Inspection on 25/10/06 for New Hope Project

This inspection was carried out on 25th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Hope Project 07/11/05

New Hope Project 07/06/05

New Hope Project 27/09/04

New Hope Project 25/05/04

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

CARE HOME ADULTS 18-65 New Hope Project 377-381 Queens Road New Cross London SE14 5HD Lead Inspector Ornella Cavuoto Unannounced Inspection 25th October 2006 10:00 New Hope Project DS0000025652.V317123.R02.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 New Hope Project DS0000025652.V317123.R02.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. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Hope Project Address 377-381 Queens Road New Cross London SE14 5HD 0207 6356339 0207 635 0066 Newhopepenrose@freeuk.com 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) Penrose Housing Association Omolara Oluyomi Amusan Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 November 2005 Brief Description of the Service: New Hope Project is registered for 12 men who are mentally disordered offenders leaving regional medium secure units. The service is offered in partnership with South London and Maudsley Mental Health Trust under the supervision of a Community Forensic Consultant. Service users are expected to work with the psychiatric services throughout their stay at the Project. Penrose Housing manages the project. The property is owned and maintained by Hyde Housing Association. It is located in New Cross Gate, close to local shops, community facilities and public transport. The home has been converted from three houses and provides service users with en-suite bedroom accommodation on the first floor. The house is set back from the main road and there is a garden at the rear of the property. One of the twelve places is kept for overnight trial visits by prospective service users. A planned rehabilitation programme is offered to assist service users to move on to suitable alternative accommodation where less support will be provided. Individual and group work in the home aims at developing service users skills and abilities. Service users are supported to attend day centres, adult education and training, leisure and recreational activities. Potential service users receive information about the service from referring agents (CMHTS, consultants and medium secure units) so that service users can find out about the service before a referral is made. Upon the receipt of referral applications the home sends prospective service users information about the service namely leaflets on the service, Residents Handbook, service specifications and CSCI inspection reports. CSCI Inspection reports are also kept on the residents’ notice board that both potential and current service users have access to or they can be made available on request. Range of monthly fees charged are £ 3,986.92 per bed space over 4 weeks to £4,983.65 per bed space over five weeks. No additional charges are made. This information was provided to CSCI November 2006. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over nine hours. The manager was not present on the day the inspection took place but one of the project’s deputy managers facilitated the inspection process. In addition, two staff members and three service users were spoken to. Other methods used included inspection of records and a partial tour of the building. What the service does well: What has improved since the last inspection? Service users’ wishes as regards to illness and death have been recorded as part of their individual care plans. Records of interviews carried out are now included on individual staff files. Staff are now completing inductions that meet with Skills for Care specifications. Improvements have been made in respect to fire procedures with the time of fire drills now being recorded. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are fully assessed before they are offered a place at the home. Service users move in for a trial stay before their stay is confirmed. All service users are issued with a Licence Agreement but the fees for the home are not included. EVIDENCE: The personal files of four service users were inspected. One of the service users had moved into the home in the last few months whilst another had moved in recently. There was evidence on all the files that detailed assessments and risk assessments had been obtained prior to service users being offered a place and commencing a trial stay at the home. In addition, there was evidence that the home had carried out their own detailed assessment and risk assessment with service users. Prospective service users move into the home for a trial stay of three weeks before their stay at the home is confirmed. One of the rooms within the home is specifically used for prospective service users staying at the home for this trial period. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 9 All the service users whose personal files were examined had been issued with a licence agreement that had been signed by them. However, the agreement did not specify the fees charged, what they cover and when they must be paid and by whom and any additional charges not covered by the fees for services or facilities used by service users. Effective from the 1st September a new regulation has specified this information also needs to be included in the Service User Guide (Standard 1). This was not inspected on this occasion but will be looked at the next inspection (See Requirements). New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in the drawing up and reviewing of their care plans so they know their assessed and changing needs and personal goals are reflected in their individual plans. Support is provided to encourage service users as much as possible to make their own decisions. Effective risk assessment and management supports service users to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately and confidentiality is maintained. EVIDENCE: Of the four personal files looked at three