Inspection on 02/06/06 for Leigham Lodge

This inspection was carried out on 2nd June 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leigham Lodge 18/02/08

Leigham Lodge 20/12/05

Leigham Lodge 16/05/05

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 Leigham Lodge 64 Leigham Court Road Streatham London SW16 2EL Lead Inspector Ms Rehema Russell Unannounced Inspection 2 & 5th June 2006 12:00 nd DS0000044234.V295751.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 DS0000044234.V295751.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. DS0000044234.V295751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leigham Lodge Address 64 Leigham Court Road Streatham London SW16 2EL 01491 579 270 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) DeniseDoggett@beaconcaregroup.co.uk Leigham Lodge Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000044234.V295751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Leigham Lodge was registered on 31st December 2004 to provide care and accommodation to six people with learning disabilities with challenging behaviour/autism. It is owned by Beacon Care, a private company, which has other local and national homes. The home is a two storey semi-detached building entered via an electronically operated gate with entry phone. There is limited room for parking on the forecourt inside the front gate and there is a medium sized garden at the rear. On-street parking is available in nearby roads. The home is located on a bus route and within 5-10 minutes walk from a large shopping centre with full community facilities and bus and rail routes into central London and out to the coast. The home also has its own car for individual transport. Inside the Registered Proprietor has changed the use of the ground floor from two en-suite bedrooms and two lounges, for which it was registered, to one ensuite bedroom, one lounge and a facility for one service user which occupies the previous large lounge and bedroom. The ground floor also has a bathroom with toilet, a dining room and a kitchen. Upstairs there are four bedrooms, three of which are en-suite, a bathroom with toilet, a laundry cupboard and a small office. Prospective service users would be given a Statement of Purpose and Service User Guide. A copy of the most recent CSCI inspection report would be available for perusal at the home. The Statement of Purpose states that the current fee is £1,228 per week with ‘variation around the typical costing listed… due to individual and additional service user requirements’. There are no additional charges. DS0000044234.V295751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one and a half days on 2nd and 5th June 06. The home environment was very busy due to the challenging behaviour needs of the service users. The inspector spoke with the manager and deputy manager, briefly with two support workers, observed two service users and spoke with one of them, toured the premises and looked at documentation. The home has been registered for 17 months and during that time has had three managers. The current acting manager was registered for another Beacon Care home but moved to Leigham Lodge when the second manager was dismissed. At the same time as stabilising operations at Leigham Lodge she is also developing and managing the new Beacon Care home next door which is registered for two very challenging service users. She is in the process of registering as manager for both homes. What the service does well: What has improved since the last inspection? Of the 12 requirements arising from the previous report of 20th December 2006, 7 have been implemented, 2 are in the process of implementation, 1 has been partially implemented, and 2 are outstanding. The 3 requirements that have not been implemented are the responsibility of the Registered Provider (update of policies and procedures, assessment process, review of placement). Improvements since the previous inspection include: • • • the provision of the Service User Guide in a format suitable to the cognitive abilities of the service users for whom the home is registered training for staff in the area for which the home is registered (autism spectrum) the provision of a staff training and development programme and improved floor covering for the lounge and dining room. DS0000044234.V295751.R01.S.doc Version 5.2 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. DS0000044234.V295751.R01.S.doc Version 5.2 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 DS0000044234.V295751.R01.S.doc Version 5.2 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, 4 Quality in this outcome area is poor. This judgement is a reflection of the poor practice being carried out in regard to assessment and admission of new service users. Prospective service users have the information they need to make an informed choice about where to live. The home does not have an admissions policy that ensures that the prospective service users’ individual aspirations and needs are fully assessed by staff who are familiar with the home and its service users. The home is not meeting the assessed needs of all service users. EVIDENCE: The acting manager had updated the Statement of Purpose, which is detailed and clearly laid out, and had ensured that the Service User Guide is in a format that is clear and accessible to the service user group. The home does not have an admission policy. At the previous inspection