Inspection on 31/05/05 for Inglemere

This inspection was carried out on 31st May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Inglemere 21/09/07

Inglemere 05/06/06

Inglemere 19/12/05

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 Additional Inspection of 26 April 2005 and the Announced Inspection of 31 May 2005 9:00am 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 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 Stationary 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 G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Inglemere Address 2 Pollards Hill East, Norbury, London, SW16 4UT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8679 6726 020 8679 6726 Surrey Oaklands NHS Trust NA Care Home 9 Category(ies) of Learning Disability (9) registration, with number of places Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 29 October 2004 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. Inglemere is owned, managed, and staffed by the Surrey Oakland’s Trust, a specialist health provider for people with learning disabilities. 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 Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a combination of an announced inspection undertaken within 4 hours on the 31/5/2005 and a early morning additional inspection on the 26/4/2005 carried out over 3 hours. All the residents were met during both inspection days. During the inspection the area manager and staff were met and the acting manager {deputy} was interviewed. Records, policies and care plans, and the building were examined, as were all the residents’ bedrooms. The home has not had a registered manager in post for some years. The person previously covering this post has now left and although the deputy is acting up her post is not being covered. This now creates an additional deficit in the management resources. Although there is a lack of development and a high number of unmet existing requirements in this report, the inspector believes that this is due to inconsistency and lack of management, and now also senior staff. The inspector believes that many of the requirements can be easily addressed once these posts are filled or additional management resources are made available. What the service does well: What has improved since the last inspection? Each resident now has a suitable a contract with the home. This will give the residents more rights. Pictorial complaints procedures, fire procedures and menus are now available and this should make information more accessible to the residents. A resident’s consent to medication is now recorded. This will ensure that residents’ rights in this area are maintained. A policy prohibiting staff from being involved in the production of wills has been implemented. This will further protect residents from financial abuse. The staff team has now undertaken training on issues of Adult Protection. This will raise staff awareness of these issues and how to address them. The bedroom next to the office has been redecorated as has the lounge. A new carpet has also been fitted in the hall. This has improved the environment at the home. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 6 The home’s recruitment procedures now protect the residents through vigorous staff vetting. Staff are now appropriately qualified to meet the residents needs with over 50 having the NVQ2 as required. Staff are generally satisfactorily supervised. Supervision records are now made available and not destroyed before a staff member leaves service. What they could do better: Although the Statement Of Purpose contains most of the information required it is not yet complete, completing this will help relatives and placing social workers to have a good picture of what the home provides and help them choose between different homes. The service users guide is still not satisfactory as it does not contain the views of the residents and is not available in other more accessible formats. This is important so that new residents can understand their guides and can be clear about how other residents feel about living in this home. The care plans do not reflect all of a resident’s needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty and in addition do not contain all the information required, and in particular, details of how training and other options have been explored. Including this information could reduce unnecessary restrictions of liberty for the residents. Residents do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. Residents do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to pay for. Although the food provided is sufficient in quantity and is sufficiently nutritious, residents are losing weight and are not being sufficiently encouraged to eat healthily . This is important to ensure good health. Residents do not always receive support in the way they require. Restraints Policies and guidance are not readily available to staff, and these policies and guidance are not known by them. This is needed to protect residents whilst being restrained for their own protection and to ensure that restraints only occur as a last resort. Residents’ rooms do not contain all of the furniture required under Standard 26.2. Unless the resident has made a positive choice not to and this is evidenced in their files, or recorded risk assessments show otherwise, the residents may not be getting all the furniture they are entitled to. The home needs to acquire an occupational therapist’s assessment for aids and adaptations to improve access to the general environment and for individual residents. The residents do not benefit from a well run home due to a lack of continuity of management. There has not been a registered manager for some time and the person previously covering the registered manager’s post has now left. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 7 In addition the deputy is now covering the manager’s post, which also now leaves her post uncovered. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this the involvement of the residents and relatives could be limited. 