Inspection on 21/09/07 for Inglemere

This inspection was carried out on 21st September 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Inglemere 05/06/06

Inglemere 19/12/05

Inglemere 31/05/05

Inglemere 29/10/04

Inglemere 21/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Inglemere 2 Pollards Hill East Norbury London SW16 4UT Lead Inspector Barry Khabbazi Key Unannounced Inspection 21st September 2007 08:30 Inglemere DS0000025798.V350184.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 Inglemere DS0000025798.V350184.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. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglemere Address 2 Pollards Hill East Norbury London SW16 4UT 020 8679 6726 F/P 020 8679 6726 NO EMAIL 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) Surrey and Borders Partnership NHS Trust Meghanaden Rengasamy Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th June 2006 Brief Description of the Service: Inglemere provides residential care for up to nine adults with moderate to severe learning disabilities. Some service users are also visually impaired. Each service user has their own bedroom, which is decorated to suit their individual tastes. The home is situated on a corner plot surrounded by gardens and a patio area. The home has a communal lounge area as well as a dining room. It is within walking distance of Norbury high street and transport links. The home is close to the Croydon /Merton boundary. . Fees for this home are from £1194.00 per week. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were all assessed at this inspection. This inspection also focused on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. During this inspection the new manager was interviewed. Records, policies and care plans and the building were examined. The organisation moved quickly to provide a new manager for this home. This has enabled a number of previous requirements to be met and the previously drift in standards identified in the previous report to start to be addressed. 12 out of the 16 previous requirements have now been met and evidence of work occurring on the remaining requirements was evident. In addition, Standard 36, staff supervision was assessed as exceeded at this inspection. The home is now improving steadily and so further improvements are expected by the next inspection. What the service does well: The organisation moved quickly to provide a new manager for this home. This has enabled a number of previous requirements to be met and the previously identified drift standards identified in the previous report to start to be addressed. All the residents now have a ‘person centred’ plan of care. This is seen as good practice as service users are involved in producing these which therefore records care needs from a service user’s perspective. It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in Rectal Diazepam usage. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The home now has now updated the Statement Of Purpose and Service User Guide so that they contain all the information required under Standard 1. This means that the home now provides all of the information needed for potential residents to make an informed decision about moving in to the home. To ensure that all of a service user’s needs and changing needs are known, plans of care are now reviewed by the home on a 6 monthly basis. Risk assessment guidelines are now being followed more closely, this will promote safety and promote dignity and privacy where guidelines connected to both are recorded in the risk assessment guidelines. Risk assessments have now been completed for areas previously identified as needed. This will give staff information they need to promote safety. The food provided is sufficient in quantity and is now more nutritious, and the dietician’s strategies for improving the nutritional quality of the food that the residents actually eat were being implemented. This is important to ensure good health. Staff now use their separate facilities to store their belongings, and no longer leave their bags and coats in the service users’ communal or individual space as this practice does not promote dignity and respect for the service users, or their space. Further action has been taken to ensure that staff are familiar with restraint policies and guidance. This should help protect residents from unnecessary or poor quality restraints. A cleaner has been recruited. The home is now more hygienic and clean. This environment therefore now not better facilitates the residents’ health and emotional well-being. The home has now ensured that at least 50 of staff have an appropriate care qualification, i.e. a NVQ 2 in care. This will provide a better trained workforce. Supervision sessions now meet the minimum required, and in fact have now exceeded the National Minimum Standard. This ensures a well supervised workforce. The organisation moved quickly to provide a new manager for this home. This has enabled a number of previous requirements to be met and the previously identified drift standards identified in the previous report to start to be addressed. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 7 The quality assurance system has been fully implemented. This should facilitate residents and relatives being involved in monitoring improvements in quality. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Inglemere DS0000025798.V350184.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 Inglemere DS0000025798.V350184.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): Standards, 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now provides all of the information needed for potential residents to make an informed decision about moving in to the home. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. EVIDENCE: The last report also contained the following requirement under Standard 1: The service users guide must contain the views of the service users. The new manager confirmed that questionnaires now had been completed and the required information transferred into the Service Users Guide. The service user guide has also been produced in a symbol format and a taped version. This requirement is now thefore met. The last report also contained the following requirement under Standard 1: The Statement Of Purpose must specify room sizes and both the Statement and the service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 10 The Statement Of Purpose had also been updated to contain the required information. This requirement is now also met. The home now has a Statement Of Purpose and Service User Guide that meet the requirements of Standard 1. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. Inglemere DS0000025798.V350184.