Inspection on 22/08/07 for Park View (Streatham)

This inspection was carried out on 22nd August 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park View (Streatham) 16/05/06

Park View (Streatham) 03/11/05

Park View (Streatham) 19/05/05

Park View (Streatham) 13/01/05

Park View (Streatham) 13/10/04

Park View (Streatham) 11/02/04

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

CARE HOME ADULTS 18-65 Park View (Streatham) 17 Streatham Common South Streatham London SW16 3BU Lead Inspector Sonia McKay Unannounced Inspection 22nd August 2007 10:00 Park View (Streatham) DS0000022747.V345037.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 Park View (Streatham) DS0000022747.V345037.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. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park View (Streatham) Address 17 Streatham Common South Streatham London SW16 3BU 0208-679-2364 0208 679 2364 crownwise@yahoo.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) Crown Wise Limited Mr Allen Amuaku Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 10th July 2006, the home can accommodate five named service users, over the age of 65 years, with a mental disorder. The home must advise the CSCI when any of these service users no longer resides at the home. 16th May 2006 Date of last inspection Brief Description of the Service: Parkview is a private residential home for seventeen adults with mental health needs. It is one of three homes in the locality owned by the same proprietor. The large detached home is in a residential street overlooking Streatham Common, within walking distance of transport links, shops and leisure facilities. The majority of service users have been at the home for many years and the home aims to provide them with the various degrees of support. Where appropriate, the home also helps to prepare service users for independent living. Prospective service users are provided with an information pack about the home that includes a copy of the Service Users Guide and Statement of Purpose. The CSCI inspection report is available on request at the home and a copy is available in the communal lounge. Fees range between £270.00 per week and £1219.31 per week and vary in accordance with the level of support required for an individual. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit began at 10.00 a.m. and was completed in seven hours. The inspection consisted of discussion with six residents, the deputy home manager and staff on duty. There was a partial tour of the home premises and examination of records relating to care and staffing. The Commission required that the registered manager complete a written assessment of the service provided in the home (an Annual Quality Assurance Audit or AQAA). Information supplied in this self-assessment is used to inform this report. The local placement and monitoring team manager provided feedback about the service in a survey. The Commission would like to thank all those who kindly contributed their time, views and experiences to this inspection. What the service does well: Prospective residents have adequate information about the services provided in the home and their individual needs and aspirations are assessed and recorded in a written plan. People have an opportunity to visit the home for a trial period before making a decision to move in. The home environment is clean, comfortable, well decorated and furnished. There is regular consultation with residents and this results in changes being made to how the home is run. Residents are able to enjoy the lifestyle of their choosing within the confines of shared living. Residents receive personal care in the way they need and in the way that they prefer and physical healthcare needs are generally well met. Medication is handled well by staff and residents are encouraged to take responsibility for their own medication where possible. People can work and attend college whilst living in the home and they can also maintain their friendships and relationships. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 6 Meals are enjoyed and meet people’s cultural needs The home manager responds to complaints well and encourages residents to use the complaints procedure. Staff are trained to recognise abuse and what to do if they suspect someone is unsafe or being abused. The manager is registered and experienced and the staff and residents know him well and feel able to approach him with any problems or issues. What has improved since the last inspection? What they could do better: Written plans for how care will be provided are clear and concise, but the plans have not been agreed with residents in all cases. It is important that residents are consulted on these plans and agree to them. There is a need for better joint working with other professionals for one resident, who lacks capacity to make decisions, who may need extra support to access adequate healthcare. There is a need to assess the risks posed to people when they are being supported towards greater independence. This will ensure that staff do not provide too much or too little support and allow residents to rehabilitate more effectively and safely. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 7 Records of the feedback given to some people who have made complaints is not well documented. This is important so that the registered provider can check on what has been done. People must receive feedback to reassure them that their complaints are being listened to and acted upon. The way that new staff are checked is adequate but must include a new criminal records check, even if staff have obtained one from a previous employer. This will provide a more up to date check on the person and remove any chance of falsified documents being accepted. This will provide residents with better protection. The manager is registered and experienced but has yet to obtain vocational qualifications in care and management. This must be done to ensure that residents benefit from a well run home. There are a range of activities available in the home for people to do, but there is some indication that they are in need of review, as some residents said they were getting a bit bored. More must be done to ensure that residents can adjust the heating in their own bedrooms to a temperature that suits them and to protect residents from passive smoking. The Commission must be notified of any event in the care home that adversely affects the health, safety or welfare of any resident. Better records must be kept of the outcomes of the inspection visits carried out by, or on behalf of, the registered provider, on the running of the service. These reports must be supplied to the Commission each month. 