Inspection on 01/10/07 for London Mental Health Care Centre

This inspection was carried out on 1st October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

London Mental Health Care Centre 24/04/09

London Mental Health Care Centre 06/05/08

London Mental Health Care Centre 13/11/06

London Mental Health Care Centre 19/12/05

London Mental Health Care Centre 09/06/05

London Mental Health Care Centre 19/05/04

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

CARE HOME ADULTS 18-65 London Mental Health Care Centre 78-80 Arran Road Catford London SE6 2NN Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 1st October 2007 08:45 London Mental Health Care Centre DS0000025631.V342262.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 London Mental Health Care Centre DS0000025631.V342262.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. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service London Mental Health Care Centre Address 78-80 Arran Road Catford London SE6 2NN 0208 6988770 0208 6988770 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) Mr Dhaneswar Dooraree Care Home 15 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (15), of places Physical disability (1) London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 15 persons with a mental health problem, one of whom may also have a physical disability to include four persons who may also have a learning disability - see attached sheet for details 13th November 2006 Date of last inspection Brief Description of the Service: The London Mental Health Care Centre is a care home registered to provide accommodation and care to 15 adults with mental health problems. It is situated in a quiet side road off the Bromley Road approximately 15 minutes walk from the shopping centre and civic amenities in Catford. The home has 13 single rooms, and one shared room. There is a communal area for dining, and an activities area where there is a television and a pool table. There is a goodsized garden with patio area with outside seating. There is also a quiet room for private meetings of staff and residents The home aims to provide support and accommodation to residents who are undergoing rehabilitative care programmes. The skills that they acquire will enable them to move on to more independent living situations where possible. Accessing local services and integration with the wider community are an implicit part of the rehabilitation programme. The staff team includes a number of RMN’s and staff with NVQ qualifications. The weekly fees are between £ 700 - £1,300. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by one inspector. The inspector spent time with the staff on duty observed the daily activities and chatting to resident. The medication administration and records were checked. A selection of heath and safety documentation was inspected as well as records relating to staff training and recruitment. Residents were selected for case tracking, this included speaking to the residents where possible, and assessing assessment information, care plans and risk assessment documentation for that individual. A tour of the premises was undertaken including communal areas and individual bedrooms. The inspector interviewed staff during the inspection and focused on training and explored topics relating to their knowledge and skills to undertake the job they do. Feedback was provided at the end of the site visit to the Manager and the Deputy Manager. What the service does well: What has improved since the last inspection? The home has reviewed its adult protection policy and clearly set out the procedures for reporting such event including external avenues for referral. The home has recruited some new staff members and there is little in the way of agency or temporary staff used and that provides more consistency to residents London Mental Health Care Centre DS0000025631.V342262.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. The summary of this inspection report can be made available in other formats on request. London Mental Health Care Centre DS0000025631.V342262.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 London Mental Health Care Centre DS0000025631.V342262.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are subject to assessment procedures conducted by staff in the home Prior to admission residents are provided with information on the service. Information provided under the CPA procedures and from the multi disciplinary team provides a good framework on which to base care. EVIDENCE: At the time of the inspection there were 12 residents in. The assessment information for two resident was inspected. In the first file there was a pre admission questionnaire and information received under section 117 after care. This had been provided by the care coordinator and referred to the resident’s mental health and past history. The homes own assessment included mental health issues and presenting risks. The activities of daily living assessment was in tick box format which provided some information. In addition there was information received from a previous residential care home and correspondence relating to CPA reviews. The information on the enhanced CPA was without a date or signature. Previous medication charts were also on file. Within this file there was house rules terms and conditions, the resident’s guide and Statement of Purpose. Signatures of the resident and Manager were in place. The second resident to be case tracked had in their file information included in the pre admission assessment which detailed the residents needs and history. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 9 There was also a pre admission questionnaire, which included details of the resident’s mental health. Multi disciplinary assessments include those from the Occupational Therapist dated 21/8/07, which included reference to violence, and a forensic risk assessment although the enhanced CPA form was blank. There was Section 117 aftercare conformation and resident guide on file. Other assessment information included terms and condition although the room to be occupied was not indicated, house rules and a property disclaimer. London Mental Health Care Centre DS0000025631.V342262.