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): Standards, 6 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs, and how the home meets these needs, are not fully recorded in care plans This could affect the home’s ability to meet all a resident’s needs. Service users are supported to make decisions about their lives. Service users are not appropriately supported to take risks as part of their independent lifestyle, as risk assessments do not contain all the information required to facilitate minimising restrictions of liberty for the residents. EVIDENCE: The last inspection report contained a requirement for a record of all of a service user’s needs and how they are to be met and by whom, to be recorded in their plans of care. The care plans have been re-written and are much improved and more holistic. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 12 However, the care plans still do not reflect all of a resident’s needs. For example, support at mealtimes and educational and spiritual needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. This requirement remains in force. The last inspection report contained the following requirement: Plans of care must be reviewed by the home on a 6 monthly basis. This is now occurring and this requirement is currently met. Standard 7 requires that staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. Requirements to facilitate and evidence this process have been made under Standard 9 below. Although a minor shortfall in meeting this Standard therefore exists, a requirement has already been made under Standard 9 and will not be duplicated here. The last inspection report contained the following requirement under Standard 9: The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty are assessed as necessary for the protection of service users. New risk assessments had been devised and this requirement is now met. The last inspection report contained also the following requirement: Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. This has not occurred. The existing requirement regarding this will also remain in force until fully met. However for clarity the requirement will be changed as follows: For any pre planned restrictions of liberty or pre planned restraints {cot sides, locked doors etc.}, risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. Inglemere DS0000025798.V350184.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): Standards 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate.. This judgement has been made using available evidence including a visit to this service. Residents are supported to be a part of the local community and are able to take part in appropriate activities, but his could happen more regularly. Residents do not receive all the paid holidays they are entitled to. Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This would facilitate more funding and additional holidays for residents that they do not have to pay for. Residents are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Service users’ rights are now better respected and responsibilities recognised in their daily lives. Residents are offered a healthy diet and have choices in meals offered. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 14 EVIDENCE: The last inspection report contained the following requirement: The home manager must develop the range of fulfilling activities available to service users in and out of the home. This affects both the activities and community interaction Standards. There had been a noticable improvement but these are still limited with infrequent weekend outings. The expectation would be evening outings during the week and additional outings at weekends. The manager was asked to send in records of activities for the next two months to help them evidence the changes and help the inspector assess the changes. The requirement remains in force untill fully met. Residents are offered a holiday with £150 of extra staffing hours. The residents are currently required to pay for the cost of the holiday themselves. The last inspection report contained a recommendation for each service user to be offered a seven day holiday. Holidays are still funded by the service users and not the organisation. The existing recommendation remains in force. The staff team at Inglemere encourage service users to remain in contact with their family members. There is an open visitors policy. The home has regular social events, such as a Christmas party. Family and friends are invited to any social events held at the home as well as reviews. The home has a key worker system and it is part of their role to keep parents and carers informed of their progress. Visitors can be seen in any of the home’s communal areas as well as the service users’ bedrooms. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. At the weekends there is more flexibility with breakfast and bedtimes. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 15 The menu at Inglemere is based on a four-week rota, which reflects the likes and dislikes of the residents. The dietician employed by the Trust then checks the menus. Referrals to the dietician are made where required. Alternative meals are provided if the service users do not like the main option. The last report recorded that ‘a number of residents are of low weight and records showed that they are continuing to lose weight. For instance, in one case a drop from a low 43 kg to 40 kg was recorded. Communications with the dietician identified that this was due to the staff not encouraging residents sufficiently to follow dietary plans.’ The following recommendation was set at that time. The home should devise a coherent strategy for balancing a resident’s food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and its outcome included in daily notes. The home had since implemented the dietician’s recommendations and a new menu had been produced that showed an improved in nutritional content. The recommendation is currently met. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 16 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): Standards, 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. Although there has been much improvement, residents still do not always receive personal support in the way they require. Residents’ physical and emotional health needs are generally met. Residents’ medication is usually well managed to ensure maximised good health. EVIDENCE: The remaining requirement under Standard 6, for care plans to record all needs, also affects the rating of Standard 18. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 17 The second to last report recorded the following: Three staff bags, two coats and a jumper were observed on furniture and the floor in the service users’ lounge. Staff do have separate facilities to store their belongings and should not infringe on the service users’ space. At the last inspection, three staff bags and one coat were again stored in the residents’ lounge. As this poor practice had continued after being pointed out in, it now represented a clear lack of respect for the residents, their space and their rights. As this practice had continued the previous recommendation was then replaced with the following requirement: Staff must use their separate facilities to store their belongings, and should not leave their bags and coats in the service users’ communal or individual space. At this unannounced inspection it was clear that this practice had been challenged as there were no staff items in the lounge. This requirement is therefore currently met. The last inspection report also recorded the following under Standard 18: Risk assessment guidelines are not always followed. A baby monitor is used to monitor a service user at night until he goes to sleep. The monitor receiver was on, in the residents’ lounge on the first and second mornings of the inspection, despite guidelines to minimise loss of dignity stating that it should be turned off at night once the service user goes to sleep. This meant that anyone in the lounge on those days could have overheard any noises in the service user bedroom removing any privacy on these days. The following requirement was set: Risk assessment guidelines must always be followed, and specifically in this instance, where directions to promote dignity and privacy are recorded. At the time of this inspection the monitor was off while the area was being used by other service users. This requirement is therefore also currently met. However, both these areas will continue to be monitored. On the 26 of April 2005, an early morning additional inspection occurred. The residents were observed to come down into the lounge without any staff supervision or support. A blind resident was seen to be confused and could not find a chair. This resident eventually sat down on a chair that another resident was sitting in. The resident already in the chair became very distressed and attempted to hit the blind resident. The inspector guided the blind resident into a vacant chair before an incident occurred. The following requirement was then set to address this lack of staff personal support and guidance observed: Staff must always provide adequate supervision, support and guidance for the residents. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 18 At the time of the following inspection, it was again noticed that residents were left to go from breakfast to the lounge unsupervised. It was however noted that the period left alone was shorter than last time. This requirement remained in force at that time. On the first day of this inspection, shouting was heard from the lounge while I was about to ring the bell. I went straight to the lounge and again no staff were present. The requirement therefore remains in force. However, the manager stated that a review of staffing was currently underway. Hopefully this will address any shortfalls. See also Standard 24 for associated recommendation. Healthcare needs are recorded in the service users’ files. Service users are supported to attend outpatient appointments and other medical appointments as required. The service users at the home are registered with a local G.P. They are able to access community health facilities such as opticians and district nurses as required. The service users also have access to dentists and chiropodists. District Nurses and other healthcare professionals attend when required and meet service users in private. It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in rectal diazepam usage. The home has a copy of the British Medical Association guide to medication and a copy of the British National Formulary in place. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept securely in a locked metal cabinet fixed to the wall. This home uses a controlled drugs register when controlled drugs are used. A recent incident of a member of staff forgetting to administer medication creates a minor shortfall under this Standard. The home followed procedures in reporting this to adult protection and then following confirmation, investigating the issue. As this was possibly a one off and is currently being addressed by the home’s management, a requirement is therefore not needed at this time. However this area and the current investigation will continue to be monitored. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies and procedures relevant to protection are now better known to staff and therefore better facilitate protecting residents from abuse. Complaints are generally managed well and there were no complaints since the last inspection. EVIDENCE: Neither the Commission or the home have received any official complaints since the last inspection. The organisation’s complaints procedure was clear and contained all of the elements required to meet this Standard including a response time of less than 28 days. This was also the case for the local procedure, which included details of how to contact the Commission at any stage of a complaint. The complaints procedure was also converted into symbol subtitles. The home has a copy of Croydon’s Vulnerable Adults Policy. The Trust runs mandatory training in this area. The last annual inspection report contained the following requirement: Guidance regarding the use of unplanned restraint and guidance regarding acceptable forms of restraint, and the use of other techniques to avoid restraint must be made available to staff and these procedures must be known by them. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 20 By the time of this inspection, the manager has discussed this policy and guidance with staff and put a copy in the daily notes for easy and regular access for staff. This requirement is therefore currently met. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, and, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment and furniture generally meet the residents’ needs, although the environment does not always promote the residents well being. Service users’ bedrooms generally promote independence and contain all the furniture required. The home is now more hygienic and clean. This environment therefore now not better facilitates the residents’ health and emotional well-being. EVIDENCE: The building is generally well maintained with regular maintenance provided by the Trust’s works department. The last few inspection reports have highlighted concerns about the level of service user supervision provided at the home. See Standard 18 for details. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 22 The positioning of the dining room and lounge are at opposite ends of the building, with no direct line of sight from one room to another on the ground floor. This makes indirect observation difficult, for example, staff in the dining room have to walk around a corner and down a corridor to see into the lounge. The inspector also found it impossible to observe both these areas at once or even within a short period of time. At the last inspection, the following recommendation is set to explore this: The provider should examine the suitability of the current layout of the building and explore whether it is conducive to safely meeting the care needs of the service users, based on current staffing levels. A review of staffing in relation to the building is currently underway. The recommendation will remain until the review has concluded and any action required taken. The home has specific policies on the disposal of clinical waste, infection control and Control of Substances Hazardous to Health. There are laundry facilities with a sluice and an industrial type machine, which is capable of washing at high temperatures. The laundry is separate from the kitchen and has floors and walls that are easy to clean. The last report recorded that , the cleanliness of the home was borderline at best, but definitely not tidy at the time of the unannounced inspection. As a cleaner is about to be recruited this area will be monitored and requirements only made if the service manager’s strategy for improvement in this area does not bring the improvements needed. Since that time the cleaner has been recruited and the cleanliness of the environment has improved. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 23 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): Standards 32, 34, 35, and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are met by appropriately qualified staff. The home’s recruitment procedures protect the residents through vigorous staff vetting. Residents needs are met by appropriately trained staff. Staff are well supervised and this Standard is currently exceeded. EVIDENCE: An initial ‘in house’ induction is provided for all staff from their starting date. There have been no new staff since 2000. This Standard will therefore be examined in more detail once a new staff member starts. At that time the required 6 weeks induction and six month foundation training to Sector Skills Council workforce training targets will be inspected. At the last inspection, staff recruitment files were examined and found to be in order. Again as there had been no new care staff is was not possible to reInglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 24 assess this standard. However, as stated it was met at the last inspection and so remains met. The last report contained the following requirement: The home must ensure that at least 50 of it’s staff have a NVQ 2 in care. This has now been achieved and the requirement is therefore currently met. The last report contained the following requirement: The provider must ensure that staff receive a minimum of six regular supervision sessions per year. Supervision records examined on this occasion had not only caught up with the six sessions per year but had exceeded this figure by almost double. The requirement is therefore now met and the staff supervision standard is exceeded. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The organisation has recruited a manager and this report demonstrated that the home is now well managed. Although the manager still needs to complete his registered managers award qualification. The home has now implemented a quality assurance system and an annual development plan, which increase the involvement of the residents and relatives in measuring improvements in quality. The environment is generally safe. EVIDENCE: Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 26 The previous report sited gaps in management cover over the last few years as contributing to the identified significant fall in standards. In addition, concerns regarding the care team leader’s performance in covering of management issues were also raised. The following requirement was then set: The provider must ensure that sufficient and suitable management staff are employed to facilitate completion of management tasks{which includes providing information to inspectors}. The organisation has moved quickly to provide a new manager for this home. This has enabled a number of previous requirements to be met and the previously identified drift standards identified in the previous report have started to be addressed. This requirement is therefore now met. The new manager is a qualified nurse and is currently undertaking the registered managers award. The following requirement is only needed technically: The manager must complete the registered managers award. The last annual inspection report contained the following requirement under Standard 39: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan is produced and is open to the service users, to allow measurement of achievement in improving quality. An annual development plan has now been developed and this reflects recent user satisfaction surveys where appropriate. In addition this information is to feed back to the service users to make them central to the process. This requirement is currently met. All of the health and safety policies and procedures relevant to this standard were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were present and all these items are locked away securely. An asbestos survey had occurred in line with the current asbestos at work regulations. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, emergency lighting, 5 year wiring testing, Portable Appliance Testing, Boiler and gas testing, and Bacterial analysis and testing of the water supply. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 2 x 3 x x 3 x Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement A record of all of a service users needs and how they are to be met and by whom must be recorded in their plans of care. {Timescale 1/12/2004 not met}. For any pre planned restrictions of liberty or pre planned restraints {cot sides, locked doors etc}, risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. The home manager must develop the range of fulfilling activities available to service users in and out of the home. {Timescale of the 30/4/2004 not met}. Staff must always provide adequate supervision, support and guidance for the residents. {Timescale of the 01/07/05 not met}. The manager must complete the registered managers award. {new requirement} DS0000025798.V350184.R01.S.doc Timescale for action 01/11/07 2. YA9 13(7) 01/11/07 3. YA12 16. (2)(m)(n) 01/12/07 4. YA18 12[4]a b 01/11/07 5. YA37 9 [1] 01/04/08 Inglemere Version 5.2 Page 29 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 YA14 YA24 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the home. The provider should examine the suitability of the current layout of the building, and explore whether it is conducive to safely meeting the care needs of the service users, based on their individual needs and current staffing levels. Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Inglemere DS0000025798.V350184.R01.S.doc Version 5.2 Page 31 - 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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