had evidence of a care plan having been drawn up. The other file belonged to a service user that had moved into the home and had recently completed their trial stay at the home. During this period the service user is allocated a key worker who works with them to identify their needs and areas with which they require support in preparation New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 11 for drawing up a care plan once their stay is confirmed. There was evidence within the file that the service user had received regular key work sessions and areas of needs were being looked at with them. The other care plans in place were comprehensive and addressed personal, health and areas of social support including daily structure. Restrictions imposed on service users under the Mental Health Act or due to other legal issues were specified within individual care plans and there was evidence that service users are involved in the care planning process with their views being noted and also their responsibilities as well as their key worker’s responsibilities to achieve identified goals being outlined. Reviews of care plans had taken place six monthly. This is completed in line with Care Programme Approach (CPA) reviews. In addition to this, there was evidence that service users had received regular key work sessions and weekly psychiatric clinics had been held at the home where the individual care and support needs of service users had been addressed. Two of the care plans had not been signed but there was a note on one of them that it required signing by the service user and had just recently been reviewed. Although the other care plan was not signed there was clear evidence of service user involvement in the drawing up of the care plan. However, it is advised that care plans should be signed as soon as possible after a review of a care plan and a new one being put in place (See Recommendations). There was evidence within key work sessions that service users are supported to make their own decisions within restrictions imposed as a result of the Mental Health Act or other legal issues in certain cases. Service users spoken to confirmed this. Monthly resident meetings are also held in which service users are given an opportunity to have an input on decisions about aspects of living in the home. All service users manage their own finances. Information about advocacy services is made available to service users. As mentioned there was evidence that detailed risk assessments had been obtained prior to service users coming into the home. Risk assessments had also been completed in respect to service users’ mental health with triggers and indicators of relapse specified and management and contingency plans put in place. Furthermore, all service users had a rehabilitation checklist completed with them. This looks at all aspects of daily living with service users such as shopping, cooking, transport, personal safety, social skills amongst others. This acts as a risk assessment to identify areas that service users need support and/or where presenting risks need to be managed. These are reviewed six monthly. The home has a robust confidentiality policy and all service users sign a confidentiality agreement form that specifies to whom service users agree for personal information to be disclosed. A copy of this is kept on their personal files. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Service users take part in appropriate educational and occupational activities and also make use of the local community. Opportunities are provided to allow service users to engage in different leisure activities. Service users are supported to maintain appropriate relationships. Routines at the home promote independence and respect service users’ rights. Service users are encouraged and supported to cook their own meals. EVIDENCE: The aim of the home is to prepare service users for more independent living. As a result encouraging and supporting service users to get involved in educational and occupational activities is an important part of service users’ stay at the home. The home has an Employment Training and Education (ETE) Manager for all Penrose homes and one of the staff working at New Hope acts as a co-ordinator supporting service users to access opportunities and monitoring how service users are progressing on courses and work New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 13 placements. One service user living at the home was involved in doing some voluntary work whilst other service users were involved in courses run by a Community Outreach Support (COS) scheme within the borough that provides a range of different educational and leisure activities including brick laying, carpentry, cookery, computing, a music group and football. Furthermore, the home has it’s own in-house employment scheme where service users can apply for two posts working as housekeepers and also one to work as a gardener for which they are paid. One of the service users spoken to confirmed they had been given a job working as a housekeeper that they enjoyed as they said, “it gives me something to do”. It was reported that service users doing the house keeping jobs were to receive training in manual handling. It is also advised they receive training in health and safety (See Recommendations). Service users are supported to make use of the local community. All are taken out to the local area when they move in to assess their support needs in respect to be able to shop, use public transport and manage their personal safety as part of completing the rehabilitation checklist. Service users were seen going out on the day of the inspection to use the local shops. It was also reported that some of the residents use a gym and attend church locally. All have access to free travel. Service users spoken to confirmed that they are provided with opportunities to engage in a range of leisure activities inside and outside the home such as going on trips. One service user recently went on a day trip to France. Another service user stated