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. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, and 5 Although the home provides most of the information needed for potential residents to make an informed decision about moving in to the home, the residents do not have all the information they need. The residents’ rights are enhanced through their contract with the home. EVIDENCE: The last inspection report contained the following three requirements under Standard 1, 1,The service user guide should be in a format suitable for the service users. 2, The service users guide must contain the views of the service users. 3, The Statement Of Purpose must specify room sizes and the S.O.P. and service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. All these 3 requirements were not met at the time of this inspection and remain in force. The home has not had a new service user start for at least 3 years. It was therefore not possible to assess standard 2 fully at this time. The last inspection report contained the following requirement under Standard 5; The home should provide the service users with a standard form of contract for the provision of service and facilities in respect of each service user. Contracts were in place for all the residents by this inspection and this requirement is now met. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 10 Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, and 9. Residents’ assessed needs, and how the home meets these needs, are not fully recorded. This could affect the home’s ability to meet and show how it has met all a resident’s needs. 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. One file sampled only recorded 5 needs for a resident that had a high level of need. Needs not recorded included educational and personal care needs. As this had not occurred the requirement remains in force. One resident’s file contained only 9 daily notes entries for the last 12 months. The following recommendation is now therefore set: Daily notes should be recorded daily and reflect how the care plan was implemented on that day. The last inspection report contained the following requirement: Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 12 The home must provide service users with accessible information regarding its policies, activities and services. Pictorial complaints procedures, fire procedures and menus are now available and this requirement can be considered currently met. However, this should be an area of ongoing development and will be monitored for continual development. 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. There, risk assessments are required to be amended to refer to the above parameters and therefore evidence the above process fully. Although a minor shortfall in meeting this Standard therefore exists, a requirement has already been made 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. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty, for example the use of baby monitors and the locked kitchen gate. The existing requirement regarding this will remain in force until fully met. The last inspection report contained 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. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17 Residents do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. Residents do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to pay for. Although the food provided is sufficient in quantity and is sufficiently nutritious, some residents are losing weight and are not being sufficiently encouraged to eat healthily . This is important to ensure good health. 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. These are still limited with only 2 evening outings per month. The expectation would be evening outings during the week and additional outings at Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 14 weekends. The home has plans to expand the number of outings and activities. The requirement remains in force untill fully met. There is an open visitors policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Family and friends are invited to any social events held at the home as well as reviews. The residents are given a choice of having keys to their bedrooms and the front door of the home. Not all of the residents have taken up this option. 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 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. 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. This will be monitored and a requirement set if necessary. The following recommendation is however set at this 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. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 20. Residents do not always receive personal support in the way they require which can affect their dignity and indpendence. Residents’ medication is satisfactorily managed to ensure maximised good health. EVIDENCE: 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 is now 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 G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 16 Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. A resident’s preferences for how personal care is to be conducted is included in the ‘Person Centred’ Plan of care. The home provides consistency and continuity through the use of designated key workers. Residents have access to relevant professional support to maximise independence, including physiotherapists. See Standard 29 for access to occupational therapists. The last inspection report contained the following requirement: The home must obtain and record the service users’ consent to medication. Where verbal consent is not possible, the home must obtain this for new service users through the use of independent advocates. For existing service users, a record of the advocated view will be accepted. Any advocated view of non-consent must also be recorded. This has now been implemented and this requirement is now met. Medication profiles and clear Medication Administration Record sheets were seen in records sampled. Medication is kept securely in a locked metal cabinet fixed to the