in December 2005 it was found that the assessment of the most recently admitted service user had been undertaken by the Registered Provider’s Clinical Manager and that the former Registered Manager of the home had not been part of the assessment process. It was pointed out that this is poor practice and a requirement was made for the Registered Provider to ensure that the manager/deputy of the home is always fully involved in the assessment of potential service users. At this inspection it was found that this requirement had been ignored and that the Clinical Manager had carried out DS0000044234.V295751.R01.S.doc Version 5.2 Page 9 the assessment for a new service user without any involvement of the home’s manager. The Clinical Manager had informed the manager that the new service user was to be collected and admitted to the home on a certain date, with the service user not having met any of the home’s staff nor having a trial visit. This is poor practice. See Requirements 1 & 2. At the December 2005 inspection it was found that the most recently admitted service user had been admitted to the home on the understanding that certain physical and staffing conditions would be met, but that these conditions had been provided for. This meant that the needs of the service user were not being met. It also impacted negatively on the quality of life other service users at the home. In addition the service user’s predominant current behaviours and needs arise from mental health issues, for which the home is not registered, and which is in contrast with the needs of all other service users and the skills for which staff had been appointed. An immediate requirement was therefore issued for a case conference to be held to fully assess and review the placement of the service user at the home. This case conference was not held. At this inspection it was found that the pre-assessed conditions were still not being met and that the behaviour of the service user and the facilities provided continued to adversely affect the quality of life for the other service users at the home. An immediate requirement was therefore made for the Registered Provider and Group Operations Manager to attend a meeting with CSCI however due to the absence of the inspector from work for a lengthy period following the inspection, at the time of writing this report the meeting had not yet taken place. DS0000044234.V295751.R01.S.doc Version 5.2 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed and changing needs and personal goals of the four established service users are reflected in individual care plans. Staff assist service users to make decisions about their lives by interpreting their behaviours and moods. Risk assessments and risk management strategies have been undertaken for all service users. EVIDENCE: Three care plans were seen. All were generated from the Care Management Assessments/pre-admission assessments and contained a pen portrait of the service user, a weekly activities schedule, an assessments package covering the full range of needs, and a goal plan. The latter has intermediate, medium and long term goals. Documentation such as weekly activities schedules are signed by the service user where possible, and all documentation is subject to six-monthly review. One of the care plans seen had been read and signed by the service user’s family. Each care plan has guidelines for managing difficult behaviours, and all staff are required to sign and date to certify that they have read and understood the guidelines, which is good practice. DS0000044234.V295751.R01.S.doc Version 5.2 Page 11 Four of the five service users at the home have limited cognitive and verbal abilities. Staff therefore assist service users to make choices/decisions by interpreting their behaviours and moods. One service user says one word only but can indicate by sound when she wants to sleep. An appointment with a behavioural therapist has been made in regard to understanding the times when she becomes aggressive towards others. Another service user can say a few words only but can indicate which clothes she wishes to wear, when she wants to change her clothes, and what she wants for lunch. A third service user, who is non-verbal has been referred to the speech & language therapist but currently staff are only able to assist him to make choices by interpreting his behaviour. A fourth service user can use a range of simple words and is able to tell staff his wishes and choices. He has exercised choice by refusing to attend a gardening project and refusing to continue attending an employment scheme after a few weeks, with these choices being respected. All care plans have a risk assessment section. Risk assessments are well laid out, clear and detailed, and all have been reviewed and signed as read by staff. Only the most recently admitted service user is able to go outside of the home independently and the acting manager has consulted with outside professionals and specialists in regard to minimising the risks that may arise, although the service user is generally non-cooperative with staff. The service user was placed at the home with the understanding that she would be independent in regard to feeding herself. Very poor facilities for this were provided by the Registered Provider, consisting of a microwave oven and a kettle, and the microwave oven has now been removed following a health and safety risk assessment