed at least six monthly as specified within the National Minimum Standards was still not available. One service user had an annual review held in November 2005 but this information had not been updated or reviewed. For another service user presently staying at the home on an interim placement, there were detailed support guidelines that had been drawn up in September 2005 that also had not been reviewed or updated. At the last inspection it was reported that multi –disciplinary reviews are carried out by the local authority every six months with all service users and family members are invited to attend but these are generally held at the day centres or the main council offices and support workers from the home are not always invited to attend particularly for short –stay service users. In addition, a copy of the review is not always sent to the home. This is clearly not appropriate practice. It is important as part of service users’ overall care that the home needs to ensure they are kept informed of any changes in the needs of service users who regularly attend the home on respite and also for those on interim placements. At this inspection it was reported that meetings have been held with Lewisham Partnership who provide all referrals to the home to discuss roles and expectations in working together and the issue of reviews was discussed. However, the home needs to ensure that they fulfil their own responsibilities and ensure that all service users’ plans are regularly reviewed as required as well as ensuring that staff regularly attend external reviews and copies of these are obtained (See Requirements). Evidence of service user or where appropriate of family/representative involvement in the drawing up of information contained in the service user plans was still not in place for all service users. As recommended at the last inspection, the process of cleaning and archiving old information contained in the plans has been started but needs to be completed for all service users. Also it was reported that staff have been advised to use the “End of Stay Report” for service users as previously recommended to provide a summary of their stay at the home and any progress or changes made in respect to their care. However, evidence of these having been completed could not be identified. Finally, the overall format presently being used for service user plans is still in need of being reviewed to ensure that they are more person Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 12 centred to enable service users to understand them more easily (See Requirements and Recommendations) In respect to the home introducing a key worker system this has begun to be implemented by the home. There was evidence that support workers had been allocated to work with individual service users and also that the role of the key worker and responsibilities involved have been discussed with staff as part of a team meeting. There was some evidence that indicated that service users are supported to make decisions about their lives, for example in a review held with one of the service users. Also, it was reported that one of the service users had been supported to access a local advocacy service. However, evidence from the other service user plans that were inspected on how service users are supported to make individual choices was limited. This needs to be demonstrated more clearly within service user plans. Also, it is recommended that information regarding advocacy services is made generally available to all service users who stay at the home (See Requirements and Recommendations). Subject to a previous requirement that service users are offered opportunities to participate in the day to day running of the home this has been partially met. Service user meetings have been regularly held on a monthly basis within the home in which service users have been encouraged to give their views on various aspects of how the home is run. In addition, there is a service user meeting held within the whole of the organisation in which service users from each home can attend. It was reported that one of the service users has been involved in this meeting and has also been involved in sitting on a recruitment panel. Another option that was discussed with the registered manager as a way of increasing service user participation is to involve service users in parts of the staff meeting. Although the home is to send out customer satisfaction questionnaires in the near future as part of self- monitoring (See details regarding Standard 39) and it was also reported by the registered manager that a strategy meeting is now being held which is attended by senior management and aims to look at ways of improving the service including how to get service users and carers more involved, more efforts are still needed to ensure service users are able to fully contribute to the development and running of the home (See Requirements and Recommendations). At the last inspection it was identified that risk assessments for service users were generally inadequate with those looked at within service user plans being out of date or had not been drawn up at all, for example in relation to a service user who has a tendency to abscond, a risk assessment was not in place detailing action to be taken by staff in the event that the service user may go missing. At this inspection, it was found that following a review meeting a detailed risk assessment had been drawn up for this service user. Also, for another service user a risk assessment had been completed in respect to Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 13 pressure area care with all staff having to sign that they had read the details of the risk assessment. However, some improvements still need to be made in this area to ensure areas of risk presented by service users are fully addressed and to avoid limiting their preferred activity or choice. For example one service user who often helps in the kitchen to cook the evening meal did not have a risk assessment in place to ensure action is taken to minimise any potential risks/hazards (See Requirements). Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 14 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): 11,12,13,14,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home still needs to provide evidence that service users are being given opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are supported to become part of and participate in the local community. Although service users are engaged in appropriate leisure activities these are not always clearly evidenced within service user plans The home supports and encourages service users to have appropriate personal and family relationships. The daily routines and house rules of the home promote independence and individual choice. There was evidence that service users are being supplied nutritious varied and balanced meals but staff must ensure accurate records are maintained of all meals provided to individual service users. EVIDENCE: Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 15 It was evident within service user files that service users are offered specialist interventions and opportunities by trained staff to help facilitate their personal development in respect to emotional and communication needs. However, as identified at the last inspection there was limited evidence available that service users are being provided with opportunities to maintain and develop independent living skills. As previously mentioned the “End of Stay Report” which requires staff to write an assessment on the level of service user participation and level of skills observed in respect to practical, social and food skills is still not being regularly completed. The registered manager acknowledged that this is an area that does require improvement but that the establishment of the key worker system should ensure this matter is addressed more effectively (See Requirements). There was evidence within service user plans that service users are supported to find and keep appropriate jobs and take part in education or training and other fulfilling activities. For example, one service user who lives at the home on a permanent basis has an office job that they attend one day a week. Another service user has been supported to attend a computer course. Daily records for individual service users that were inspected demonstrated that they are regularly supported to be part of and make use of the local community and facilities such as shops, library, cinema pubs and restaurants. Staff accompanying service users to the shops and to attend the local library was observed during the inspection. Also, it was evident that the home values and seeks to reflect the cultural and racial diversity of service users with a balanced staff team working at the home. All service users have individual activity plans in place that detail all the activities that service users engage in during the week some of which are organised by the day centres where service users attend. These demonstrate that service users are engaging in appropriate leisure activities. There was also evidence from the daily logs that service users are engaged in other activities. For example, one service user was taken to play football with other service users from other PLUS houses at Blackheath and then went for a drink in the pub. In addition, it was observed during the inspection that service users were engaged by staff to play board games whilst one service user watched a video. Although there is a form “ Keeping Track Data Information” which is aimed at recording and monitoring the opportunities service users are being provided with to participate in activities, it was evident that staff are not using these regularly (See Recommendations). The home supports and encourages service users to maintain family links and friendships inside and outside the home. It was evident during the inspection that visitors to the home such as family members are made to feel very welcomed. A relative of one of the service users spoken to said, “I enjoy coming here, I get on well with the staff”. There was evidence from a review Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 16 held with one of the service users that they had been encouraged to invite their friends for dinner at the home and in discussions with the service user they confirmed that they have had friends come over from other houses within the organisation. Also, some of the service users attend the Gateway club. This is a social club where people with or without a learning disability can attend including family members and friends. There was a lot of positive interaction between staff and service users observed during the inspection and the atmosphere of the home was one that was very relaxed and comfortable. It was also evident that service users when not attending day centres exercise a lot of individual choice in terms of their daily routines and how they wish to spend their time. In respect to meals provided to service users the home does not have a planned weekly menu. Instead, individual service users are asked what they would like to eat for lunch and supper and this is then prepared. During the inspection it was observed that one of the service users was accompanied to the shops to buy some fish as they had specifically requested they wanted this for their supper. As there is a turn over of service users with individuals staying at the home sometimes for short periods on respite, this arrangement does ensure that personal preferences are catered for and specific cultural needs are also met. It was reported that it does not pose problems in respect to food shopping or that there is a repetition of meals provided to service users. A record of all meals eaten by service users is kept as part of their individual daily log. A sample of these was checked and it was evident that where this had been completed service users were being provided a good variety of meals that were nutritious and balanced. However, some had been left blank. This needs to be addressed. An accurate record needs to be kept so that staff are kept informed about what service users have eaten on previous days so that a nutritious and varied diet is maintained (See Requirements). An evening meal was observed which was prepared for all the service users who appeared to enjoy the food. Staff also ate with them creating an informal and homely atmosphere. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Although the home has robust policies and procedures for dealing with medicines these need to be applied consistently by staff. EVIDENCE: All service user plans contain very detailed guidelines on all aspects of personal support and care required by service users including personal preferences around personal care, eating and drinking preferences, individual communication needs, mobility needs and managing behaviour presented by service users. However, as mentioned previously the information presented in service user plans is in a format that would prove difficult for service users to understand and they would benefit from a more person centred approach being used (See Recommendation in relation to Standard 6). It was clearly evident from service user plans and within the daily logs that service users physical and emotional needs are being well met with regular liaison with a range of healthcare professionals including mental health teams, physiotherapists, G.P’s, speech therapists, district nurses, dentists, Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 18 chiropodists amongst others. Appointments relating to service users health needs are recorded on a Medical Report form. In addition in relation to service users individual health needs there was evidence of monitoring of pressure areas, fluid intake and an epilepsy monitoring form. The home has a robust medication policy and procedure and staff do a daily stock check of individual service users medication of which records are maintained. It was reported that only permanent staff administer medication and that they have all received training from the local pharmacist. None of the service users living at the home at the time of the inspection were administering their own medication. A sample of three Medication Administration Record sheets (MARs) was checked. Two of the three MAR sheets inspected had gaps where medication had been given but this not been signed for. Also, where a service user had been on social leave the appropriate code had not been used and had been left blank (See Requirements). Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a robust complaints procedure, which is also in an accessible format for service users. There are comprehensive adult protection procedures and a whistle blowing policy in place to ensure service users are protected from abuse. EVIDENCE: The home has a robust complaints procedure that includes the stages of, and the timescales for the process. This is also in a format accessible to service users with “Widget” picture graphics being used. A copy of this complaints procedure was seen to be placed on a notice board which is visible to service users. In addition, it was noted that within the service user plans that were inspected as part of a carer’s agreement, which is signed, a copy of the complaints procedure is issued to the main carer. There was also evidence from the minutes of service user meetings that service users are encouraged to voice any concerns they may have about the home. The home keeps a log of informal and formal complaints. There was only one informal complaint logged that had been dealt with appropriately. The home has also had one formal complaint that is ongoing made by the family of a service user who was placed on respite at the home regarding the management of their care. The organisation responsible for the overall management of the home and the local authority against which a complaint has also been made are addressing this. Details of the complaint were seen and it is evident that it is being dealt with appropriately. However, a report regarding an incident that partly resulted in the complaint being made was not Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 20 sent to CSCI immediately and neither was notification received by CSCI about the complaint (See Requirement in respect to Standard 42 and Recommendations). The home has robust policies and procedures on adult protection and whistle blowing. The home also has a comprehensive policy regarding the management of service user finances. Subject to a previous requirement that staff must receive adult protection training, it was evident from staff training records that the majority of them have now had training in this area. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 21 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Generally service users live in a homely, safe and comfortable environment. The home is clean and hygienic. EVIDENCE: The home is spacious, comfortable and generally well decorated and maintained. The home has had some areas of the home recently decorated and furniture replaced and it was reported that more is to be carried out with the self- contained flat to be painted and carpet in there to be replaced. It was noted in carrying out a tour of the premises that the carpet in one of the service user bedrooms on the ground floor and also in one of the lounges downstairs were quite badly stained and in need of being cleaned or possibly replaced. The registered manager reported that these would be replaced in due course as part of renewals for the home. The home was clean and free from offensive odours at the time the inspection was held. The home has adequate laundry facilities and an adequate policy and procedure for control of infection. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 ,35 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although service users are supported by competent staff the required target that 50 of staff must be National Vocational Qualification (NVQ) qualified or working towards one has still not been met. There are sufficient numbers of staff working at the home. Staff recruitment records are not kept within the home. Staff are receiving training to enable them to meet the joint and individual needs of service users. Staff are still not receiving regular supervision. EVIDENCE: The home now has a full complement of staff after a long period of having to carry vacancies. Five staff members have joined the team within the past couple of weeks prior to the inspection coming from other PLUS homes that have recently been de-registered. Therefore, all of them are experienced and have worked for the organisation for a number of years and are already familiar with some of the service users living at the home. It was reported by the registered manager that the training records of the staff that have started have not yet been received to check their qualifications and whether or not they have completed a NVQ Level 2. In terms of the other staff working at the home four staff members are due to start a NVQ Level 3 in September and one Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 23 is due to start a NVQ Level 2. One staff member is presently studying for a NVQ Level 3 and one is doing a NVQ Level 2 and one has completed. Based on the number of staff working at the home, the required target within the national minimum standards of 50 of staff being NVQ qualified or working towards one has still