they had been on a trip to Oxford. A timetable of future trips that had been planned was in place that included for example, going to a firework display, different museums, a boat trip and the IMAX cinema. Activities were also looked at within resident meetings with a DVD night, bowling and swimming being discussed. There was evidence within individual care plans that service users are supported to maintain appropriate personal and family relationships. Service users spoken to confirmed this. It was reported that service users are able to have visitors in their rooms although all visitors have to leave the home by 11.30pm. Routines at the home do promote independence and respect service users’ rights. All service users are given a key to their rooms and the front door. Service users spoken to confirmed this. Service users come to the office for their mail that they receive unopened and sign when they have collected it. Staff do not enter service users’ rooms without their permission. Individual rooms have an intercom telephone. One service user spoken to stated staff always ring them in advance prior to entering their room. On the day of the inspection this method was used to ask one of the service users if their room could be inspected as part of the inspection and the staff member knocked before going in. Service users’ responsibilities in relation to housekeeping tasks and restrictions on smoking and the use of alcohol and drugs were specified New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 14 within the Resident’s Handbook, a copy of which is issued to service users when they move in. Service users are encouraged to shop for their own food and to cook their own meals. When service users enter the home they are observed preparing a meal and cooking it as part of completing the rehabilitation checklist to identify if service users require any ongoing support and monitoring in this area and/or if there are any risks that need to be managed. These are then addressed as part of their individual care plan. As mentioned previously in relation to standard 12 service users do cookery as part of those activities provided by the COS scheme. It was also reported that cookery groups are provided in house at intervals to support service users. Whether or not service users are coping with cooking their own food and are eating a nutritious diet is checked in key work sessions. Weekly health and safety checks are carried out on the kitchens including cupboards and fridges and service users will be observed cooking on occasions. This also assists staff to identify any concerns /problems being experienced by service users to maintain a balanced diet and to prepare meals. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported in a flexible and responsive way. The physical and emotional health needs of service users are well met. The home has robust systems in place to support service users to take responsibility for their own medication. Service users personal wishes on illness and death have been specified as part of service users’ care plans. EVIDENCE: Service users are encouraged to be independent in terms of managing their personal care. Prompting is provided as required. As mentioned the home operates a key work system that provides consistency of support. Service users spoken to were very positive about the support received from the staff. One service user spoken to said,” The staff are there if I need them which is a good thing”. Service users’ health and emotional needs are well met with evidence that these are addressed as part of service users’ care plans and monitored in key work sessions. A consultant forensic psychiatrist and community psychiatric New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 16 nurses/ social workers working with individual service users attend the weekly psychiatric clinics held at the home where service users’ mental health is carefully monitored and their medication regularly reviewed. Service users are supported to register with a local G.P but are actively encouraged to take responsibility for their own physical health care needs and to make their own appointments and ensure they attend any hospital appointments although prompting is given where needed. The medication policy and procedures used by the home are robust. All staff have to undergo a comprehensive medication proficiency assessment and do a test prior to being allowed to administer medication. Service users are supported to take responsibility for their own medication within a risk management framework where it is assessed to be appropriate. A decision to allow service users to self- administer is made in consultation with the consultant psychiatrist, other mental health professionals involved in their care as well as input from key workers. Regular spot checks to ensure service users are taking their medication as required are carried out and recorded. A sample of Medication Administration Records (MAR) sheets were inspected and all were found to be accurate. However, although there was evidence that fridge temperatures for the cold storage of medication had been recorded daily the room temperatures where medication is kept have not been recorded and this needs to be addressed (See Requirements). Subject to a previous requirement that service users’ wishes with regard to death and illness are recorded in their care plans this has been met. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Service users spoken to stated that their complaints have been listened to and acted on appropriately. Service users are generally protected from abuse . EVIDENCE: The home has a robust complaints policy and procedure. All service users are issued with a copy of the complaints policy and they are required to sign a form as confirmation of this that is kept on their personal files. Service users spoken to were aware of how to make a complaint. Both had made complaints but stated they were satisfied with how these had been dealt with. The complaints log was inspected and two complaints had been recorded since the last inspection. One was made by a service user about the attitude of another service user towards them and one was from a relative of a service user who had left the home about some personal belongings that had gone missing from their room. Both complaints had been investigated and were appropriately and efficiently addressed. There is a comprehensive adult protection policy and procedure in place at the home and there was also a copy of Lewisham’s Multi- Agency Vulnerable Adult Protection Procedure for staffs’ information. In addition, service users are provided with information about POVA (Protection of Vulnerable Adults). The home has not had any adult protection issues since the last inspection. The majority of staff have received training on adult abuse/protection and the staff spoken to on the day of the inspection had good knowledge and understanding New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 18 of adult abuse and procedures to follow if abuse was either identified or suspected. However, there are a four staff that still need to undertake training in this area although all have recently been employed to work at the home with two of the staff only starting within the last month. Also, training is in the process of being arranged. Therefore the standard is deemed met. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28 &30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers an environment that is safe, comfortable and well maintained. There are shared spaces that complement service users’ individual rooms. The home is clean and hygienic. EVIDENCE: The home offers accommodation to a very good standard. The premises are suitable for it stated purpose, comfortable, safe and well maintained. At the time the inspection was held the communal areas of the home had just been decorated and the décor was bright and airy. Service users’ individual rooms are supplemented by a number of shared spaces that include a large lounge with a television that also has Sky channels, a smaller lounge where service users can listen to music or use the computer. This room is non-smoking. There is a dining room, which is sometimes used as a meeting room to hold CPA reviews, two kitchens domestic in nature, one of New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 20 which also has a dining table where service users can eat. Finally, there is a small attractive garden at the rear of the property. The home was clean and hygienic on the day of the inspection. As mentioned previously the home employs two of the service users as housekeepers to clean communal spaces. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 good. This judgement has been made using available evidence including a visit to this service. Staff are generally qualified and competent to meet the needs of service users. The home’s recruitment practices generally protect service users although the home must ensure that where individuals are employed internally the staff file is obtained prior to them commencing work within the home Staff are all inducted and are provided opportunities to undertake regular training although evidence of staff completing mandatory training was lacking. EVIDENCE: Two staff working at the home are presently working towards achieving a National Vocational Qualification Level 2 and Level 3. One staff member had achieved a NVQ Level 3. Other staff have relevant qualifications that are above the level of NVQ, for example having a degree in psychology, social work qualifications and a diploma in counselling amongst others. Three staff files were checked. Two were found to meet with regulation in that all necessary checks such as Enhanced Criminal Record Bureau checks and information including two references had been obtained. Subject to previous requirements there was evidence of interviews on files and the home has New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 22 systems in place to check the physical and mental health of persons recruited. However not all files had an up to date photograph in place. Also, one staff member who had recently started working at the home was recruited internally within the organisation and their staff records were not available for inspection as they had still not been obtained from the home where they had been working previously although a reference and evidence of the interview undertaken was in place. The home needs to ensure that staff records for all staff working at the home are available and kept on the premises. Also, where workers are recruited internally it is advised their records are obtained prior to allowing them to commence working in the home (See Requirements). There was evidence that staff do receive an induction that meets with Skills for Care specifications with one staff member who started working at the home recently having the Skills for Care booklet that they were working through whilst another new staff member confirmed they were also working through the booklet. There was evidence that staff have received an annual appraisal and a copy of the home’s annual training plan was sent to CSCI shortly following the inspection, as this was not available on the day the inspection was held. The plan is comprehensive and details mandatory training and also a range of specific training to support staff to be able to meet the needs of individual service users effectively such as risk assessment training and harm reduction and healthy living in substance misuse amongst others. The home is able to access training for staff from the South London and Maudsley Trust (SLAM). However, in terms of mandatory training there was a lack of evidence that staff have completed this as outlined within the training plan. It was reported that there has been a turn over of staff in the last few months and newer staff would not as yet have completed this training. Although some evidence was sent to CSCI following the inspection that some staff had completed first aid training and one had done food hygiene and fire safety evidence in