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. 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. Care plans are produced which are reflective of resident needs although daily events were limited. Individual risk are in place although more detail could be included to reflect community living in an unrestricted home. EVIDENCE: The care plan of the residents included in case tracking were inspected .The first resident had been admitted 25/7/07,although there was confusion over the actual admission date, and possibly he had been admitted 17/4/07 on extended leave of absence then fully admitted July 07. This care plan was in a typed format and the interventions section was to a reasonable standard and would provide staff with a framework on which to address care. This was dated 25/7/07 and contained the resident and staff London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 11 signature .There was a weight chart in place, which indicated no significant variation in weight. There was a record of key worker sessions. This resident required close monitoring .The inspector asked for the records relating to the close monitoring These were muddle and not in date order. More specifically the record for the date 27/9/07 was not available. This is significant as the resident had absconded during this day. The inspector checked with the CSCI office regarding the notification under Regulation 37 although this could not be located or confirmed as received. The record in the daily events for this period was also limited. There was a letter received by the home after this resident was found and subsequently returned to the home, this described his presentation when found. The resident required 1:1 supervision although with only three staff on duty this would be onerous. The 1:1 supervision was referred to in the resident’s records and signed by the Manager. During the site visit the Psychiatrist arrived to asses the gentleman and arrangement were made for transfer. There was a risk assessment produced through the CPA. There was an individual missing person’s procedure including a description of the residents. Risk assessments in relation to community living in an open door facility need to be in place where appropriate for residents. There was reference to a ward round discussion of the resident September 07. In the second care plan the resident had been admitted 4/9/07.This resident’s psychiatric history was detailed . There was hand written care plan, which outlined his mental health condition some social issues and “ medical compliance”. This was dated 16/9/07.It did not include the residents signature nor that of the staff member. Staff sated that it was sometimes difficult to get resident to sign any documentation and the same was true for the taking of their photographs. The daily event entries were limited and mainly referred to physical aspects of care and little on rehabilitation or psychological input. London Mental Health Care Centre DS0000025631.V342262.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. 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. Residents do have access to community facilities family contact and leisure activities. More structured rehabilitation should be provided, as the service is to enable move on to more independent living in less supported accommodation. EVIDENCE: The home is for those resident who suffer from mental illness but who are able to live in a community setting with less support. The goal for many residents is to live independently. The home is there to promote enhance and develop daily living skills. The home encourages resident to do their own shopping cooking and maintaining their own bedrooms as part of their rehabilitation to enable more independent living. Residents were observed spending time in the home coming and going. Breakfast was taken at the time that the residents wanted it. A choice of foodstuffs was provide as well as juice and a bowl of fruit. Promoting healthy eating can be difficult with this type of residents tend to veer to convenience London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 13 food and take aways as they do not have the interest or concentration span to prepare and cook food. A member of staff was playing pool with one resident. The inspector felt that there was little in the way of rehabilitation or structured programmes. The type of resident in this facility will be difficult to engage with and motivate, although all efforts to do so must be continued. One staff member did comment that she had seen little in the way of engagement in the community and this was different to her pervious experience. She did add that the lack of community involvement may be due to the resident’s condition or their lack of interest in going out. No visitors were in during the site visit, it was said that there are only a few residents who get visitors at any time . There was a selection of daily newspapers and the TV was playing throughout the site visit. Most residents have their own music systems TV and mobile phones. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are provided by staff in the home with support from the multi disciplinary team. The procedures and records for medication administration introduce a margin for error and pose a potential risk to residents. EVIDENCE: One resident who was selected for case tracking was on close observation. The inspector asked for the records relating to the close monitoring. These were muddled and not in date order. More specifically the record for the date 27/9/07 was not available. This is significant, as the resident had absconded during this day. In this resident’s file there was reference to health care input from the GP and information receive under CPA procedures. Some of the information was unclear regarding the resident’s legal status i.e., under section or not. The information must be clear on such matters and retained in an orderly manner. The inspector spent a period in the office, during which time the medications were being administered. The residents attend the office for their medications and the staff on duty administer these. The staff was seen to administer the London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 15 medication to one resident. As the inspector entered the office door, the staff member put the medication into the residents hand although in so doing, dropped one tablet onto the floor .He proceeded to pick it up and give it to the resident. The inspector pointed out that this was poor practice. The staff member responded that the resident had asked that the medication be given to him although the inspector was not witness to this conversation. Two medications of those residents who were included in the case tracking were selected for inspection. The senior staff member on site was asked about some of the uses and side effects of the medication he had administered, the responses were limited . The medication charts were retained in a separate file. Within this file there was information sheets on those medications in use including the dose , side effects . A list of staff administering medications was retained. The homely remedies sheet was signed by the GP and dated. There was reference to a drug audit having been conducted June 07. On those charts, which were hand transcribed, had one signature was in place. Once this was pointed out the Deputy Manager ,Mr Harry Dooraree, went through the charts putting a second signature in place. This is poor practice. On the chart included as part of case tracking the medication administration Sheet was poorly completed without signatures for those medications received. An entry for Movicol sachet had nothing else indicated and the entry for Depixol injection had no dose indicated, although this would be administered by the CPN. The medication policy includes self medication procedures although could expand upon assessment of compliance and competence aspects of this. Please see requirement 1. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 16 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): T The quality rating in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. ome has in place policies and procedures dealing with complaints and protection. Staff need to retain comprehensive information on complaints and detail if the complainant is satisfied with the outcome. Staff’s knowledge on adult protection procedures was limited and would not afford sufficient protection to residents. EVIDENCE: The information on how to make a complaint was on display and there was a supporting policy on this. Within the AQAA information it stated that 14 complaints had been referred to the home and 14 had been upheld. The Manager stated that this was usually to do with disagreements amongst residents. The information retained in respect of complaints was limited and needs to fully represent the complaint, the investigation, findings and outcome. In a previous potential adult protection matter, correspondence from the CSCI was sent to the home in respect of timely and appropriate reporting of such matters. The adult protection policy had been updated March 2007 and included the adult protection coordinator for the area and other avenues for referral including the CSCI and the police. In addition there was a policy on whistle blowing . The inspector selected staff for interview and adult protection was on of the topics asked about. It was apparent in all cases that the staff had a limited London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 17 knowledge of the subject and specifically the action to take, including reporting and recording of such matters. Within the policies file there was a policy on physical interventions, however this did not state what interventions were appropriate or how they were to be addressed. No staff in this home have had control and restraint training . The home should reconsider this policy to clearly state its position i.e. no physical intervention to be carried out. From the staff training list provided at inspection two staff had completed abuse training out of the thirteen listed. Please see requirement 2. London Mental Health Care Centre DS0000025631.V342262.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. 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 home is maintained in a domestic fashion with large communal areas. More effort is required to maintain the home to an optimum standard both in terms of cleanliness and safety. EVIDENCE: The inspector toured the communal areas and some of the bedrooms .It was noticeable that the standard of cleaning had deteriorated especially the carpets in the corridor. The linoleum and carpet were marked in several of the communal areas . Some deep cleaning was required including paintwork and furniture .The inspector was told that the domestic post for three days a week was vacant and that this was being recruited to. As the inspector arrived the kitchen door was propped open and within this are there were cleaning materials on an open shelf. There were staff in the vicinity however more care should be taken to ensure potentially hazardous items are safely stored. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 19 Bedroom 6 was very pleasant; bedrooms 9 and 10 were reasonably well maintained. In bedroom 14 there was a portable radiator in use ,this needs to be risk assessed. One resident did say that it was cold in her bedroom and the heating didn’t work the inspector noted that the hot water outlets were running cool although work on the plumbing and heating was being addressed during the site visit. A comment received in one questionnaire related, “ The toilets need to be cleaned more “. This needs to be addressed. Please see requirement 3. London Mental Health Care Centre DS0000025631.V342262.