not been met (See Requirements). Subject to a previous requirement that the registered manager must define minimum staffing levels due to the home having fluctuating staffing levels depending on the number of service users admitted to the home and their support needs with some requiring one to one or two to one support, this has been met. During the inspection it was observed that there were sufficient numbers of staff on duty. The registered manager is constantly reviewing staffing levels. Some agency staff are used in situations of staff sickness or when an emergency admission occurs and extra staff are required at short notice. However, only agency staff that are familiar with the home and service users are used. It was also reported that the organisation is looking to build up a bank of staff to try to minimise the use of agency staff. Regular staff meetings are held. Minutes of the meetings were seen that indicated a good range of topics are discussed including issues in relation to service users, staffing issues and general matters relating to the day to day running of the home. The home does not keep staff recruitment records within the home. However, CSCI have provided staff information sheets to PLUS to record for all individual staff details regarding their recruitment and that all necessary information has been obtained. A sample of these were checked and found to be in order. There was evidence that staff do receive training on a regular basis and there I is an organisational induction day that newly recruited staff attend. The staff who have recently joined the staff team already worked for PLUS and so have been given a short induction to help them become familiar with the home. Records of this have not been maintained but two of the staff spoken to confirmed they had been inducted. The home accesses a lot of training via Lewisham Partnership. Individual staff training records indicated that staff have completed mandatory training such as manual handling, food hygiene, first aid amongst others. Evidence was also seen of an annual training plan specifically to address mandatory training to ensure that this is regularly updated. In relation to specific training there was evidence from records that staff have completed a variety of courses to ensure that staff are able to meet the specific and joint needs of service users including understanding epilepsy, skills teaching, management of aggression, autism, cerebral palsy, adult protection and diversity and equal opportunities although some of these has been completed some time ago. There was evidence of an up to date annual training plan for specific training needs of staff. It was reported that training needs have been identified through Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 24 supervision sessions held with staff. However, annual appraisals have not been completed and this needs to be addressed (See Requirements). The registered manager reported that staff are still not presently receiving supervision at least once every two months as required within the national minimum standards. It was explained that the deputy manager is to undertake a course in supervision whilst the registered manager is to do a refresher course. Supervision duties will then be shared between them (See Requirements). Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is generally well run but the registered manager is still to attain the necessary qualifications to fully ensure that the home and the staff team are managed effectively. Service users benefit from the ethos, leadership and management approach if the home. The home has introduced a recognised quality assurance system to ensure that service users views underpin self- monitoring, review and development of the home. Although the home does generally protect the health, safety and welfare of service users there are areas that need improvement. EVIDENCE: The present registered manager has experience of managing services and working with adults with disabilities. However, she has still not completed a NVQ Level 4 in management or the Registered Managers Award (RMA). She Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 26 reported that she never really started the course she previously enrolled on finding it difficult to fit it in with the demands of work and home. However, she is due to commence the NVQ Level 4 again via the Open University. It is important that the registered manager obtains this qualification and it is recommended that study leave be organised to support them to complete this (See Requirements and Recommendations). It was evident through observation that the registered manager has developed a positive and inclusive ethos within the home and provides a clear sense of direction and leadership. Subject to a previous requirement that the home needs to provide evidence that quality assurance tools are in place including consultation with service users, relatives and other stakeholders as part of self –monitoring, this has been partially met. The home has recently introduced a formally recognised quality assurance system –PQASSO (Practical Quality Assurance System for Small Organisations) which looks at twelve different areas of service delivery including user- centred service, monitoring and evaluation. The registered manager reported that all staff are to be inducted around how to implement the system. With regards to customer satisfaction questionnaires it was reported these are to be sent out shortly to service users, carers and other stakeholders involved in the service. However, copies of the questionnaires were not available for inspection (See Requirements). In respect to health and safety the home had partially met a previous requirement in that there was evidence of an updated fire risk assessment being in place. In addition there was evidence that the safety and welfare of service users is protected as the home has carried out weekly tests of fire alarm call points, fire drills have been completed and there was evidence that staff have received training in fire safety. Weekly checks of water temperatures have taken place. A COSHH (Control of Substances Hazardous to Health) risk assessment has been completed and as previously discussed staff receive mandatory training in areas such as manual handling and first aid (See details regarding Standard 35). Maintenance certificates were also seen regarding fire equipment, gas safety and servicing of the gas boiler and of specialist equipment. However a comprehensive building risk assessment has still not been completed. In addition, as mentioned previously there was a considerable delay in the home sending CSCI a regulation 37 incident report, which needs to be addressed with all future incidents being reported as soon as possible following an incident occurs (See Requirements). Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 2 X Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 28 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 YA2 Regulation 5 (1) (b), (c). Requirement Timescale for action 30/11/06 2. YA6 12 (2) & (3). 3. YA6 15 (2). The registered provider must ensure that all service users are issued with a contract outlining the terms and conditions of service users stay within the home and services and facilities to be provided. (Previous timescale of 31/05/06 not exceeded). The registered manager must 30/11/06 ensure that service users, their relatives and/or representative where appropriate are involved in the drawing up of care plans and support guidelines and these are signed to indicate their involvement. (Previous timescale of 30/06/06 not exceeded). The registered manager must 30/11/06 ensure that staff must be involved in any external reviews held for service users who attend the home and a copy of the review is obtained and kept on service users files. Also that the home undertakes reviews of service user plans at least six monthly. (This is an updated DS0000025625.V294274.R01.S.doc Version 5.1 Holmbury Dene Page 29 requirement) 4. YA7 12 (3) The registered manager must ensure that service users are supported to make their own decisions and individual choices and that this is clearly demonstrated within service user plans. The registered manager must ensure that work is done and evidence is provided that service users are offered opportunities to participate in the day-to-day running of the home. (Previous timescales of 31/03/05 31/10/05 partially met. Previous timescale of 30/06/06 not exceeded). The registered manager must ensure that comprehensive risk assessments are in place for all service users that these include control measures and an action plan to minimise the identified risk and these are regularly reviewed and updated. (Previous timescale of 30/06/06 not exceeded). The registered manager must ensure that service users are provided with opportunities to learn and develop life skills and this is monitored and recorded within the service user plan. (Previous timescale of 30/06/06 not exceeded). The registered manager must ensure that meals provided to service users are recorded daily to ensure that service users are provided with a varied and balanced diet. The registered manager must ensure that procedures for the administration of medication are consistently and accurately adhered to by all staff, specifically that where DS0000025625.V294274.R01.S.doc 30/11/06 5. YA8 16 (2) (n) & 24 (3) 30/11/06 6. YA9 13 (4) 30/11/06 7. YA11 12 (1) & (2) 30/11/06 8. YA17 16 (2) (i) 30/11/06 9. YA20 13 (2) 30/09/06 Holmbury Dene Version 5.1 Page 30 10. YA32 18 (1) (c) 11. YA35 18 (1) (c) 12. YA36 18 (2) 13. YA37 9 (2) (b) (i) 14. YA39 24 (1) 15. YA42 13 (4) & 23 (4) medication is dispensed that it is signed for and where medication is not dispensed appropriate codes are used. The registered manager must ensure that 50 of support staff achieve the NVQ level 2 or 3 award. (Previous timescale of 31/12/05 not met & timescale of 30/06/06 not exceeded) The registered manager must ensure that all staff receive an annual appraisal to ensure staff are supported to look at their personal development and individual training needs are identified with them. The registered manager must ensure that staff receive at least six supervision sessions annually. The registered provider must ensure that the registered manager is supported to complete the NVQ Level 4 in management. (Previous timescale of 28/02/06 & 30/09/06 not exceeded) The registered provider must ensure that as part of the quality assurance system that has been put in place that customer satisfaction surveys are completed with service users, relatives and other stakeholders, the results of these are compiled into a report and also used to look at ways of improving the service addressed within an annual development plan. (This is an updated requirement) The registered manager ensure that staff adhere to all health and safety procedures DS0000025625.V294274.R01.S.doc 30/05/07 30/11/06 30/11/06 31/03/07 30/11/06 30/06/06 Holmbury Dene Version 5.1 Page 31 specifically that regulation 37 incident reports are sent to CSCI promptly and that a building risk assessment is completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA2 YA6 Good Practice Recommendations The registered manager should try to ensure that needs assessments for service users obtained from the local authority are as up to date as possible. The registered manager should consider introducing a format for service user plans that use a person centred approach to make information more easily understood by service users. The registered manager should consider cleaning the files and archiving any old and out of date information to make the information more easily accessible. The registered manager should consider implementing the End of Stay Reports to help identify personal goals and changing needs and also to establish different periods service users are staying at the home. The registered manager should try to ensure that advocacy information is made available to all service users. The registered manager should consider giving service users opportunities to attend staff meetings where appropriate. The registered manager should try to ensure that the Keeping Track Data Information form is used more effectively by staff to record and monitor activities that service users are involved in. The registered manager should try to ensure that CSCI should be kept informed of all formal complaints received by the home, provide details of any investigations and also inform CSCI about the outcome. The registered provider should consider providing the registered manager study leave to enable them to DS0000025625.V294274.R01.S.doc Version 5.1 Page 32 3. YA6 4. YA6 5. 6. 7. YA7 YA8 YA14 8. YA22 9 YA37 Holmbury Dene complete the NVQ Level 4 in management. Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Holmbury Dene DS0000025625.V294274.R01.S.doc Version 5.1 Page 34 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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