respect to other mandatory training that staff have completed was lacking such as in food hygiene, health and safety, infection control (See Requirements). New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been a new manager appointed since the last inspection. The home has good quality assurance systems in place that ensures service users views underpin self-monitoring, review and development but monthly provider visits need to take place monthly. The health, safety and welfare of service users are promoted and protected although where water temperatures exceed 43c this needs to be acted upon. EVIDENCE: One of the deputy managers has now been appointed manager of the home after the registered manager left. They are still to be registered by CSCI but an application has been submitted and this is in the process of being completed. This standard could not be fully assessed as the manager was on annual leave at the time the inspection was held but evidence suggested the home was well managed and run. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 24 The home has good systems in place to ensure that a quality service is delivered. These include a residents’ representative who is paid to attend a monthly tenants forum and also attends staff meetings that are held fortnightly on a monthly basis. Resident meetings are held monthly. The home completed a customer satisfaction survey with service users in February 2006 evidence of which was sent to CSCI shortly following the inspection as this was not accessible on the day. The results of these were complied in a short report. There was a low response with only four surveys completed by service users but action to be taken to address the issues highlighted by the surveys was outlined within the report. Also, as part of a team day held in July 2006 the home had drawn up outcomes of feedback received from stakeholders, service users and also staff and aims to improve the service. In addition, the home is still working to ’Project Goals’ compiled previously as part of an improvement agenda for the home and service users. In terms of monthly provider reports evidence was available that these had been completed although these had not been carried out consistently on a monthly basis as required and copies of the reports had not been sent to CSCI (See Requirements). The home has comprehensive health and safety policies and procedures in place and monthly health and safety checks have been carried out with one staff member acting as a health and safety officer. There was evidence that incidents are logged and where required reported to CSCI. There were up to date maintenance certificates in place for gas, fire and electrical wiring although a certificate for Portable (electrical) Appliances Testing (PAT) was not available and a copy of this needs to be sent to CSCI as evidence this has been carried out. The home had carried out weekly tests on fire alarm call points and subject to a previous requirement fire drills had been carried out regularly and times these were held had been noted. The home did have a fire risk assessment and building/ environment risk assessment but these had not been reviewed. In addition, water temperatures had been checked regularly and these showed that temperatures often exceeded the recommended level of 43c at one point temperatures being recorded as high as 71c. The home must address this and ensure temperatures are maintained at the recommended levels (See Requirements). New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 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 2 3 3 X 2 X X 2 X New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 26 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 YA5 Regulation 5(1)(b) Requirement Timescale for action 31/03/07 2. YA20 13(2) 3. YA34 19 (1) (a) & (b) 4. YA35 18(1)(c) The registered provider must ensure that the licence agreement issued to service users as a statement of terms and conditions is revised to include the amount of fees to be paid by whom and what this covers. The registered provider must 31/03/07 ensure that the temperatures of the rooms where medication is stored are monitored and recorded on a daily basis to check the temperature does not exceed 25c. The registered provider must 31/03/07 ensure that staff records include a recent photograph. Also that where staff are recruited internally their records should be obtained from where they worked previously prior to allowing them to commence working in the home. The registered provider must 31/03/07 ensure that all staff complete the required mandatory training and that evidence this has been completed is retained on individual staff files. DS0000025652.V317123.R02.S.doc Version 5.2 New Hope Project Page 27 5. YA39 26 6. YA42 13 (4) 7. YA42 13(4) 23(2) (c)(4) The registered provider must ensure that provider visits to the home are completed monthly and copies of reports are sent to CSCI. The provider must ensure that water temperatures are delivered close to 43 C unless risk assessments indicate that service users are able to check water temperatures for themselves (Previous timescale of 31/12/05 not met) The registered provider must provide evidence to CSCI that Portable Appliances Testing (PAT) has been carried out. Also, fire and building/environment risk assessments need to be updated. 31/03/07 31/03/07 31/03/07 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. 2. Refer to Standard YA6 YA12 Good Practice Recommendations The registered provider should try to ensure that care plans are signed by service users as soon as possible after they have been reviewed. The registered provider should consider the provision of health and safety training for those service users carrying out housekeeping jobs. New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 28 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 New Hope Project DS0000025652.V317123.R02.S.doc Version 5.2 Page 29 - 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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