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. 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. Staffing levels need to be at a sufficient level to address resident’s needs including supervision, rehabilitation programmes and escort duties. Staff need to be sufficiently trained to undertake the job they do to ensure residents receive competent care. EVIDENCE: The home works with the following staffing number three in the morning and afternoon and two night staff. On the day of the site visit there was one gentleman on 1:1 supervision although the staff numbers were the same as a regular day, in such cases the staff numbers should be reviewed and increased. As the inspector arrived the person in charge was the night staff. He explained that the Deputy Manager was running late and he was covering. There were two day staff on duty with him. The inspector spoke to the night staff who stated that the had been in post for 5/6 years working full time and that he was NVQ level 3. He stated that he has previous experience in care homes. He was asked about break times , he explained that the sleeping in staff member was woken up between 3am and 5 am whilst he had his break .He also stated that between the hours of 5 am and 8 am cleaning took place . London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 21 He stated that he received training and attended these on his time off. In the last twelve months he had attended fire training and health and safety. In addition he confirmed training in the following topics: infection control, manual handling first aid – 4 day course and had completed abuse training as part of his NVQ course. The inspector asked questions relating to adult abuse and he demonstrated a reasonable knowledge of the types and support of the resident however he did not relay that he would record or report it this was even after prompting. He was also asked about restraint and gave a limited definition although little else. Other areas of questioning confirmed that this staff member has a limited knowledge and shortfalls in those topics related to mental health . He was further asked questions on the Mental Capacity Act and was unable to give a response . The inspector raised this with the Manager once he arrived and suggested that training in relevant topics be improved. Another staff member was interviewed who had started 9/8/07and was a carer. She had been referred through the Job seekers scheme. This staff member had previously worked in care and had received training including first aid health and safety and some mental health training. She stated that she had received two hours induction over a two-week period. She stated that she had covered issues such as fire precautions, infection control and COSHH. She was due to start NVQ level 2. On questioning this member of staff he too had little knowledge on adult protection issues. This staff’s personnel file was selected for inspection. Her photograph was on file. The application form was well completed and identity checks were on file. There was an interview sheet and an offer letter. An induction checklist was included although this references little in the way of mental health issues. There was a health declaration and confirmation of her address. There was a CRB issues through Harwin Associates whom the inspector was advised were the umbrella body. Two references were received although none were obtained from her previous employment in care where she had been for seven years. . There were issues regarding this and this was fed back at the end of the inspection, and followed up by letter. A personnel file of a bank staff member was inspected. This file contained a photograph, copy of passport and an application form with a work history back till 1999. On this application form, under the section on work history, the information provided differed from that on his CV. This should have been explored at interview .The Manager did provide an explanation to the inspector when this was queried. The two references received included a personal reference and the second from a school it was difficult to establish if they had any information regarding her work. There was an induction form and a certificate for NVQ in childcare. The CRB was on file as was the offer letter. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 22 The personnel file of the Deputy Manager was inspected. This gentleman had been in post since 1999. On file there was a photograph and application form His original GNC statement of entry was on file. One reference was completed although on the second reference it was difficult to establish where it was from. There was a health questionnaire and a CRB dated November 03 Terms and Conditions and three records of supervision were also on file. The records relating to supervision were limited. This staff member was interviewed and confirmed training in manual handling medication procedures management of violence and other topics. Some of this training had been received some years previous and may need to be updated. He had a limited awareness of the procedures under adult protection and whistle blowing, although again failed to respond by reporting it or for abuse recording it. Two subjects which staff at a senior level should be aware of are the Mental Capacity Act and the Freedom of Information Act both of which may impact on the work they do This staff had no knowledge of either topics. In respect of infection control, MRSA and clostridium dificile he had little knowledge. Other topics relating to mental health rehabilitation, supervision, section 117, he demonstrated a good knowledge. Another care staff interviewed confirmed a five day induction period with two of those days supernumerary. Induction included fire COSHH, residents and building lay out. She said that she had received training in another facility in respect of mental health and had worked with psychiatric residents previously. She stated supervision was conducted. Of the staff working in the home 7 have completed NVQ level 3 and 5 NVQ level 3. The staff training records indicated training through Mulberry House in house training and DVD’s. Please see requirements 4 and 5. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 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 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 home has insufficient management hours to effectively manage the service support the staff and promote a quality service. Health and safety service certificates were up do date to ensure that the premises are safe. Staff need to be trained and updated in the mandatory topics to effectively perform the work they do. EVIDENCE: Mr Raj Dooraree attended the inspection shortly after the inspector arrived and spent periods thorough out the day with the inspector. Mr Dooraree advised the inspector that he was still covering this home and Albion House. This has been the case for some time and was on the previous inspection referred to the Regulation Manger for advise. It was evident that the home has insufficient London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 24 management hours and this was relayed at the previous inspection and at this one. This was identified by the Manager himself during the inspection. The inspector checked three residents’ finances, all residents have bank accounts. The money retained on site had signatures of the residents and staff member. Receipts are retained only if residents provide them, which is often not the case. The employer’s liability was valid. A selection of health and safety certificates were inspected. The home has no specialist equipment lift or hoists. Confirmation of the five year electrical inspection and annual portable appliance testing were in place. The gas certificate was current. The legionella certificate needed addressing, as it was not current. The Manager stated this would be rectified and confirmation of this forwarded to the CSCI. The records for hot water temperatures were confusing as they showed 60 degrees although it is questionable from where these were obtained The Manager stated this was the kitchen sink. The home was given information on where to locate information on water temperatures and to check the health and safety web site. In relation to fire, the weekly alarm tests were recorded, as were emergency lighting checks. There were records of fire training for those staff on induction as well as records relating to fire training thereafter. The last fire training was June 07 and most staff had attended. The fire alarm had been serviced 28/3/07 and the extinguishers 19/7/07. Training in respect of mandatory topics needed updating as several were seen to have expired including first aid. The policy and procedures file contained some London Mental Health policies and some information sheets. The home should ensure that it has policies and procedures for all aspects of the running of the home, and that these are reviewed regularly. The minutes of residents meetings were on site, and these are circulated once produced. Relatives meetings are not organised as they have open door access at any time to staff and are invited to attend reviews. The inspector was advised that a quality questionnaire was due to be circulated although this document was not available for inspection. Please see requirement 6. London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 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 Standard No Score 1 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 X 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 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. YA20 Standard Regulation 13 Requirement The Registered Manager must ensure that medications are safely administered and that comprehensive records are in place for all medications. Timescale for action 30/11/07 2. YA22 13 The Registered Manager must 31/12/07 ensure all employees, including care and ancillary staff are fully conversant with adult protection and whistle blowing procedures. This requirement is now outstanding. Previous time frame for action 31/3/07. The Registered Manager must ensure that all areas communal and individual bedrooms are retained hazard free and risk assessed where appropriate Previous time frame for action 31 /12/06. This is now outstanding The Registered Manager must ensure that all staff undergo induction training immediately on commencement of employment, which covers DS0000025631.V342262.R01.S.doc 3 YA24 23 30/11/07 4. YA35 19 30/11/07 London Mental Health Care Centre Version 5.2 Page 27 statutory topics and those related to the resident group. Previous time frame for action 31 /12/06. This is now outstanding 5 YA35 18 The Registered Manager must ensure that staff are provided with training which equips them with the skills to do the work they do The Registered Manager must ensure that Regulation 37 reports are forwarded to the CSCI in a timely manner. 30/03/08 6 YA42 37 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA22 Good Practice Recommendations 1. The Registered Manager should consider another recording system to ensure that they are able to evidence the investigation trail and period of time this took. The Registered Manager should ensure that staff supervision is conducted six times a year minimum, or more frequent should the employee require it. The Registered Manager should assess and audit staff’s adherence to the homes policies and procedures 2. YA36 3. YA41 London Mental Health Care Centre DS0000025631.V342262.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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