CARE HOME ADULTS 18-65
New Hope Project 377-381 Queens Road New Cross London SE14 5HD Lead Inspector
Kate Matson Unannounced 7th June 2005 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 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 Stationary 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 G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service New Hope Project Address 377-381 Queens Road New Cross London SE14 5HD 020 7635 6339 020 76350066 newhopepenrose@freeuk.com Penrose Housing Association Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Omolara Oluyomi Amusan CRH Care Home 12 Category(ies) of MD Mental Disorder registration, with number of places New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th September 2004 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. The project is managed by Penrose Housing. 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. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 6.5 hours. On the day of the inspection, most service users had gone for a trip out and unfortunately this meant that the inspector was only able to speak to two service users who had chosen not to go. The inspection also included speaking to the two deputy managers and other staff, a tour of the building, and examination of records. What the service does well: What has improved since the last inspection? What they could do better:
Service users are not consulted about their wishes with regard to illness and death so the home is unable to ensure that those wishes can be respected. Although the home offers a good standard of accommodation, it was noted that there was no communal non-smoking area meaning that non-smokers have only their room in which they can enjoy a non-smoking environment. It was also noted that a blind was missing from one service user’s bathroom compromising their privacy. Current recruitment practices allowed a staff member to start work before a check had been made against the list of people considered unsuitable to work with vulnerable adults, placing service users potentially at risk of abuse. A
New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 6 letter was sent to the provider about this issue immediately after the inspection. Staff are well trained but a training plan is needed to ensure that training is based on the needs of staff and service users. There are good quality assurance systems in place but an annual survey of service users’ views, currently conducted organisation-wide, needs to be conducted within the project and include the views of other stakeholders, such as relatives, social workers, GPs and other professionals involved in the home, for the home to effectively review its quality of service. Copies of reports of visits conducted by the registered provider to review the quality of service need to be sent to CSCI to evidence that the quality of service is monitored. The health safety and welfare of service users is generally protected and promoted but a certificate of safety of electrical appliances was not available, as at the last inspection, to ensure the safety of service users. Also although some staff have food hygiene certificates some staff who are involved in food preparation do not and therefore cannot evidence that food is handled safely. 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. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) We did not look at any of the these standards EVIDENCE: All of these standards have been inspected over the previous twelve months and had been considered to be met and were therefore not inspected on this occasion. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) We did not look at any of these standards EVIDENCE: All of these standards have been inspected over the previous twelve months and had been considered to be met and were therefore not inspected on this occasion. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) We did not look at any of these standards EVIDENCE: All of these standards have been inspected over the previous twelve months and had been considered to be met and were therefore not inspected on this occasion. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 Personal care and healthcare support are provided in a way that encourages independence but within a risk management framework to ensure the well being of all service users and others. Consultation with service users is needed to ensure that the wishes of service users with regard to illness and death could be carried out. EVIDENCE: There is a key worker system to ensure that personal support is provided consistently and in a way that promotes service users’ independence. All service users have regular contact with the consultant forensic psychiatrist who visits the project weekly as well as social workers and/or community psychiatric nurses. This regular contact ensures that any problems can be dealt with at an early stage. Service users are actively supported to be responsible for their own physical health care needs. Service users are supported to self-administer medication within a risk management framework, where appropriate. Two staff administer medication, only after completing training and a proficiency assessment. The medication records and storage were examined, and were largely in order although a couple of minor errors were noted. Refresher training was being organised to ensure the number of errors is reduced. Although the home is not a home for life, previous inspections had recommended that service users wishes with regard to illness and death be
New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 12 recorded in their care plans. A chaplain was arranged to speak to service users about this as it was felt to be a sensitive issue that service users did not wish to discuss. This was not successful. A resolution to this problem needs to be found so that the project can ensure that the wishes of service users with regard to illness and death can be carried out. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There are systems in place to ensure that service users’ views are listened to and acted upon. The home’s policies and procedures ensure that service users are protected from abuse. EVIDENCE: The complaints record showed a low level of complaints that had all been responded to appropriately. Service users spoken to confirmed that they knew how to complain. A recent development is a monthly meeting between the manager and service users to discuss any issues that may arise. There are appropriate policies in place regarding protection from abuse. All staff have undergone in-house adult protection training. Service users’ financial interests are protected by encouraging independence, and where support is required, robust recording of transactions. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30. The home offers an environment that is clean, hygienic, comfortable and safe. En-suite accommodation to all of the single bedrooms suit service users’ needs and promote their independence, although a missing blind meant that the privacy of one service user was compromised. There is adequate shared space though there is no space provided for non-smokers other than their bedrooms. EVIDENCE: The home offers a safe and pleasant environment for service users. There is adequate space comprising, single bedroom accommodation with ensuite facilities, and shared kitchens, dining room and laundry facilities and two lounges and a meeting room for communal use. The accommodation is bright and well maintained, and decorated and furnished in a homely way. It is commendable that all bedrooms are provided with double rather than single beds. It was noted in the service users room that was viewed on the day of the inspection that there was no blind at the bathroom window. A blind needs to be provided to ensure the privacy of the service user. It was also noted that smoking is permitted in both of the lounges, meaning that any non-smoking service users are unable to watch television or listen to music in a smoke free environment, unless in their own room. This must be
New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 15 addressed so that service users can socialise outside of their rooms in a smoke free environment. The home was clean and two service users are employed to clean communal areas other than kitchens, which are the responsibility of all service users. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 An aspect of the home’s recruitment procedure, potentially placed services users at risk of abuse. Staff are well trained though the lack of a training plan does not evidence that training is based on the needs of staff and service users. EVIDENCE: It was confirmed that all of the appropriate checks are completed prior to staff commencing work at the home. However, on examination of staff files, evidence of some of the checks was not available and it was found that one staff member had commenced work before the receipt of a new disclosure from the criminal records bureau and a check against the list of people considered unsuitable to work with vulnerable adults. This is of concern because it places service users at risk of potential abuse. The organisation has a training coordinator and is now using the Skills for Care standards (formerly TOPSS) for induction and foundation training. Most staff have completed NVQ level 3 in Care and it is planned that 3 new staff will also undertake the training. This ensures that staff are skilled to deliver care that meets the needs of service users. All staff have an individual training and development profile, which is reviewed annually, to assess training needs on an individual basis, but there did not appear to be a training plan for the home as a whole. This is necessary to ensure that training is based on the needs of staff and service users.