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. Park View (Streatham) DS0000022747.V345037.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 Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents have adequate information about the services provided in the home and their individual needs and aspirations are assessed and recorded in a written plan. People have an opportunity to visit the home for a trial period before making a decision to move in. EVIDENCE: There are two documents that provide information about the service provided, a statement of purpose and a service users guide. The service users guide contains a summary of the information provided in the statement of purpose and additional information about the services provided, the home environment and the outcomes of resident satisfaction surveys. The ‘Resident’s guide and associated individual contracts must provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (both personal care and food) and the payment arrangements (resident contribution/local authority contribution) must be stipulated. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 10 The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the resident. (See requirement 1) There has been one new admission to the home since the last inspection visit. Adequate pre-admission information was obtained and the home manager completed a detailed needs assessment before a placement was offered. Prospective residents are offered an opportunity to visit the service before moving in for a trial period. Park View (Streatham) DS0000022747.V345037.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 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Written plans for how care will be provided are clear and concise, but have not been agreed with residents in all cases. There is evidence of wider consultation however. There is improvement in the way that known risks are documented and assessed but there is still a need to assess the risks posed to people when they are being supported towards greater independence. This will ensure that staff do not provide too much or too little support and allow residents to rehabilitate more effectively. EVIDENCE: Each resident has an allocated key worker; responsible for meeting with the resident on a regular basis and updating the care plans. Care plans are reviewed regularly and are in accordance with decisions made in the care programme approach (CPA) meetings also held for the majority of residents. Care plans examined during this inspection were well organised and up to date. Although the plans have been reviewed regularly, some have not been Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 12 agreed by the resident themselves (there is no evidence that the resident had read and signed the plans). (See requirement 2) Staff respect peoples rights to make decisions, and that right is limited only through the assessment process, involving the resident and as recorded in the persons care plans. Residents choose when to get up and went to go to bed and how to spend their time and they are involved in making decisions about daily menus, activities and house issues. The provider sends each resident a questionnaire every month. This consultation relates to a wide range of user satisfaction topics and provides people with an opportunity to inform decisions about the range of activities provided. The outcomes of this consultation is also discussed in house meetings. None of the residents are involved in local independent advocacy/self advocacy groups. It is recommended that information about these resources and support to contact them be made available to residents if they wish. (See recommendation 1) Most residents are able to manage their own finances, but the provider acts as the state benefit appointee for some and residents can also ask staff to keep their money in safe-keeping to help them with budgeting. Good records are kept of these accounts and receipts are obtained for expenditures. A spot check of money held in safekeeping showed that detailed and accurate records are maintained. Each resident has detailed risk assessment around any known risk areas and this reflects the risks identified in care needs assessments and CPA review notes. Risk assessments are reviewed along with care plans or when new risks are identified. A general risk assessment audit tool that will enable staff to make assessments and then safely devise programmes for increasing independence has been developed, as recommended in the previous inspection report, but is not yet in effective use. (See recommendation 2) Missing persons procedures are in place and the home responds promptly to unexplained absences by residents. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 13 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 adequate This judgement has been made using available evidence including a visit to this service. People are able to enjoy the lifestyle of their choosing within the confines of shared living. There is a range of activities available in the home for people to do, but there is some indication that they are in need of review. People can work and attend college whilst living in the home and they can also maintain their friendships and relationships. Meals are enjoyed and meet people’s cultural needs and there is more opportunity for people to cook for themselves. EVIDENCE: Residents are mostly able to maintain their friendships and relationships themselves. Family and friends are welcomed, and with the resident’s agreement are involved in meetings and activities. Residents choose whom they see and can see visitors in the privacy of their bedrooms. The use of shared bedrooms is being phased out, as this reduces people’s privacy and should only be used if people express a desire to share Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 14 accommodation. Many residents have lived in the homes for a long time and a social network has developed. A range of the recreational activities is available including art classes, social evenings and occasional day trips