Inspection on 23/05/07 for Milestone

This inspection was carried out on 23rd May 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milestone 27/02/08

Milestone 26/06/06

Milestone 16/12/05

Milestone 23/08/05

Milestone 19/01/05

Milestone 16/07/04

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

CARE HOME ADULTS 18-65 Milestone 1 Milestone Court, Wales Close London SE15 2SL Lead Inspector Lisa Wilde Unannounced Inspection 22 and 30th May 2007 11:30 nd Milestone DS0000007104.V324769.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 Milestone DS0000007104.V324769.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. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Milestone Address 1 Milestone Court, Wales Close London SE15 2SL 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) 020 7639 8628 www.turning-point.co.uk Turning Point London & S.E.Region Delrene Walker Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 14 (fourteen) men with mental disorder other than dementia, 1 (one) of whom may be over 65 years old. 26th June 2006 Date of last inspection Brief Description of the Service: Milestone provides accommodation and care for 14 men who have a forensic mental health background. The home is purpose built and divided into two blocks. The first block has accommodation and facilities for six service users in rooms and the second block has 8 self-contained flats. The communal areas are accessible to all service users, including wheelchair users but some of the rooms and flats are not. There is no lift at the home. The home is off the Old Kent Road close to Peckham and New Cross. There are nearby facilities and services including public transport, shopping, leisure, health and social care support. At the time of the inspection there were no vacancies. Fees for a place at the home are £849.50 per week. The home makes the reports of the Commission’s inspections available in the reception of the home. Milestone DS0000007104.V324769.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 day in May 2007. The inspector spent that day at the service talking to service users, staff and the Registered Manager, looking through records and touring the building. Further information was sent onto the inspector a few days after the day at the service. The residents at the home all said that they generally were “alright” and “had no problems” apart from particular issues mentioned in the main part of this report. The Registered Manager and staff have worked hard since the last inspection to improve the service and this has meant that many of the previous requirements had been met. However there are still significant problems and the home is not yet reaching the required standard. The inspector will expect further improvement to have been made by the next inspection otherwise enforcement action will be considered to ensure compliance with the National Minimum Standards. What the service does well: The standards assessed at this inspection showed that the home makes sure that: • • • the needs of men who want to move to the home are assessed by staff before they move to the home. there are care plans in place that are based on the areas of need that have been identified before someone moves to the home. generally there are good systems in place to monitor how medication is held and given out to service users. Service users are supported to selfmedicate when they have been assessed as able to do this safely by staff and other members of the care team. the communal areas of the home are large enough for the number of service users and they are kept clean and tidy. rooms and flats are large enough and have enough toilet and bathroom facilities to meet the standard. the home is fully staffed and there are enough staff on duty at all times. • • • Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • • no one should be offered a place at the home when the staff team does not believe they can effectively support them. residents must have a structured weekly programme in place that includes activities in the local community and links with in-house programmes. residents must be supported to attend regular GP, dentist, optician and chiropodist appointments. the medication stock checking and administration systems must improve. adequate records must be held in the home for the Commission to assess if recruitment procedures are being operated effectively. staff must have the skills and abilities to fully meet the residents’ needs. there must be a comprehensive quality assurance system in place that makes sure that all areas of the home are regularly assessed and plans put in place to improve every year. residents must be fully consulted about what they want and what they think of the service they are offered. the fire safety systems must be checked regularly enough. DS0000007104.V324769.R01.S.doc Version 5.2 Page 7 • • • • • • • Milestone 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. Milestone DS0000007104.V324769.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 Milestone DS0000007104.V324769.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): 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. Staff assess the needs of men who want to move to the service but sometimes men are offered a place at the home when the staff team does not believe they can effectively support them. Men who want to move to the service and current residents are given information about what the service offers so that they know what they can expect and what is expected of them. EVIDENCE: There was a previous recommendation that the Registered Individuals should revise the Service Users Guide so that it is more accessible and useful for the service user group. This had not yet been done. (See Recommendation 1) The referral procedure for when someone wants to move to the home is appropriate. Staff visit someone who wants to move to the home and conduct and assessment of their needs. These assessments were seen on some not all of the files that were looked at during the inspection and they are completed using the person’s own words to allow them to say what they feel about moving to the service. These needs assessments do not currently ask about Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 10 any cultural, ethnic, religious, social or relationships requirements which would form the basis of any care planning in these areas. (See Requirement 1) One man has recently been offered a place at the home even though the staff team and the Registered Manager had said that following their assessment they did not believe they were ready to move to the home. This man has struggled to maintain the placement and it is probable that he will have to leave the service. (See Requirement 2) Once someone has been offered a place at the home they come for a series of trial stays base on their individual needs. One man was undergoing his trial stays at the time of this inspection. When someone moves to the home there is a trial period of a few months before the placement is finally confirmed and the man is and given a licence agreement. Signed and dated licence agreements were on file in the three files that were looked at during this inspection but some details were not filled in for some of them such as room number, fees to be paid and aims of the service. (See Requirement 3) Milestone DS0000007104.V324769.