New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Although there are good quality assurance systems in place the absence of a satisfaction survey specific to New Hope does not ensure that service users’ views underpin review and development at the home. The health, safety and welfare of service users are largely promoted and protected though the absence of food hygiene certificates for some staff and the absence of a certificate of safety for electrical appliances potentially places service users at risk. EVIDENCE: The home has many good systems in place to ensure that a quality service is delivered. These include: monthly meeting with service users and the manager, a residents’ representative who is paid to attend a monthly tenants forum and a monthly management meeting, an advocacy worker paid to represent service users’ views, regular review of policies and procedures, and a team review day. The organisation also completes annual service user satisfaction surveys; however, this does not include the views of relatives or other stakeholders and is not specific to New Hope. In order for the project to effectively review the quality of it’s service, it must conduct its own satisfaction
New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 18 survey and include the views of relatives, visiting professionals and other stakeholders as well as those of service users. Although project goals had been identified, they should be further developed to a written annual development plan to reflect aims and outcomes for service users. Although the registered provider conducts monthly, unannounced visits to the home to review the quality of service, the reports of these visits are not sent to CSCI as required. These must be sent to CSCI to evidence that the provider monitors the service. The home has safe working practices in operation to ensure the health safety and welfare of service users. Records showed that fire, gas and electrical systems in the home are regularly checked, serviced and inspected. It was noted that a fire drill was due and fire call point tests were not being checked weekly, but this had been highlighted in a recent team meeting and staff gave assurance that a fire drill was planned and call points were now being tested weekly. It was also noted, as at the last inspection, that although electrical appliances are inspected there is no certificate available to evidence that this has been done by a qualified person. This must be addressed to ensure that service users are safe. Although service users mainly prepare their own food, there are occasions when staff are involved in food preparation. It was found that although some staff have food hygiene certificates, not all of those involved in food preparation have one. This must be addressed to ensure that food is handled safely and service users health is protected. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 4 2 2 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
New Hope Project Score 3 3 3 1 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 20 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 21 Regulation 15 Requirement The registered manager must ensure that service users wishes with regard to illness and death are recorded in their care plans. If they do not wish to discuss the issue this must be recorded. The registered provider must ensure that all windows in service users accommodation are provided with curtains or blinds in order to protect their privacy. The registered provider must ensure that there is at least one no smoking, communal area available for service users. The registered provider must not allow any new staff to commence employment in the care home until a satisfactory CRB disclosure at the appropriate level has been received, and a check has been made against the POVA list. New staff may commence employment in the home before the receipt of a CRB disclosure provided certain conditions are met, including a check against the POVA list having been made. The registered provider must ensure that all staff records Timescale for action 31/10/05 2. 27 16 (2) (c) 30/07/05 3. 28 23 (2) 31/10/05 4. 34 19 (1) 07/06/05 5. 34 19 (1) 30/09/05
Page 21 New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 6. 35 18 (1) (c) (i) 7. 39 24 8. 39 26 9. 42 23 (2) (c) 10. 42 18 (1) (c) (i) required by regulation are in place for all staff, and are available for examination at future inspections The registered provider must ensure that there is a staff training plan in place, based on an assesment of the needs of service users and the whole staff team The registered manager must ensure that annual surveys are conducted of the views of service users, their representatives, professionals and other stakeholders, in order to review the quality of service offered at New Hope. The registered provider must ensure that copies of reports of visits conducted in accordance with Regulation 26 are sent to CSCI Southwark Office. The registered provider must ensure that a certificate of safety for electrical appliances is available for inspection. The registered provider must ensure that all staff who are involved in food preparation have food hygiene certificates 31/10/05 30/09/05 30/09/05 31/08/05 31/10/05 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 39 Good Practice Recommendations It is recommended that project goals are further developed into an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. 2. New Hope Project G52-G02 S25652 New Hope V243753 070605 Final Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 46 Loman Street Southwark London SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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