to the seaside. There is an ‘in-house’ social gathering each week and there is also a movie projector and screen for regular movie nights. The house vehicle has not been available recently and this has reduced the frequency of the excursions, and is missed by some of the residents. Annual holidays are not part of the package of care provided by the home. (See recommendation 3) The opportunities for social activities are generally limited to group activities. Whilst there is value in such activity, feedback from placing authority care managers involved in the care of some of the residents indicates that the service is viewed to be rather institutional. One resident said that the organised activities are getting a bit boring and less well attended. (See recommendation 4) Some residents are involved in employment and college courses. In the AQAA (Annual Quality Assurance Audit) the home manager identifies encouraging residents to find out and take up opportunities for education and employment as an area of planned improvement in the next twelve months. Times for getting up and going to bed are not fixed. Residents are offered a key to the front door and to their own bedroom and all bedrooms and bathrooms can be locked from the inside. Records are kept of all main meals served in the home. Meals are prepared by a cook and served in the communal dining room at reasonably set times, although residents wishing to have a meal later can do so. A reasonably varied range of meals is provided, including culturally appropriate meal options and themed menus for social evenings, such as Indian, Irish, African and Caribbean. Residents spoken with said that the meals are good. The bulk of the food provisions are stored in a locked pantry in the basement. Provisions available include fresh produce and food is stored hygienically. Since the last inspection, residents have been provided with a cooker and their own food preparation and storage areas, within the communal dining room. Residents can now prepare some meals themselves. Staff said that this has included light meals and baking activities. This gives people more opportunity to cook their own meals, as recommended in the previous inspection report. Park View (Streatham) DS0000022747.V345037.R01.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. Residents receive personal care in the way they need and in the way that they prefer. Physical healthcare needs are generally well met, but there is a need to better consider joint working for one resident who may need extra support from professionals to access adequate healthcare. Medication is handled well by staff and residents are encouraged to take responsibility for their own medication where possible. EVIDENCE: People are generally able to manage their own personal care with little more than occasional reminders or advice. When a resident needs assistance with things like washing and bathing, the nature of the support required by staff is carefully detailed in a written care plan. Assistance with personal care is given in the privacy of bedrooms or bathrooms. There are both male and female staff and staff from a diverse range of cultures. This is reflective of the resident group and local population. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 16 There is a written record of the physical and psychiatric healthcare attended by each resident. The cases tracked during this inspection show that an appropriate range of healthcare professionals are involved and residents also receive support to make and attend appointments if necessary. One resident, who has a communication difficulty, and increasing cognitive impairment, visited the dentist in January 2006. Dental treatment was advised but has not been given. Staff on duty were unsure of how this was going to be resolved as there is no specific plan. There is a need to review this situation with the resident and other professionals as necessary to ensure that the resident’s best interests are fully considered. (See requirement 3) All residents are registered with a local GP practice and most have input from community based psychiatric nurses. Accidents are recorded in an accident book that is in accordance with Data Protection legislation. Medication is stored in a secure medicine cabinet in the office and is administered by staff. Medication policy and procedures are in place and are adequate. Staff training includes the safe administration of medicines. Medicines are supplied by a local pharmacy in blister packs. The supplying pharmacist regularly inspects the handling of medication in the home and the most recent report of January 2007 is good. Justified stock checks take place regularly and the outcomes recorded. This is a check on whether medication is being administered properly. There are no gaps in recordings on the MAR charts examined during this inspection (Medication Administration Records). There is also progress in helping more residents to administer their own medication and medication policy and procedures were reviewed in March 2007. Risk assessments and safe storage in bedrooms for medication is in place. Residents fill their own weekly dose boxes with support from staff. The pharmacist advised better labelling of these containers and this has been done. Creams and bath additives are now stored properly in peoples bedrooms and the administration of these products by staff is recorded as necessary, as required in the previous inspection report. Park View (Streatham) DS0000022747.V345037.R01.