carried out after an incident. Staff now provide a meal for the service user, which she eats in her room as it was always intended that she should not access the rest of the home. DS0000044234.V295751.R01.S.doc Version 5.2 Page 12 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 this service. Staff support service users to take part in age, peer and culturally appropriate activities and to access the local community according to their needs and behavioural limitations. Appropriate leisure activities are provided and staff support and encourage service users to maintain family relationships. Service users rights are only partially respected at the present time. Service users are offered a healthy and nutritious diet. EVIDENCE: Opportunities for service users to develop independent living skills are limited due to their cognitive impairments, however staff assist three service users to lay the table and to wipe the table and mats, and the fourth service user is supported to hoover his room and do his laundry. Staff liaise with outside professionals, such as speech & language and behavioural therapists, in order to interpret and improve service users’ communication skills. DS0000044234.V295751.R01.S.doc Version 5.2 Page 13 Education and employment are not feasible for service users due to their cognitive impairments, although the more able service user attended an employment scheme for a short while but then decided he did not want to continue. Staff support service users to take part in age, peer and culturally appropriate activities, such as attending a Jewish day centre, providing Caribbean and Portuguese food, attending a monthly social club for people with learning difficulties. The most recent service user, who is able to come and go as she pleases, goes out regularly to an area that serves her cultural needs and where she has acquaintances. Service users are supported to participate in the local community as far as their behavioural characteristics allow. For example, the service user who becomes very anxious if people are physically close to him is taken for daily walks, as is another service user who cannot be taken to the shops or café because of her continual behaviour of grabbing and hitting. A third service user is taken shopping, to the cinema and to cafes and the park. A fourth service user requires a wheelchair in order to go out and had not been taken out for the two months prior to the inspection as there was a problem with the wheelchair she had formerly been using and the home was waiting for a new chair to be supplied via the service user’s Care Manager. The need for ramp access to the home to facilitate wheelchair use will be discussed later in the report. The most recently admitted service user is fully physically independent and accesses the local community at will. Leisure activities are provided for service users according to their individual interests and capabilities. One service user listens to music, watches television and is taken to a disco monthly. Another service user watches television, has a fortnightly aromatherapy session and enjoys eating out at local cafes on a regular basis. A third service user enjoys drawing, doing jigsaws, watching video films and playing with beads. A fourth service user, who requires 1:1 staffing, does not engage in set activities but has been provided with sensory equipment in her room. The manager has planned some joint leisure activities for the home during the summer, including trips to Battersea and Richmond parks, and a disco and games to be held at the home. Staff encourage and support service users to maintain family relationships. One service user is supported to visit her family once per month, which her mother told the inspector she was very appreciative of, one service user is visited by her father occasionally and her keyworker has tried twice to meet with the service user’s sister to discuss her care plan, and one service user is visited by his sister monthly. The fourth service user does not have any known family but the fifth service user has regular visits from her son and daughter. The home no longer has a second lounge where visits can take place as this has been used to accommodate the placement of the fifth service user. Staff respect service users’ rights and support them to undertake minor responsibilities according to their cognitive and physical capabilities. For DS0000044234.V295751.R01.S.doc Version 5.2 Page 14 example, three service users are supported to help lay and clear the table at mealtimes, one service user is supported to clean his own room and help with his laundry, and in acknowledgement of the right to come and go as she pleases, the meal for the most recently admitted service user will be kept aside for her if she does not want to observe the mealtime. At the previous inspection the inspector was concerned that with the placement of the most recent service user, some of the rights, individual choice and freedom of the other service users were being compromised. Although some of these concerns are in the process of being addressed, others remain. For example, the loss of the second lounge, which is now being used as a bedroom, means that the right of one service user to access the lounge is being restricted because their behaviour triggers anxiety and distress in another service user. This also means that the second service user’s right to have their assessed need for a place of quiet and calm in which to spend their day is not being met. See Requirement 3 and Recommendation 1.This issue will also be addressed later in the report under the Environment section. Menus were seen and demonstrated that service users are given varied and nutritious meals. Mealtimes are set for the service users who have autistic spectrum disorder, as is suitable for their behaviours, but a meal is put aside for the service user who is independent and non-autistic so that she is able to be fully flexible in the times that she eats. DS0000044234.V295751.