wall. Records examined showed that all medicines administered are recorded on MAR sheets, which were up to date at the time if the inspection. The Trust has a policy on the administration of medication and also provides accredited training in this area. The following is seen as good practice: Medication training occurs annually and additional annual training occurs in ‘as and when medication’ and also in rectal diazepam Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Complaints are generally managed well and there were no complaints since the last inspection. The home’s policies and procedures relevant protection are not all known to staff and therefore do not fully facilitate protecting residents from abuse. EVIDENCE: There had been no official complaints made to the home or the Commission 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 converted into symbol subtitles. The last inspection report contained the following requirement: A policy prohibiting staff from individually benefiting from residents wills, or being involved in making residents wills, must be made available to staff, and these policies and guidance must be known by them. This has now occurred and this requirement is currently met. The last inspection report contained the following requirement: The registered manager must ensure the staff team undertakes training on issues of Adult Protection. This has now occurred and this requirement is currently met. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 18 The last inspection report recorded the following: The organisation has its restraints policy and guidance spread over 3 separate documents. The home was only able to produce one document containing limited restraints guidance called “Responding to Aggression and Violence” policy and procedure. This states that physical restraint should only be used as a last resort and should be recorded to justify the action taken. This did not contain any guidance about what forms of restraint were acceptable and which forms were not acceptable, for example holding clothing instead of flesh to avoid damage to service users. A brief minor unplanned restraint was observed during breakfast, where a member of staff pulled a service user by the arm to the dining table. The following requirement is therefore set. 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. Although this guidance has now been produced, only the deputy manager had signed to confirm they had read and understood it. The requirement will therefore remain in force until these procedures are known by staff. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 29, and 30. Although the environment is currently well maintained and suitable furniture is available, residents’ rooms do not contain all the furniture required. This may be because a resident has chosen not to or because of risk. However this must be recorded to ensure that residents have all the furniture they are entitled to. The home does not have all the specialist equipment required to meet all a resident’s needs this could reduce their independence or affect their safety. The home is hygienic and clean; this environment therefore facilitates the residents’ health and emotional well being. EVIDENCE: The last inspection report contained a requirement for the bedroom next to the office to be redecorated. This has occurred and that requirement has been met. In addition the lounge has been redecorated and a new carpet has also been fitted in the hall. The last inspection report contained the following requirement: Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 20 Service users’ rooms must contain all of the items listed in Standard 26.2, unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. This has not occurred and this requirement remains in force. The last annual inspection report recorded that there were no general or individual occupational therapist assessments for aids and adaptations available for inspection. In addition there were no specialist assessments or equipment for the service user with a sensory impairment or the service user that uses a wheelchair. The following requirement was then set to address this shortfall: The home must acquire an occupational therapist’s assessment for aids and adaptations for the general environment and individual service users. This had not occurred and this requirement remains in force. The home was clean and tidy at the time of the inspection. 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. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35, and 36. Staff are appropriately qualified to meet the residents’ needs. The home’s recruitment procedures protect the residents through vigorous staff vetting. Staff are generally satisfactorily supervised which should ensure good practice and a continual improvement in the support offered to the service users. EVIDENCE: The last inspection report contained the following requirement: All Elements of Schedule 2 {staff files} must be kept securely on site and be available for inspection. This includes CRB checks and records of staff disciplinary action. This has now occurred and this requirement is now met. An initial ‘in house’ induction is provided for all staff from their starting date. There have been no new staff since 2000. The existing requirement regarding this is now currently withdrawn. This Standard will therefore be examined in more detail once a new staff member starts. At this time the required 6 weeks induction and six month foundation training to Sector Skills Council workforce training targets will be inspected. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 22 There are now 5 of the 9.8 full time equivalent staff with a NVQ 2 qualification. This meets the 50 ratio required under Standard 32. The last inspection report contained the following 2 requirements regarding staff supervision: 1, Supervision records must be made available during an inspection to evidence that all the elements of Standard 36.4 are covered in each supervision session and to evidence the frequency of supervision. 