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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Plans are put in place that show how staff will meet resident’s needs and manage or minimise risks so that residents are clear about what support they are receiving at the home. Residents are not fully involved in and consulted about all aspects of service at the home, which means that they are not really allowed to give practical input into how the home is run. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that care plans are in place to cover all areas of need that are identified with residents and that these plans are reviewed at least annually. This area has improved since the last inspection and care plans are now in place that cover many areas which are reviewed every three months. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 12 There was also a previous requirement that the Registered Manager must ensure that needs assessments and care plans address residents’ needs around culture/ethnicity/religion/sexuality and social requirements. There is evidence that this issue has been raised with staff and some of the areas are starting to be discussed with some residents but as mentioned previously the initial needs assessment does not yet cover these areas and all staff are not yet effectively asking residents if they need support in all of these areas. Some care plans and minutes of key work sessions or reviews were supportive but some were overwhelmingly negative and focussed only on what the resident had not done or couldn’t do as opposed to acknowledging achievements and developing skills. (See Recommendation 2) There was a previous requirement that the Registered Manager must ensure that residents are made fully aware of the consequences of their actions at the home in order that they can make informed decisions and take responsibility for their behaviour at the home. Some residents have been evicted from the home for unacceptable behaviour and staff reported that the home is a lot less chaotic than it used to be. The Registered Manager said that she has told staff about the impact of the Mental Capacity Act but not all staff were aware of the changes and there is not yet an organisational policy or staff guidance available that tells them how capacity will be assessed in the future at the home. (See Recommendation 3) There was a previous requirement that the Registered Manager must work with staff and service users to develop a comprehensive and effective system of service user involvement that allows service users to comment on and influence the service they receive. There have been improvements in this area for example residents’ meetings have become more focussed and attendance has increased and resident surveys are sent out. (See Requirement 4) There was a previous requirement that the Registered Manager must ensure that staff research into local agencies or individuals who can advocate for residents and then make residents aware of these people. Active efforts must be made to encourage residents to use support from independent advocates who ideally share some of their cultural, ethnic and social background. A local advocacy agency has been identified although none of the current residents have said that they want to use the service. There was a previous requirement that the Registered Manager must ensure that effective risk management plans are in place that are made clear to service users, that identify action staff will take to manage or minimise behaviour that is not acceptable at the home. The Registered Manager must ensure that staff follow these plans. There was a lot more evidence in the files examined that risk assessments are conducted and plans put in place that tell staff what to do to manage or Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 13 minimise the risk. Staff reported that the levels of unacceptable behaviour have reduced. There are some problems in the home in the past that have been reacted to with blanket rules around risk that may not be entirely appropriate e.g. no children are allowed in the home and no alcohol is allowed in the home. The Registered Manager said that she is reviewing both these policies and will be talking to staff about them in the near future and indicated that the visitors policy at least will probably be changed to allow residents to have children visit them if they are appropriately supervised. It is important that risk is assessed as an individual issue wherever possible and genera rules are not in place that limit some resident’s inappropriately. (See Requirement 5) Milestone DS0000007104.V324769.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, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents do not yet have fulfilling and stimulating individual programmes of activity in place, which means that they are not improving their skills and abilities as much as possible in order to move on from the home to less supported accommodation. Residents are supported by staff on an individual basis to plan, shop for and cook as they choose, which means that they are being helped to make their own decisions while being offered advice in order to improve their diet. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that residents have a structured weekly programme in place that includes activities in the local community and links with in-house programmes. There have been improvements in this area and staff have started talking to Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 15 residents about developing a structured weekly programme but a lot of residents still do not have many things to do. There is a music group every fortnight and other groups are being considered. One resident said that there was not enough to do at the home. (See Requirement 6) There was a previous requirement that the Registered Manager must ensure that residents are offered healthy, nutritious meals of their choice, cooked in the way they require. The cooking procedures have changed in the last few months and there is no longer a cook for the home. Residents now plan meals, shop and cook for themselves with staff support as they need it. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Monitoring of healthcare issues is not consistent which means that residents are not being supported to regularly and effectively take care of their health. Medication monitoring is generally effective which means that residents usually receive their medication as they are supposed to. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that residents are encouraged and supported to attend regular GP, dentist, optician and chiropodist appointments and that records show evidence of this support. The Registered Manager said there are new forms that are used to monitor if residents are going to regular appointments but these are not being completed for many residents. (See Requirement 7) There was a previous requirement that the Registered Manager must ensure that the medication stock checking procedures are effective. There is anew procedure in place whereby staff now check the medication every shift. On Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 17 checking there was one example of an error where the stock records did not match the medication administration charts. (See Requirement 8) There was a previous recommendation that the Registered Manager should make sure that a sample of staff’ initials is recorded on the list of staff authorised to administer medication. There was a previous recommendation that the Registered Manager should make sure that during medication reviews, GPs and consultants are made aware of medication that service users never or rarely take and that these medications are removed from prescriptions or made into medication that can be taken as required by the service user. The Registered Manager said that medication reviews should take place every three months but records showed that although minutes of CPA reviews state what medication the residents are on, they do not show if medication has been reviewed. Staff reported that at least one service user has not had their medication reviewed for years. One resident’s key work notes showed that they regularly complain that they feel they are made too tired by their medication. (See Requirement 9) Staff have all received recent medication training and are booked on a further refresher course. Some residents are being supported to take their own medication. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 18 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 adequate This judgement has been made using available evidence including a visit to this service. The home does not record day-to-day issues complaints or concerns, which means that there is no central monitoring of patterns of concern and residents may not be being listened to properly and their problems may not be sorted out quickly enough. Procedures are in place to make sure that residents are protected from harm and abuse. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that a record is maintained of all concerns and issues, in order for day-to-day patterns of concern to be audited and any action taken to be recorded. There is now a file to record this information but there was only one concern logged from September 06. There has been a recent complaint by neighbours about noise levels but this was not recorded in the file. Some residents told the inspector about things that weren’t working in their rooms that they had told staff about but these were not recorded in the concerns file. (See Requirement 10) There was a previous requirement that the Registered Manager must ensure that a separate confidential record is maintained of all allegations made about staff. This is now being done although there have not been any safeguarding allegations made about staff since the last inspection. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 19 Some staff have attended safeguarding adults training and others have been booked to do it in the near future. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 20 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, 25, 26, 28 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Currently a lot of work is being done and a lot of money is being spent on the home to make sure that residents have communal areas and rooms/flats that fully meet their needs. Staff regularly support residents to clean their rooms which means that they are being supported to live in more pleasant surroundings and to maintain their licences at the home as required. EVIDENCE: There were previous requirements that the Registered Manager must conduct an audit of all residents’ rooms and flats to make sure that all furniture and fittings required by the standard are provided and that residents are regularly supported to keep their rooms and flats to an acceptable level of cleanliness. Any carpets or other fittings that are so dirty that they are beyond repair must be replaced. The Registered Manager has secured £140,000 from the Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 21 organisation to redecorate and renovate the home. This work has started and is sue to finish at the end of July. The communal areas are getting new carpets and redecorated, there is anew kitchen and all residents are getting new bathrooms. There will be a new lobby and staff office in the reception area. This work could obviously not be assessed as it was in progress but it can be assumed that the significant work taking place will meet the standard. All residents said they were happy with their rooms and flats and had everything they needed. Staff support residents to clean their flats and rooms every week and the rooms and flats that the inspector saw were clean enough. All residents spoken to said they were happy with their rooms. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 22 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, 33, 34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are not fully trained and do not all have a full understanding the conditions and behaviours of residents which means that residents are being supported by a team that is not fully able to meet their needs. It is not possible to fully assess if the home has effective recruitment procedures in place because the records are kept at head office and the home has not competed the Commission’s recruitment checklist. This means that it is not possible to fully assess if the home is doing all it can to make sure that new staff are who they say they are and have been checked as safe to work with vulnerable adults. EVIDENCE: Most staff have now completed or are undertaking the NVQ Level 2 or 3 in Care or Promoting Independence. During the inspection staff showed varying levels of understanding of the residents’ needs and how to support them. The inspector was concerned that all staff did not show a detailed enough awareness of how the specific conditions of the residents, how that affected Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 23 their behaviour and how staff should respond to ensure that aims and objectives of the home were met. (See Requirement 11) The current staff team is not fully reflective of the resident group in that they are overwhelmingly female and mostly African or Caribbean whereas the resident group is only male and made up of a wide variety of ethnic backgrounds. There is nothing that can be done about this until staff vacancies arises but additional efforts must be made to understand and meet the needs of people with different backgrounds and social contexts. Staff talked about equality and diversity issues with the inspector and showed varying levels of understanding of the issues involved with some being quite limited. Some staff are attending training in this area and one member of staff has been identified to start attending the organisations’ equality and diversity groups. These issues will be further assessed at the next inspection. (See Recommendation 3) There was a previous requirement that the Registered Individual must ensure that the Commission’s recruitment checklist is completed and held on file at the home for all staff. The Registered Manager had not understood what was required by this and so it had not yet been done. (See Requirement 12) There was a previous requirement that the Registered Manager must ensure that staff address and record all issues of illegal drug use appropriately and that the police and other professionals are involved as required. This is now being done. Staff have been booked on some core training but not all records were available on the day of the inspection so they were sent onto the inspector a few days later. They showed that a lot of the core training has been done but there are still certain areas where statutory core training has to be attended. This staff team has been at the service for along time so core training should be a rolling programme (See Requirement 13) Training plans showed that staff are allowed to attend training additional to the basic requirement such as a diploma in forensic mental health and the NVQ Level 4 Registered Managers Award although they have to do this in their own time. Staff discussed the difficulties involved in challenging other members of staff about different ways of working and the inspector was concerned about some of the examples that staff mentioned. Managers of home in this organisation receive supervision from their line managers but do not receive specialist clinical supervision or support and the Registered Manager said that at this service given the complexities of the needs of the resent groups this would be helpful. (See Recommendation 4) Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 24 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 adequate This judgement has been made using available evidence including a visit to this service. The new Registered Manager is competent and effective which means that residents are living in a home that is being better run than it used to be. The home has some systems in place for monitoring its service but there is not yet a comprehensive quality assurance system in place that makes sure that all areas of the home are regularly assessed and plans put in place to improve every year. There are systems in place to monitor health and safety, which are generally operated effectively by staff (apart from in the area of fire safety), which means that residents are protected from harm while at the home. Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 25 EVIDENCE: The newly Registered manager has been working with this service user group for ten years and been in management for five and half years. She has completed the NVQ Level 4 in Management. There was a previous requirement that the Registered Individuals must ensure that the Registered Manager begins the NVQ Level 4 in Care. This has now been done. There was a previous requirement that the Registered Individuals must ensure that the monthly monitoring visits occur and reports of these visits are forwarded to the Commission as required. This had not been done completely regularly since the last inspection but the guidance has now changed and these reports do not need to be forwarded to the Commission every month. There was a previous requirement that the Registered Individual must ensure that there is a comprehensive quality assurance system in place at the home that continuously monitors all areas of the service. This system must be based on the views of service users and other stakeholders and must produce an annual business and development plan that shows how the home will improve and better meet service user needs. There has been a recent service audit by a senior manager but the report is not yet available. The Registered Manager is in the process of completing her report that will feed into the service audit. The Registered Manager said that she plans to take her report to the staff meeting for discussion and then to the residents’ meeting for discussion. There is a plan being developed for the home that will aim to show how the home will improve over the forthcoming year but it is not yet completed. Work has improved in this area but it is not possible to say as yet that the requirement is met. (See Requirement 14) There was a previous recommendation that the Registered Individuals should consider using a professional, externally accredited quality assurance tool at the home. This is not being done as the organisation has drawn up its own plans for quality assurance. There was a previous requirement that the Registered Manager must ensure that all health and safety procedures are operated effectively and all the required documentation and records are in place. Most of the required documentation was in place but weekly fire system checks have been missed in the past few months. In addition, the monthly fire drills records show that there are consistently some residents who do not evacuate when the fire alarm is sounded but files do not show what is being done about this. (See Requirements 15 & 16) The home has a record that is supposed to be completed to show which residents are in or out of the building but the inspector observed this not being Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 26 used all the time due to the amount of times some residents come and go. (See Requirement 17) Milestone DS0000007104.V324769.