Inspection on 18/10/07 for 10 Love Walk

This inspection was carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Love Walk 25/06/08

10 Love Walk 11/07/06

10 Love Walk 15/12/05

10 Love Walk 25/04/05

10 Love Walk 25/10/04

10 Love Walk 20/05/04

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

CARE HOME ADULTS 18-65 Love Walk, 10 London SE5 8AE Lead Inspector Ms Alison Pritchard Key Unannounced Inspection 18 & 26th October 2007 12:00 th Love Walk, 10 DS0000007105.V349362.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 Love Walk, 10 DS0000007105.V349362.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. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Love Walk, 10 Address London SE5 8AE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company Name of registered manager Type of registration No. of places registered (if applicable) 020 7703 3001 0207 252 4958 lovewalk@missioncare.org.uk www.missioncare.org.uk Mission Care Jacqueline Perdrix-Howard Care Home 22 Category(ies) of Physical disability (0) registration, with number of places Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 (twenty two) people with physical disability, some of whom may be over 65 years old. 11th July 2006 Date of last inspection Brief Description of the Service: 10 Love Walk is a 22-bedded care home for people with a range of physical disabilities. It is located in a quiet residential road in Camberwell. The home is situated close to local shops, public transport and services and has a small car park. The home was purpose built and each of the bedrooms is single and has a large en-suite toilet /bathing facility. There is a lift to enable residents who use wheelchairs to access the first floor. Mission Care, a Christian organisation, runs the home. Mission Care also runs nursing homes for older people in the Bromley area. In October 2007 there were 22 residents and no vacancies at Love Walk. The Registered Manager of the home said that she provides a copy of an information pack about the home to potential residents. They are invited to visit and she ensures that they are given information about the home, Mission Care and local facilities. CSCI reports are discussed in residents’ forum meetings and copies provided for the residents. In October 2007 the weekly fees for the home ranged between £620 and £738. No additional charges are made. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over two days in late October 2007. The inspection methods included observation of care practice; discussion with residents and staff; inspection of residents’ files and a range of records and policy documents. Residents, staff, involved professionals and relatives were sent survey forms so that they could contribute to the inspection process. Feedback was received from 7 residents, also from relatives, staff members and professionals. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ was completed by the Manager of the home in advance of the inspection and returned it to the inspector. It provides information from the manager about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. The Manager, residents and staff facilitated the inspection visit. They were helpful and courteous throughout the process. What the service does well: What has improved since the last inspection? A number of improvements were identified at this inspection: Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 6 • • • • • • • • Some redecoration has taken place in the building and more is planned. This has improved the environment by making it brighter and more homely for residents. Staff have shown their commitment to improving the physical conditions for the residents by taking part in redecorating and refurbishment. There is now a deputy manager in post and restructured senior team. This has allowed there to be more frequent supervision for the staff and for responsibilities to be delegated amongst the senior team. Staff commented that there have been significant improvements in the training opportunities available to them. Staff now make daily entries about residents’ welfare and progress, this allows better monitoring of health conditions and other issues. Complaints records are now kept in a more ordered manner allowing more effective monitoring of their outcome. Cleaning items which may have presented risks to residents are now stored safely. Arrangements for dealing with residents’ valuables are now safer and subject to management checks. This protects both the residents and the staff who assist residents with these matters. The recording of fire drills has improved. What they could do better: There were a number of problems identified with the home’s systems for dealing with medication. Two of these issues led the CSCI to issue immediate requirements to the home to ensure that swift action was taken to protect residents. These requirements made were to make sure that the residents are given medication according to the doctor’s instructions and that the home check regularly to make sure that they have sufficient medication in stock. Another immediate requirement was issued about the staff recruitment practice. It was required that staff who are employed to work at the home have the correct checks and references undertaken so that the managers can be sure of their suitability to have contact with vulnerable people. It has been required for a significant length of time that care planning systems are improved. This remains an area for improvement. The systems to make sure that risks are identified and addressed need to be improved to make sure that residents and others are safe. Some of the information provided before a resident comes to live at the home needs to be amended so it includes all of the required information. Despite the redecoration and refurbishment that has been carried out some areas of the home remain in need of improvement to provide a more homely environment for the residents. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 7 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. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changes are required to the information given to potential residents. This will ensure that they have sufficient information on which to make a decision about the suitability of the home. The current residents will be further protected by changes made to the information with which they are provided. EVIDENCE: The statement of purpose and service user guide are combined into one document which was last reviewed in September 2007. The document contains most of the information that is required. Some specific items of information were required by regulation to be in the service user guide from September 2006. The necessary changes concern information about the fees charged by the care home. The necessary information is not included in the document. See requirement below. The guide includes the summary from the most recent CSCI inspection report of the home. It is recognised that the intention in providing information in this way was to be helpful to potential residents. However extracts may not be used or reproduced without the permission of CSCI. This was discussed with the manager during the inspection and she agreed to ensure that the extract is removed and a copy of the whole report is supplied with the service user guide. The service user guide includes views of residents about the home as required. The way in which the information is reproduced could be seen as compromising Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 10 residents’ privacy. It is required that the information is given in a form which does not allow readers to identify specific residents and their views. See requirement below. Assessments of need are obtained from social workers who are involved with the potential resident prior to their admission. These documents were available on file for reference by staff. The Manager stated that a format for an assessment of a potential resident is being prepared. Discussion with the Manager showed her awareness of the importance of considering residents’ cultural needs as part of the admission process to ensure that they can be addressed. Currently new residents are not provided with written confirmation that the home can meet their needs. See requirement below. Each resident is issued with a statement of terms and conditions, which describes their rights and responsibilities, and the responsibilities of Mission Care in providing the service. The home’s admission policy gives a commitment to ensuring that potential residents have the opportunity to visit the home prior to making a decision about whether it will meet their needs. A recently admitted resident confirmed that he had visited the home before his admission. The Manager of the home stated that she provides a copy of an information pack about the home to potential residents and she ensures that they are given information about the home, Mission Care and local facilities. The service user guide states that there is a trial period which usually lasts for four weeks. The National Minimum Standard which is applicable, (standard 4.3), states that there should be a minimum ‘settling in’ period of three months after which it is expected that the placement be reviewed and its suitability assessed. See recommendation below. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs and goals are not adequately reflected in their individual plans. The need for improvement in this area is long standing. Other than through the care planning system the residents have the opportunity to contribute their views through residents’ meetings. The systems for assessing risks need to be improved. EVIDENCE: Three care plans were examined in detail during the inspection. It was found that the plans do not adequately describe the residents’ needs and how the home will meet them. Over time different formats have been used and as a result there is a lack of consistency in the way that care plans are completed and while some are detailed others are minimal in content. Arrangements were being made for photographs of the residents to be taken to be included in the care plans. A new format that has been introduced to record residents’ needs is called ‘GRADERS’. This details residents’ needs in the areas of gender; race; age; disability; ethnicity; religion and sexuality. This is a useful format that Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 12 promotes and encourages consideration of how the home will meet the diverse range of residents’ needs. Discussion with staff demonstrated that they are aware of residents’ needs but they are not adequately documented. In some cases contradictory information about residents was contained in files without explanation or clarification. This does not support the provision of consistent and effective care. Efforts were being made by key workers to review care plans each month. None of the care plans seen had been signed by residents or their representatives, neither had the care plan review records. (See recommendation below). However one of the residents said that he is familiar with his care plan , agrees with it and is able to see it whenever he wishes. The issue of care plans and the need for improvement has been the subject of repeated requirements for several inspection reports. The Manager, with whom this matter was discussed, is aware of the inadequacies of the system and the need for improvement. She expressed her commitment to achieving the necessary improvements. The Manager is arranging training in person centred care planning for staff and this will contribute towards the achievement of change. Residents’ feedback was that they are able to make decisions about how they spend their time, particularly at weekends and in the evenings. One resident said that this is one of the positive aspects of the home, saying ‘we are free birds here, you can do whatever you like’. Some