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 this service. Service users receive personal support in a respectful and dignified way, and their healthcare needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff were observed to address service users with dignity and respect and to guide their difficult behaviours in a friendly but firm manner. Service users were well groomed and dressed and their appearance reflected their ages and personal choices. Staff described the ways in which they ensure that service users chose the clothes they wished to wear, guiding them if choices were inappropriate, and one member of staff had spent hours in a shop recently whilst a service user searched a vast number of wallets before making his choice. The service user was very proud of the wallet and excited about its purchase. Verbal and documentary evidence demonstrated that the healthcare needs of service users are assessed and responded to by staff. For example, when a keyworker had noticed a service user often fiddling with her ear she arranged DS0000044234.V295751.R01.S.doc Version 5.2 Page 16 for a GP appointment. Each service user has a health action plan and these evidenced regular health appointments, plus best interest meetings as appropriate. Health action plans also evidenced the involvement of speech & language and behavioural therapists, regular weight monitoring, and consultation and use of specialists, such as the Kings Special Care Dentistry unit, as necessary. Storage, administration and recording of medication were checked and no problems were found. The home uses the monitored dosage system. All doses were signed for and there was a list of specimen signatures available, which is good practice. DS0000044234.V295751.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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. There is a suitable complaints procedure for service users but the one available for relatives/interested parties is incomplete. Staff have been trained in adult protection but the abuse policy does not include current practice and therefore does not ensure the protection of service users. EVIDENCE: The complaints book was seen and evidenced that no complaints had been received by the home since the previous inspection. A complaints procedure in appropriate format for service users was displayed on the notice board in the entrance hallway. This complaints procedure contained all of the required information but the complaints procedure in the policy file that is given to relatives/interested parties was incomplete. It did not give information about the stages of the complaints procedure that follow after the complaint has been to the home’s manager and the response is found to be unsatisfactory. There should then be recourse to the parent organisation. See Requirement 4. The manager was fully conversant with abuse and whistle blowing procedures and all staff have undertaken adult protection training. However the abuse procedure issued by the Registered Provider is out of date and must be updated to ensure it reflects current procedures in regard to local and placing authorities. See Requirement 5. DS0000044234.V295751.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally homely, comfortable and safe with the exception of the lounge furniture and furnishings. The majority of bedrooms are attractive and comfortable. However, two rooms occupied as a bedroom and kitchenette are in poor condition. The home is clean and hygienic throughout with the exception of these two rooms. EVIDENCE: The previous report required that the dining room and lounge floor coverings were replaced by good quality, washable vinyl and this had been done. Four of the occupied bedrooms have good quality furnishings and fittings and are arranged to suit the individual needs and preferences of the service users. For example, one service user’s room has framed photographs of relatives plus framed prints of famous paintings, another has pictures of interest and a collection of soft toys that the service user enjoys touching. All of these bedrooms were attractive, homely and personalised. One service user has shredding behaviours and staff have made this room as homely and safe as DS0000044234.V295751.R01.S.doc Version 5.2 Page 19 possible, using a monitor so that staff will know as soon as the service user awakes and can therefore prevent him shredding his sheets and clothes. In order to accommodate a service user who is intended to be largely independent, the Registered Provider is using the large quiet lounge as a bedroom and a former bedroom as a “kitchen and bathroom” area. No alterations had been made to the former bedroom and only a microwave oven, fridge and kettle had been provided as kitchen equipment, with no sink nor water supply, save the washbasin in the en-suite shower and