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home manager responds to complaints well and encourages residents to use the complaints procedure. However, the records do not show whether people have been given proper feedback about what has been done about their complaint in some cases. This must be done to reassure people that their complaints are being listened to and acted upon. Staff are trained to recognise abuse and what to do if they suspect someone is unsafe or being abused. EVIDENCE: There is a complaints procedure, which includes timescales for investigation and feedback. The complaints procedure is given to each resident in the guide to the home. The record of complaints shows that four complaints have been made since the last inspection. The actions taken and the outcomes are recorded as required, although there is a lack of evidence of what feedback each complainant has been given about their complaint. This is important so that people are reassured that their complaints have been listened to and addressed. (See requirement 4) Procedures are in place for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) and for referring staff that may be Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 18 unsuitable to work with vulnerable adults for inclusion on the protection of vulnerable adults register. There have been no adult protection issues referred to the local authority safeguarding adults team since the last inspection visit. Staff demonstrate an understanding of the occasional verbal aggression by residents and deal with it appropriately. Physical intervention is not used. The homes policies and practices regarding looking after people’s money and financial affairs ensure their protection from financial abuse. Staff have received training in the protection of vulnerable adults and the recently appointed director of care regularly poses situational scenarios to staff to identify further training needs. Park View (Streatham) DS0000022747.V345037.R01.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, 26, 27, 28 & 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and safe environment. There is a range of communal areas and the gardens have improved. More must be done to ensure that residents can adjust the heating in their own bedrooms to a temperature that suits them and to protect residents from passive smoking. EVIDENCE: The home is clean, well furnished and attractively decorated. There is a ground floor communal dining room that is also used for social activities. There are two more communal lounges on the second floor, both with roof terraces. One lounge is a dedicated smoking area. There are front and back garden paved areas with shrub planting, hanging baskets and seating. A large barbeque and seating area has been built in the Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 20 back garden since the last inspection. This means that residents can make more use of out door space and enjoy some meals outside in good weather. A programme of cyclical redecoration is ongoing. There is good access to local amenities, services and transport links. The home overlooks Streatham common, an open green space. There are 13 single bedrooms and two double bedrooms. (See recommendation 5) Residents spoken with said that they are satisfied with their bedroom accommodation, although some could not adjust the temperature of the radiators in the bedroom and this makes the rooms uncomfortable at times. People should be able to adjust the heating to a temperature of their choice in their own bedrooms. (See requirement 5) Some residents said that passive smoking continues to be an issue, with some residents smoking outside of the designated smoking lounge. Some residents are unable to get upstairs to the smoking lounge, as they cannot manage the stairs. This means that they smoke in their bedrooms and sometimes in the communal dining room. The home has also received a complaint from a resident. Given the recent changes in legislation about smoking and the need to provide smoke free communal and dining areas, steps must be taken to resolve this challenging issue. (See recommendation 6) Eight bedrooms have en-suite facilities. There are twelve shower facilities, two bathrooms, and fifteen toilets. There is a communal laundry in the basement. Although there are four bedrooms situated on the ground floor, the home is not suitable for people with a physical disability as the only accessible communal area is the ground floor dining room. Park View (Streatham) DS0000022747.V345037.R01.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 & 36. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The majority of staff have obtained a vocational qualification in providing care to people. This means that they are trained to a certain standard. There is also ongoing training about the individual needs of the residents and regular refresher courses. The way that new staff are checked is adequate but must include a new criminal records check, even if staff have obtained one from a previous employer. This will provide a more up to date check on the person and remove any chance of falsified documents being accepted. This will provide residents with better protection. EVIDENCE: The AQAA (Annual Quality Assurance Audit) completed by the home manager says that there are seventeen members of staff in the team. Fourteen staff are female and three are male. Fifteen members of the staff team have attained a National Vocational Qualification (NVQ) in Care. Five staff have attained an NVQ at level 3 and 10 staff have attained an NVQ at level 2. This is evidence of having a qualified staff team. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 22 There is a staff training and development plan in place, as required in the previous inspection report. This ensures that staff receive mandatory training and appropriate refresher courses updates for things like first aid and fire safety and areas of training specific to the needs of the resident group. The registered manager intends to improve staff training by: • Recruiting new staff who have already attained a vocational care qualification in Care • Providing training in equal opportunities • Providing better training around infection control Examination of two sets of records relating to the recruitment of two members of staff indicates that staff recruitment involves completion of an application form, a face to face interview and taking up of appropriate references. However, the copies of enhanced criminal records checks held on file are copies of recent checks made by other employers. Criminal records checks must be taken up by any new employer as the checks are not transferable. (See requirement 6) There is also a need to obtain a photograph of one of the employees, as a copy of a passport photograph is not sufficiently clear. (See requirement 6) It is also noted that the completed application forms examined are not headed with the name of the service. Instead the forms are for another service run by the registered provider. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is registered and experienced but has yet to obtain vocational qualifications in care and management. This must be done to ensure that residents benefit from a well run home. There is progress in developing the quality assurance systems, although more must be done to ensure the day to day running of the service is monitored properly. EVIDENCE: The registered manager has been in post for many years and has a medical qualification. He is competent and experienced but has yet to complete a care or management qualification. The AQAA (Annual Quality Assurance Audit) states that the manager is currently on a waiting list for a funded RMA placement (Registered Managers Award). Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 24 This is an unmet requirement from the previous inspection report. The registered manager and registered provider must ensure that the registered manager obtains these essential vocational qualifications. (See requirement 7) The deputy manager assists the home manager and has taken over a number of key management areas. The deputy manager is experienced and works in a full-time capacity. She has obtained an NVQ level 3. Feedback from staff and residents during this inspection indicates that people find both of the managers approachable. There are quality-monitoring systems in place that are based on seeking the views of the residents. The results of these topical surveys are published and made available to residents, along with the action that is being taken to address any specific issues identified in the consultation. The AQAA says that the views of residents are actively sought in regular group and individual meetings. The views of other stakeholders (for example health professionals, families and advocates) in regard to how the home is achieving goals for service users are now being sought, as recommended in the previous inspection report. The result of this area of consultation is not yet available. The registered provider and director of care have both visited the service to conduct monitoring visits. The quality of feedback given to the registered manager is variable, some reports are brief and some are detailed. (See requirement 8) Records are kept of any incident. Examination of these records indicates that an incident took place with one resident, in the presence of other residents, becoming very challenging and verbally threatening, resulting in staff having to lock themselves in a kitchen. The residents CPN was notified but the Commission was not. The home has notified the Commission and placing authority of other events as required. (See requirement 9) A record is kept of any accident, and action taken as a result. This includes use of emergency services as required (for example, calling an ambulance). Steps are taken to ensure environmental safety; such as risk assessment and having gas and electrical equipment professionally safety tested each year. There are regular fire evacuation drills and tests to make sure that the fire detection equipment is working properly. Employers Liability Insurance is in place and the certificate displayed in the staff office and the registration certificate is displayed in the office. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 X 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 X 26 2 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 2 X Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The registered person must ensure that written care plans are dated and agreed by residents. The registered person must ensure that advised dental treatment for one resident (who lacks capacity) is discussed with the relevant health professionals and the placing authority social worker, in the resident’s best interests, if necessary. The registered person must ensure that there is clear feedback to people who make complaints about what has been done to address their complaint. The registered person must ensure that people are able to regulate and adjust the temperature of the central heating in their own bedrooms. The registered person must not employ staff in the home unless evidence of all appropriate DS0000022747.V345037.R01.S.doc Timescale for action 30/11/07 2. YA6 YA7 15 30/11/07 3. YA19 13 30/11/07 4. YA22 22 30/11/07 5. YA24 YA26 23 30/11/07 6. YA34 19 30/11/07 Park View (Streatham) Version 5.2 Page 27 7. YA37 10(3) recruitment checks have been obtained. Checks must be in accordance with Regulation 19 and Schedule 2 of the Care Homes Regulations 2001. The registered person must 30/11/07 ensure that the registered home manager undertakes appropriate training in NVQ level 4 and the Registered Managers Award, or equivalent courses. Although there is some progress, this previous requirement is not met. 8. YA39 26 9. YA42 37 The registered person, or responsible individual, must visit the service in accordance with Regulation 26, to monitor the quality of the service being provided. Copies of the reports on the findings of the monthly, unannounced visits must be supplied to the registered manager and to the Commission. The registered person must notify the Commission of any event in the care home in accordance with Regulation 37. 30/11/07 30/09/07 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 YA7 YA9 Good Practice Recommendations The registered persons should assist residents to find out about and participate in local independent advocacy/self advocacy groups. The registered persons should implement the use of the recently developed ‘risks around activities of daily living’ DS0000022747.V345037.R01.S.doc Version 5.2 Page 28 Park View (Streatham) 3. 4. 5. YA14 YA14 YA25 6. YA28 assessment tool so that residents and staff are clear about areas of support required. The registered person should ensure that residents have access to, and choose from a range of, appropriate leisure activities including an annual seven-day holiday. The registered person should review the current range of structured activities available to residents. The registered person should ensure that service users who are currently sharing a bedroom are offered the option of a single bedroom when a room becomes available. The registered persons should take steps to ensure compliance with recent changes in legislation about smoking in communal areas and protect residents from passive smoking. Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 29 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 Park View (Streatham) DS0000022747.V345037.R01.S.doc Version 5.2 Page 30 - 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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