residents have been assisted to move on to placements where they can live more independently in accordance with their wishes. Residents’ forum meetings are held every month. The minutes of the meetings show that they provide opportunities for managers to consult with residents and for residents to raise their own issues of concern. The Manager has stated that it is an aim to increase residents’ participation in the management of the home through their involvement in recruitment. This is encouraged. A recent meeting was attended by a representative from a local advocacy service which has involvement with the home. Documents seen on file were called risk assessments but they did not adequately describe the range of risks presented to residents and the action taken to minimise these. This area needs to be improved as there were a number of risks which need to be carefully considered, documented and taken into account in the provision of care. The issues, which need to be addressed through a risk management framework, include risks arising from health conditions; infection control; the use of equipment such as bed rails; the management of behavioural risks to staff and residents, and mental health issues. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 13 The Manager stated that some of the senior staff have recently undertaken a training course on risk management. She is hoping that they will be able to contribute to the improvement of the home’s risk management system. See requirement below. Residents’ records and personal information is stored securely and with due regard for the protection of personal information. The organisation is registered under the Data Protection Act. Discussions with staff showed awareness of confidentiality issues. However, as noted above, the inclusion of a detailed survey in the service user guide compromised residents’ confidentiality. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There are a range of activities available for residents and it is anticipated that the recent employment of an activities co-ordinator will assist residents to follow their interests. there is good consideration of residents’ spiritual needs and awareness of cultural needs. The cook works hard to cater for the range of tastes and needs of the residents. EVIDENCE: An activities co-ordinator has been appointed to the home and a weekly programme of activities is being devised. The draft programme included a range of activities, including art and crafts, music and movement, exercise, bingo, and a discussion group. A hairdresser visits the home regularly. Arrangements are in progress for computers (with internet access) to be installed in the home for residents’ use. Visiting entertainers, such as musicians and comedians visit the home approximately monthly, an Old Time Musical entertainment had been held recently and there was a Caribbean barbecue during the summer time. The Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 15 ‘League of Friends’ arranges outings (such as to Hastings in September) and other events such as a Christmas Carol concert, a quiz night and a musical evening. Several residents attend services at the United Reform Church at the end of Love Walk. Staff reported that the home has a good relationship with the church. Personnel from the church attend the home to run a fortnightly Bible Study session. Other residents attend services which are held in the home. Each month a vicar from a local Anglican Church visits and holds a Communion service. If any residents wished to attend a different place of worship or follow a different religion, it was stated that the home would make the necessary arrangements to enable them to do so. A pastoral support worker visits the home regularly and is available to provide emotional and spiritual support. It is planned that monthly men’s groups and women’s groups will be included as part of the activity programme. Some of the residents attend day centres, some of which meet their cultural needs. In discussion the manager showed understanding of the importance of residents’ cultural and linguistic needs being addressed. In one instance the home has been advocating on a resident’s behalf to obtain the services of an interpreter. The needs of some residents, whose first language is not English, are being addressed through recruitment of a member of staff who speaks the same language as them. During the inspection a resident was accompanied by a member of staff to a restaurant which reflects his cultural background. Arrangements were being made for other residents to visit shops which serve food from their home country. Residents’ visitors are able to visit at all reasonable times and, when appropriate, without prior arrangement. A pay phone is available on the ground floor of the home for residents’ use. It is located in a separate room allowing privacy. Many residents have chosen to have a telephone line fitted in their bedrooms. The service user guide describes residents’ ‘rights and expectations’. These include the right to be addressed by their preferred names; to be consulted about the running of the home; involved in decisions of importance and to be supported to vote in local and national elections. Residents confirmed that they are able to choose to spend time alone if they wish rather than join in activities. Staff were observed to interact with residents, rather than just with each other, and to do so respectfully. Choice is available at each meal and alternatives are provided. As the cook has worked at the home for several years she is familiar with the needs and preferences of the residents. When a new resident comes to live at the home Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 16 she ensures that she spends time with them to talk about the kind of meals they like and is given information on their nutritional needs. The menu for the home has been reviewed after consultation with residents. The menu now reflects more closely the wide range of residents’ cultures. The information that residents gave to the inspector about the meals included praise for the care and attention the cook pays to providing for special diets and likes and dislikes. The cook makes considerable efforts to meet individual needs, often visiting markets where specialist items are available at a lower cost than through the usual suppliers. The meals are provided at 8.30am (breakfast); 12.15pm (lunch); 5.30pm (supper) with drinks and snacks provided 10.30am and 3.30pm. An evening snack of toast or biscuits is provided, along with a drink. The manager has arranged for sandwiches also to be available in the evening. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a staff team that knows them well and is aware of their care needs. There is appropriate contact with health care professionals. The residents would benefit further from safer systems for the administration and recording of medication. EVIDENCE: The mixed staff team makes it frequently possible for residents to be provided with personal care by a member of staff of the same gender. Staff show awareness of residents’ need for privacy, both in relation to care giving, and with residents’ personal information. There was information to confirm that residents can choose when to get up and go to bed. Staff were described by a resident as ‘good’ and ‘helpful’ and this view was echoed by other residents. Each resident has a key worker, responsible for co-ordinating their care. Discussion with the manager showed that residents’ needs and preferences in the choice of a resident’s key worker are taken into account, including those which arise from the residents’ culture and linguistic background. The residents are supported to have contact with medical and health care staff who can provide specialist input to their care. The home makes referrals to physiotherapists when this is identified as a need. Improvement in the Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 18 maintenance of the residents’ files would make it easier for the staff to track and monitor the progress of contact with health care professionals. Arrangements are made for residents to take have flu jabs if they wish and this shows commitment to health promotion by the home. A resident said that the home provides good medical care and there is easy access to health professional including the GP and dentist. Those residents who look after their own items of medication have lockable facilities within their rooms for storage. Most of the residents’ medication is looked after by the care home. It is stored safely. The home has recently begun to use a local pharmacy for its supplies of medication, this will be more convenient than previously when the pharmacy used was several miles away. A selection of medication administration records (MAR) and stocks were examined with the assistance of senior staff. Several problems were identified: • • there were several unexplained gaps on some of the MAR; in one instance the MAR was completed on several days with unexplained abbreviations. Further investigation showed that the item of medication had been out of stock and unavailable for the previous ten days. Although the item had been re-ordered after a week it was still unavailable to be given to the resident. Pre-printed labels had been attached to one of the MAR. Since the inspection this matter has been the subject of discussion between the home, the supplying pharmacist and the specialist pharmacy CSCI inspector so that a safe and reasonable resolution can be reached. Hand written instructions on one MAR were insufficiently detailed; There were no instructions in the medication file about in what circumstances medication given on an ‘as needed’ basis should be given. • • • In order to ensure that swift action was taken to protect residents an immediate requirement was issued in response to the most urgent issues. Those issues were to make sure that the residents are given medication according to the doctor’s instructions and that regular checks are made to make sure that they have sufficient medication in stock. Further requirements are made about medication issues below. A requirement of the previous inspection report stated that the Registered Person must ensure that checks of medication stocks and records are recorded. This has not been complied with and is repeated below. See requirements below. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the procedure for dealing with complaints but some may need regular reminders about how to raise concerns. All staff must receive training in adult protection to ensure they are confident in dealing with these matters. EVIDENCE: The complaints procedure is included in the service user guide. It includes details of timescales that are applicable and information on how to contact the CSCI. The procedure states that complaints, whenever possible, will be addressed within 28 days. This is in keeping with the National Minimum Standards. Staff with whom the matter was discussed were clear about the action they would take if a complaint was made to them or if they had concerns involving the protection of residents. The records of complaints made over the last year were in good order and it was possible to track the action taken in response to a complaint being made. The feedback received from residents on surveys was that the majority are aware of the complaints procedure. 43 of the residents and a relative who responded stated that they did not know how to complain so it is recommended that the residents and relatives are reminded periodically of the complaints procedure. See recommendation. The staff contract includes a clause which makes clear that staff must have no involvement in residents’ wills and cannot accept gifts, this is also made clear to residents in the service user guide. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 20 There are appropriate arrangements for residents’ to store their valuables with the home safely. Regular checks of the records and items being held are made and conformed by signatures in the records. Management checks are also made of residents’ finances which are managed on their behalf by the home. Of the permanent care staff team of thrirteen the records provided showed that six had received training in adult protection issues during the last eighteen months. The Manager of the home stated her intention for all staff to receive this training. See requirement below. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home which is cleaned to a satisfactory standard. Some redecoration has taken place and this has improved conditions in some of the communal areas. Others remain in need of attention to improve the appearance of the home. EVIDENCE: The home is purpose built and facilities are spread over two floors, bedrooms are on the ground and first floor of the home. Most of the communal facilities, two living rooms, a dining room and a large activity room are on the ground floor. Another activity room is located on the first floor. Since the last visit to the home by the CSCI some redecoration has been undertaken in the ground floor communal rooms. Information on the details and timescale for further redecoration is not yet available. Arrangements were being made for new curtains to be fitted to the dining room and the main living room. This should improve the homeliness of the rooms. The corridor of the ground floor would also benefit from redecoration. A visiting senior manager, in August 2007, described the premises as ‘in need Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 22 of a facelift’. The Manager of the home expressed her commitment to improving the physical conditions. The home has benefited from more regular input from maintenance personnel employed by Mission Care. Although there are some areas in need of redecoration the building is clean and hygienic. There were no offensive odours at the time of the inspection and were suitably heated, lit and ventilated. There is good access to local amenities. Camberwell is close by with a range of shops and leisure facilities. The premises are accessible to all residents, a passenger lift allows people with mobility problems to go the first floor. CCTV cameras are fitted to the exterior of the building to provide security from intrusion. The cameras do not impinge on residents’ lives and privacy. The home has a connection with the local police who provide crime prevention advice to the residents and to the home generally. There are environmental adaptations in the home to enable the residents to maintain their independence. The adaptations include rails in the corridors, an adapted call bell and fire alarm system, hoists and lowered switches. A team of four domestic staff maintain clean and hygienic conditions in the home. There are two laundries in the home, one which residents may use independently and another for staff to use for residents’ laundry. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a suitably qualified staff team in adequate numbers to provide satisfactory care for the residents. Some of the staff team have not received recent training is essential matters such as fire safety and adult protection. Residents will be further protected by safer staff recruitment systems. EVIDENCE: Of the fourteen permanent care staff eleven members of the team have achieved NVQ2 and ten have achieved or are working towards NVQ 3. The bank staff team have all either achieved or are working toward NVQ2. Other training undertaken by the staff team over the last year includes first aid, health and safety, fire safety, moving and handling, infection control and adult protection issues. Some members of the team have some gaps in their training, for instance six members of the team have not received training in adult protection and there are only two staff members who have been noted as having recent training in fire safety issues. These gaps need to be addressed. See requirement below. Staffing levels are appropriate for the numbers of the residents \and their needs. Copies of the rota showed that generally there are five staff on duty in the mornings and early afternoon and four in the later afternoon and evenings. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 24 Overnight two members of staff provide waking night cover. Additional assistance is available from a manager through the on call system. Bank staff fill vacancies in the rota caused by sickness and annual leave, there is a limited number of bank staff so this helps in the provision of consistent care. Three staff recruitment records were checked. It was found that one of the records did not include an Enhanced Criminal Records Bureau check. The member of staff had worked at the home since February 2007 on a permanent basis as a care worker and prior to that as a bank worker. An immediate requirement was issued to the home in response to this. On the second day of the inspection it was found that a check had been requested and an audit of other staff files had been conducted. Appropriate arrangements had been made to complete the files. It was a matter of concern that despite an earlier audit of the files no action had been taken in response to the gaps identified. Staff responsible for staff recruitment must be fully briefed on the requirements of the Care Homes Regulations 2001 in relation to safe recruitment practice as this forms an important element in the protection of residents. See requirements below. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A new manager has been appointed to the home and was registered by CSCI shortly after the inspection. Residents are able to contribute their views about the home as part of the quality assurance systems. Overall health and safety is well managed in the home but will be improved by the review of the fire risk assessment and further training for some staff who have not had recent input on fire safety. EVIDENCE: The Manager of the home has been in post since April 2007, prior to that she was the Deputy Manager of the home. The Manager was registered under the Care Standards Act 2000 shortly after the inspection took place. She has recently begun a training course to achieve the Registered Manager’s Award and NVQ4. Staff described the management style in the home as approachable and supportive. Visits from other managers take place as required by regulation. The visit reports confirm that discussions with residents and staff are included as part of Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 26 their assessment of the standard of service. A survey of residents has been conducted. More frequent meetings with residents has allowed them further opportunities to contribute their views about the care provided. The Manager stated on the AQAA that Mission Care has introduced a Quality Assurance Framework in order to monitor the operation of the homes. As the introduction of this system is recent there were no results available during the inspection. It is anticipated that this standard will be examined further at the next key inspection of the home. Records showed that health and safety tests are carried out at appropriate intervals. Weekly tests of the fire alarms are made and recorded. The last drill took place in September 2007, and prior to that in July 2007. Two members of staff have received fire warden training recently. The fire risk assessment is dated April 2006, it must be reviewed as such reviews are required annually. See requirement below. Almost all of the team have received first aid training and this will benefit residents in the event of an accident. Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 2 4 3 5 3 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 YA10 Regulation 5(1) 4(2) Timescale for action It is required that the Registered 01/02/08 Person amends the service user guide to: • include specific information about the fees charged by the home. It has been required since September 2006 that this information is included in the guide. • ensure the privacy of residents It is required that, prior to their 01/12/07 admission, the Registered Person provide residents with written confirmation that the home can meet their needs. The Registered Person must 01/02/08 ensure that care planning systems are improved by the recording of service users’ aims and goals and strategies employed by the home to support them to achieve them. Although action has begun to comply with this requirement, it is not yet met. The previous date for compliance was 01/01/07. Requirement 2. YA3 14(1)(d) 3. YA6 15(1) Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 29 4. YA9 13(4)(c) 5. YA20 13(2) The Registered Person must improve the systems for the management of risk to residents. The documented risk assessments must detail the nature of the risk and the action the home is taking to minimise it. The Registered Person must ensure that checks of medication stocks and records are recorded. The previous date for compliance was 01/10/06. The requirement is repeated and a new date for compliance set. Medication procedures must be improved. 01/02/08 01/12/07 6. YA20 13(2) It is required that the Registered Person ensure that medication is administered in accordance with the prescriber’s instructions and that medication stocks are regularly checked and re-ordered. The Registered Person must ensure that medication administration records are sufficiently detailed to allow the safe administration of medication. The Registered Person must ensure that instructions are available to staff on the circumstances in which medication is given on an ‘as needed’ basis. The Registered Person must ensure that all staff receive training in adult protection issues. The Registered Person must ensure that redecoration and refurbishment work continues to ensure that the residents benefit from an environment which is suitably decorated and homely. The Registered Person must DS0000007105.V349362.R01.S.doc 19/10/07 7. YA20 13(2) 01/12/07 8. YA20 13(2) 01/12/07 9. YA23 YA35 13(6) 01/02/08 10. YA24 23(2)(d) 01/02/08 11. YA35 13(6) 01/02/08 Version 5.2 Page 30 Love Walk, 10 YA42 23(4)(d) ensure that all staff receive regular training in fire safety issues. The Registered Person must 01/02/08 ensure that staff responsible for staff recruitment are fully briefed on the requirements of the Care Homes Regulations 2001 in relation to safe recruitment practice. It is required that the Registered Person ensure that all staff have the required checks in place before they begin work at the home. An audit of all files must be conducted to ensure that they are present. It is required that the Registered Person ensure that the fire risk assessment is reviewed annually. 22/10/07 12. YA34 18(1)(c)(i) 13. YA34 19(1)(b) schedule 2 14. YA42 23(4) (c)(v) 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA4 Good Practice Recommendations The Registered Person should ensure that all placements at the home are reviewed after a minimum ‘settling in’ period of three months after which it is expected that the placement and the suitability of the placement assessed. The Registered Person should ensure that residents or their representatives have the opportunity to sign the care plans and records of reviews in order to indicate their involvement in the planning process and agreement with the care plan. The Registered Person should ensure that the residents and relatives are reminded periodically of the complaints procedure. DS0000007105.V349362.R01.S.doc Version 5.2 Page 31 2. YA6 3. YA22 Love Walk, 10 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. Extracts may not be used or reproduced without the express permission of CSCI Love Walk, 10 DS0000007105.V349362.R01.S.doc Version 5.2 Page 32 - 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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