2, Supervision records must not be destroyed while a member of staff is still employed at the home. The supervision records were made available and are no longer destroyed. They showed that they were on target to meet the minimum six sessions per year. Both these requirements are currently met. The last inspection report also contained the following requirement: Staff must all have annual appraisals that review performance against job descriptions. This had been implemented and this requirement is therefore met. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, and 42. The failure to appoint a manager to the home means that the service users and their representatives cannot be confident that the home is run to their benefit or that there is consistent leadership . Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this, the involvement of the residents and relatives could be limited. Although the health and welfare of the residents is generally promoted, parts of the environment do not fully facilitate the residents’ health and well being. EVIDENCE: There has not been a registered manager for some time. A requirement was set at the last announced inspection requiring a registered manager to be appointed. This has not occurred, and in addition, the person covering the Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 24 registered manager’s post at that time has now left the home. The requirement therefore remains in force and has now become more urgent. The deputy is now covering her post and the manager’s post. As the previous lack of a registered manager has not been addressed and there is now also a deputy’s post not being covered, the following new requirement is now set: The Trust must ensure that employment of any persons at the care home on a temporary basis will not reduce staffing in other areas and not prevent service users from such continuity of care as is reasonable to meet their needs. The last annual inspection report contained the following requirement: 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. This has not fully been implemented, with the residents’ views and an annual development plan still needed. This requirement remains in force until fully met. The last annual inspection report contained the following requirement: Safety posters must be in a format that is accessible to the service users. This has now occurred and a pictorial fire evacuation procedure is now available. This requirement is now therefore met. An up to date 5 year wiring certificate was not available during this inspection. The following new requirement is now set to address this: An up to date 5 year wiring certificate must be sent into the Commission. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 2 x x 2 3 Standard No 11 12 13 14 15 16 17 x 2 2 2 x x 2 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Inglemere Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 12[3] Requirement The Service Users Guide must contain the views of the service users. {Timescale of the 1/12/2004 not met}. The service users guide must be in a format that is suitable for the service users.{Timescale of the 1/12/2004 not met}. The Statement Of Purpose must specify room sizes and the S.O.P. and service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. {Timescale of the 1/12/2004 not met}. A record of all of a service user’s needs and how they are to be met and by whom must be recorded in their plans of care. {Timescale of the 1/12/2004 not met}. The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty or preplanned restraints are assessed as necessary for the protection of service users. {Timescale of the 1/9/2004 not met}. Timescale for action 1/12/2004 2. 1 5 12[4]b 1/12/2004 3. 1 4[1][C] 1/12/2004 4. 6 15 1/12/2004 5. 9 17[1]a 1 3[7] 1/9/2004 Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 27 6. 9 13[7] 7. 12 16. (2)(m)(n) 8. 9. 18 23 12[4]a b 17 12[1] [4]b 10. 26 16[2]c m 11. 29 12[1]a13[ 1]b 12. 37 8. -(1) (b) 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. {Timescale of the 1/9/2004 not met}. 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. 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. {Timescale of the 1/9/2004 not met}. Service users’ rooms must contain all of the items listed in Standard 26.2 unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. {Timescale of the 1/12/2004 not met}. The home must acquire an occupational therapist’s assessment for aids and adaptations for the general environment and individual service users. {Timescale of the 1/12/2004 not met}. The registered provider must ensure that a permanent registered manager is appointed to the home. {Timescale of the 1/9/2004 30/04/04 1/7/2005 1/9/2004 1/12/2004 1/12/2004 1/12/2004 Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 28 1/12/2004 not met}. 13. 37 18[1]b The Trust must ensure that employment of any persons at the care home on a temporary basis will not reduce staffing in other areas and not prevent service users from such continuity of care as is reasonable to meet their needs. 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 must also introduce user/relatives satisfaction surveys and an annual development plan that is open to the service users, to allow measurement of achievement in improving quality. {Timescale of the 1/12/2004 not met}. An up to date 5 year wiring certificate must be sent into the Commission. 1/7/2005 14. 39 24,1,2,3 1/12/2004 15. 42 12 1/7/2005 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. 3. Refer to Standard 6 14 17 Good Practice Recommendations Daily notes should be recorded daily and reflect how the care plan was implemented on that day. Each service user should be offered a seven-day holiday paid for by the home. The home should devise a coherent strategy for balancing a residents food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and it’s outcome included in daily notes. Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 29 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Inglemere G53 S25798 Inglemere V190549 310505 stage4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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