toilet. In addition, as previously mentioned, the loss of the second lounge is adversely affecting the rights and needs of other service users. On the day of inspection both rooms were very dirty, with the inspector unable to enter the room used as a bedroom as the smell of urine was overpowering. The door to the shower en-suite in the former bedroom did not open properly due to the carpet being swollen from water spillage. Work is currently being carried out to give the service user an independent entry and exit to the home via the current “kitchen and bathroom” room and the service user is now supplied with meals by staff. As a separate room for cooking is no longer required, the room currently designated for cooking could revert to being used as a bedroom/bedsit, with en-suite shower and toilet and a separate entrance and exit, and the current bedroom could revert to a communal lounge. See Recommendation 1. The communal lounge in the main part of the home had good quality flooring but was not homely on the day of inspection. The sofa was torn and there was very little ornamentation. The service user who spends most of his time in the lounge has behavioural characteristics of shredding and damaging ornamentation, however the manager said that a new sofa had been ordered and that murals will be painted on the walls to make the room more colourful and homely. All service users are fully mobile so alterations and equipment are not necessary, with the exception of a wheelchair for one service user who is fully mobile indoors but needs a wheelchair for going out of the home. The service user’s care manager is in the process of obtaining the wheelchair but at the time of the inspection staff had not been able to take the service user for a walk for over two months and so the manager/keyworker should follow this up with the care manager to ensure the wheelchair is available as soon as possible. See Recommendation 2. The Registered Provider must provide a short ramp for the front door to facilitate use of the wheelchair. See Requirement 6. On the day of inspection the home was found to be clean and hygienic throughout, with the exception of the two rooms provided for the fifth service user who is supposed to be living independently in regard to cleaning. DS0000044234.V295751.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and trained staff. Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staff were observed to be accessible, approachable and to handle challenging behaviours with patience and understanding. Following a requirement made in the previous inspection report, staff had undertaken training in autism. They reported that they had found the course very useful and that it had improved their understanding of service users’ behaviours and changed the way in which they managed some behaviours. As the home currently has one service user who has dual diagnosis, a requirement has been made for staff to undertake training in mental health issues. See Requirement 7. The home has not yet achieved the recommended 2005 training target for 50 of care staff to achieve NVQ 2 in care. Of the 10 support workers at the home, only one senior support worker and one support worker currently have NVQ 2. Two seniors and one support worker are due to finalise their NVQ 2 within the next 4 months, and if this is achieved the target will be met. The remaining support workers are hoping to start NVQ 2 training in September 2006 if the manager is successful in securing outside funding, as the Registered Provider does not DS0000044234.V295751.R01.S.doc Version 5.2 Page 21 provide either financial or time support to its employees undertaking this training. The staff files of the two support workers who had joined the home since the previous inspection were checked and all required documentation was in place, including application forms, references, Criminal Records Bureau and Protection Of Vulnerable Adults clearance, proof of identity, and training/qualification certificates. The inspection report of 20th December 2005 required that the home provide evidence of a staff training and development programme, and this had been implemented. There is a four week induction course, evidence of which was seen on staff files, and all staff receive a minimum of 5 days paid training. The training schedule for this year includes substance misuse, self-injurious behaviour, activities & skills development, risk management, challenging needs, capacity and consent for people with learning disabilities and introduction to autism. It is recommended that all staff undertake training in equal opportunities/diversity, which is not currently part of the induction/basic training. See Recommendation 3. DS0000044234.V295751.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager runs the home well and service users benefit from her ethos, leadership and management approach. The home does not have a quality assurance system in place and so service users and stakeholders cannot be confident that their views underpin self-monitoring, review and development. Some policies and procedures are not relevant to the home and do not therefore safeguard service users’ rights and best interests. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The manager is qualified, competent and experienced to run the home, having previously managed a home for people with learning disabilities and having the Registered Manager’s Award and NVQ Level 4. At the time of the inspection the manager was in the process of obtaining registration for this home and the adjacent home, which is owned by the parent company and registered for two service users. DS0000044234.V295751.R01.S.doc Version 5.2 Page 23 The current manager was transferred to the home by the Registered Provider following a year when one manager had left the home and another had been dismissed. In the time that she has been at the home she has improved practices and documentation, stabilised the staff team and improved its morale. Staff confirmed that her management style is open, positive and inclusive and that they felt much happier and confident at the home under her leadership. There was no evidence that the Registered Provider operates an effective quality assurance and quality monitoring system. Regulation 26 monthly reports by the Group Operations Manager are being carried out but there is no other quality assurance system in place and no formal feedback from service users, family, advocates and stakeholders has been obtained and published. The acting manager has started this process by sending out questionnaires to Care Managers and service users’ families just prior to this inspection and intends to attempt to obtain views from non-verbal service users via picture cards. See Requirement 8. At the two previous inspections it was found that several of the policies and procedures provided by the Registered Provider were either out of date or not relevant to the home’s client group. At the previous inspection it was found that the new manager had updated some policies but that others were to be reviewed by the new Group Operations Manager. At this inspection it was found that several polices and procedures had still not been reviewed. This is poor practice as staff need access to relevant and up to date policies and procedures in order to inform their practice at the home. See Requirement 9. A range of health and safety certificates were seen and evidenced that the home is operating safe working practices. Documentation seen included monthly health and safety checks, fridge/freezer temperatures, fire drills and practices, annual fire and emergency lighting inspections, extinguishers and fire alarm tests, gas safety certificate and hazardous substances were stored safely. It is recommended that the actual time of fire drills is noted in the fire book. See Recommendation 4. DS0000044234.V295751.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 1 3 1 4 1 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 1 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 1 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 1 2 X 3 X DS0000044234.V295751.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14(1)(a) Requirement Timescale for action 05/06/06 2. YA2 3. YA3 4. YA22 The Registered Person must ensure that the manager/deputy assesses all potential service users. Previous timescale of 20/12/05 had not been met. See requirement 2 below. 14(1)(a) & The Registered Person must 14(1)(c) ensure that the home has an admission policy which ensures that the manager/deputy of the home is always fully involved in the assessment of potential service users and that a trial visit is always offered. 12(1)(a) & The Registered Person must (b) ensure that a case conference is held to review the suitability of the placement of the most recently admitted service user, with a report sent to the Commission. The previous timescale of 27/01/06 was not met. An immediate requirement was left for a meeting with the Registered Person. 22 (5) The Registered Person must ensure that the complaints procedure available for DS0000044234.V295751.R01.S.doc 01/09/06 05/06/06 01/11/06 Version 5.2 Page 26 5 YA23 6 YA29 7 8 9 YA32 YA39 YA40 relatives/interested parties is a full and complete description of the home’s complaints policy. 13(6) The Registered Person must ensure that the abuse policy and procedure is updated to reflect current practice, including that related to local and placing authorities. 23(2)(n) The Registered Provider must provide a short ramp for the front door to facilitate the use of wheelchairs. 18(1)(c)(i) The Registered Provider must ensure that staff receive mental health training. 24(1) The Registered Provider must establish a quality assurance system for the home. 12(1) The Registered Person must ensure that all policies and procedures for the home are up to date and relevant to its client group. Previous timescale of 31/03/06 not met. 01/11/06 01/12/06 01/02/07 01/12/06 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA28 Good Practice Recommendations The Registered Provider should consider re-configuring the facilities provided for the fifth service user and reproviding a second lounge for the remaining service users in the home. The Manager should try to ensure that the wheelchair for taking one service user on walks outside of the home is obtained as soon as possible. The Registered Provider should ensure that training in equal opportunities/diversity is given to all staff. The Manager should ensure that the actual time of fire drills is recorded. DS0000044234.V295751.R01.S.doc Version 5.2 Page 27 2 3 4 YA29 YA35 YA42 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 DS0000044234.V295751.R01.S.doc Version 5.2 Page 28 - 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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