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 X 2 2 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 (1) & (2) Requirement The Registered Manager must ensure that needs assessments and care plans address service users needs around culture/ethnicity/religion/sexuality and social requirements. Previous requirement: Unmet timescale 31/10/06 The Registered Individuals must ensure that no service user is offered a place at the home unless they believe they can meet their needs. The Registered Manager must ensure that all licence agreements issued to service users are fully completed. The Registered Manager must work with staff and service users to develop a comprehensive and effective system of service user involvement that allows service users to comment on and influence the service they receive. Previous requirement: Unmet timescale 31/10/06 The Registered Manager must ensure that the identified policies are reviewed in order to ensure that service users lives are DS0000007104.V324769.R01.S.doc Timescale for action 31/08/07 2. YA3 12 (1) (a) & 14 (1) 30/06/07 3. YA5 5 (1) 31/07/07 4. YA8 YA39 12 (1) (2) (3) & (4) & 24 31/08/07 5. YA9 12 (1) (a) 31/07/07 Milestone Version 5.2 Page 29 6. YA12 YA13 YA14 12 (1) & (2), 15 & 16 (2) (m) & (n) 7. YA19 12 (1) (a) 8. YA20 13 (2) 9. YA20 13 (2) 10. YA22 22 11 YA32 12 (1) (a) & 18 (1) restricted only when necessary and that individual risk assessments are undertaken where possible as opposed to blanket policy decisions being taken. The Registered Manager must ensure that service users have a structured weekly programme in place that includes activities in the local community and links with in-house programmes. Previous requirement: Unmet timescale 31/10/06 The Registered Manager must ensure that service users are encouraged and supported to attend regular GP, dentist, optician and chiropodist appointments and that records show evidence of this support. Previous requirement: Unmet timescale 31/08/06 The Registered Manager must ensure that the medication stock checking and administration procedures are effective. Previous requirement slightly reworded in this report: Unmet timescale 31/07/06 This now made an urgent requirement in his report The Registered Manager must ensure that residents’ medication is effectively reviewed regularly and that written records evidence these meaningful reviews. The Registered Manager must ensure that a record is maintained of all concerns and issues, in order for day-to-day patterns of concern to be audited and any action taken to be recorded. Previous requirement: Unmet timescales 31/03/06 & 31/10/06 The Registered Individuals must ensure that all staff have the DS0000007104.V324769.R01.S.doc 31/07/07 31/07/07 08/06/07 31/08/07 31/08/07 31/08/07 Milestone Version 5.2 Page 30 (c) (i) 12 YA34 19 (1) (b) & (4) 13 YA35 18 (1) (c) (i) 14 YA39 24 15 YA42 13 (4) (a) & (c) 16 YA42 13 (4) (a) & (c) 17 Milestone YA42 13 (4) (a) necessary skills, abilities and understanding to fully meet the needs of the service users. The Registered Individuals must ensure that the Commission’s recruitment checklist is completed and held on file at the home for all staff. Previous requirement: Unmet timescales 31/03/06 & 31/08/06 The Registered Individuals must ensure that all staff have attended all the required core training particularly in this instance food hygiene, fire safety and first aid. The Registered Individual must ensure that there is a comprehensive quality assurance system in place at the home that continuously monitors all areas of the service. This system must be based on the views of service users and other stakeholders and must produce an annual business and development plan that shows how the home will improve and better meet service user needs. Previous requirement: Unmet timescale 31/10/06 The Registered Manager must ensure that all health and safety procedures are operated effectively and all the required documentation and records are in place. Previous requirement: Unmet timescale 31/07/04 This now made an urgent requirement in his report The Registered Manager must ensure that further action is taken (including individual risk assessment and management plans around this issue) to address the problem of some service users not evacuating when they hear the fire alarm The Registered Manager must DS0000007104.V324769.R01.S.doc 30/06/07 31/08/07 31/08/07 08/06/07 30/06/07 30/06/07 Page 31 Version 5.2 & (c) ensure that an effective system is in place that allows staff to record accurately who is in the building at any time. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA6 Good Practice Recommendations The Registered Individuals should revise the Service Users Guide so that it is more accessible and useful for the service user group. Previous recommendation. The Registered Manager should ensure that care planning at the home is approached from the point of recognising achievements and supporting service users to develop skills and that care plans, risk assessment and other records should reflect this approach rather than the more negative approach of only emphasising failures and noncompliance. The Registered Individuals should ensure that there is an organisational policy and procedure that addresses the impact of the Mental Capacity Act and that staff understand this. The Registered Manager should consider introducing internal team discussions around current equality and diversity issues as they affect the service user and staff groups in order to support the formal training that is being offered in these areas. The Registered Individuals should consider providing a group support time to the staff team facilitated by an external therapist and additional specialist mental health input for the managers of the service. 3. YA7 4. YA35 5. YA35 Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Milestone DS0000007104.V324769.R01.S.doc Version 5.2 Page 33 - 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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