Inspection on 30/08/07 for Pathways

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pathways 09/08/06

Pathways 07/03/06

Pathways 07/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Pathways 11 Gloucester Drive Hackney London N4 2LE Lead Inspector Rob Cole Unannounced Inspection 30th August 2007 10:00 Pathways DS0000065292.V349119.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 Pathways DS0000065292.V349119.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. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pathways Address 11 Gloucester Drive Hackney London N4 2LE 020 8800 2619 020 8802 6862 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) www.pathwayscare.net Care Support Service Ltd trading as `Pathways` Ms Joanna Mary Brunt Care Home 8 Category(ies) of Learning disability (9) registration, with number of places Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service user with a Learning Disability aged 16-60 years, can be accommodated within the home. 9th August 2006 Date of last inspection Brief Description of the Service: 11 Gloucester Rd is registered with the Commission for Social Care Inspection to provide care and accommodation for eight adults who have learning disabilities and was registered in July 2004. The home is in a quiet residential road in the Finsbury Park area of the London Borough of Hackney and is well positioned to access a range of community amenities, local parks and transport links. The aim of the home is to provide a specialised service in working with service users with complex needs, in particular challenging behaviour and autism. The current rate of fees charged by the home is £226 per day. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 30/08/07 and was unannounced. The inspector had the opportunity of spending time with service users, and of speaking to staff. The homes acting manager was present for much of the inspection, and the homes area manager was also present for the first part of the inspection. Service users at the home have complex communication needs, including very limited speech. Therefore, the inspector was unable to talk directly with service users. However, they were able to spend time with service users, and observe staff interactions with service users. This helped produce evidence to help inform judgements made within this report. The inspection also included an examination of records and other documents, and a tour of the premisis. The home also completed an Annual Quality Assurance Assessment prior to the inspection at the request of the CSCI. This formed part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still some areas that must be addressed. In particular, the homes physical environment is in a very poor state, and a considerable amount of work needs to be done before it is line with National Minimum Standards. Other areas of concern include the lack of staff training around autism and epilepsy. The home must ensure that comprehensive pre admission Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 6 assessments are carried out on any prospective service users, to help ensure that the home can meet their needs. 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. Pathways DS0000065292.V349119.R01.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 Pathways DS0000065292.V349119.R01.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): 1,2,3,4 and 5. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that prospective service users are provided with sufficient information about the home, through written documentation and the opportunity of visiting the home, the home must ensure that it carries out pre admission assessments, to ensure that it can meet the needs of any prospective service users. EVIDENCE: The home has a Statement of Purpose and Service Users Guide in place. The Statement says that the mission statement for the home is “Providing support, care and accommodation for people with complex needs, through creative individualised therapeutic approaches.” The Statement includes the aims and objectives of the home, and the arrangements made for the involvement of service users in the running of the home, and details of the homes physical environment. The Service User Guide has been produced in plain English, and also pictorial form, t help make it more accessible to service users, and to meet their needs Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 9 with regard to equalities and diversity issues. The Guide contains details of the homes complaints procedure and of the social and leisure activities available. Both the Statement and the service User guide were found to be in line with National Minimum Standards (NMS). Individual contracts/statements of terms and conditions were in place for all service users. These included details of fees payable and the conditions of occupancy. Contracts have been signed by the service users and a representative of the home. There was evidence that the home is able to meet the collective and individual needs of service users. Staff spoken to had a good understanding of the needs of individual service users. All four of the current service users have autism, and the home is currently working with the National Autistic Society, and are in the process of gaining accreditation from them. At the time of inspection the home had four vacancies. However, the area manager informed the inspector that there were no immediate plans to fill these vacancies until the home has undergone a programme of refurbishment and redecoration. The home has a comprehensive admissions procedure. This states that pre admission assessments will be carried out for any prospective service users, and that they will have the opportunity of visiting the home prior to making a decision as to move in or not. There has been one new admission to the home since the previous inspection. They initially moved into the home on a respite basis, but this is now under review, with a view to the move becoming permanent. However, there was no evidence that any pre admission assessment was carried out for this service user. Staff on duty during the course of the inspection were unable to confirm if such an assessment had been carried out, and there was no documentary evidence available to indicate that an assessment had taken place. To help ensure that the home is able to meet the needs of any prospective service users, it is required that they first carry out a comprehensive assessment of their needs, prior to them moving into the home. Pathways DS0000065292.V349119.R01.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): 6,7,8,9 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users have a large measure of control over their daily lives, and that they are involved in the day to day running of the home. However, it is required that care plans are subject to regular review. EVIDENCE: Individual care plans are in place for all service users. These are generally of a good standard, clear and comprehensive, and containing detailed information on how the home is able to meet the needs of service users. Care plans cover need associated with personal care, health, social and leisure needs and needs around equalities and diversity issues, such as around disabilities and culture. Plans indicate that the home strives to promote and develop the independence of service users, for example detailing that service users are supported to get their own breakfast, and manage their own personal care as much as possible. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 11 The AQAA supplied by the home stated that care plans are to be subject to six monthly reviews. However, this is not the case for all plans. One plan has not been subject to review since the 31/01/07, while another plan has not been reviewed within the past twelve months. To help ensure that the home continues to be able to meet the changing needs of service users, it is required that all care plans are subject to regular review, at least once every six months. Risk assessments are in place for all service users. These are of a satisfactory standard, and subject to regular review. Assessments identify any potential risks, and include strategies to manage and reduce these risks, and include risks associated with epilepsy, accessing the community and the use of kitchen utensils. Risk assessments make clear that service users are supported to take reasonable risks. For example, it has been assessed that one service user poses a risk whilst travelling in the homes vehicle, but that on occasions they like to use this vehicle. Consequently an assessment has been carried out which reduces any risk, which includes them sitting in the back seat behind the front passenger seat, making sure that no one sits in front of them, and that a member of staff always sits next to them. One service user has a history of challenging behaviour, including the use of violence towards other people. The home has a clear policy in place on the use of restraint, which says that on occasions it may be used as a last resort, but only by staff who have had appropriate training. The acting manager informed the inspector that most of the staff team have had such training. The AQAA supplied by the home indicated that on one occasion in the past year restraint had been used, and this was by trained staff. The guidelines for the person on whom the restraint was used gave quite clear and detailed information on how the home was to manage any challenging behaviours they presented, and the various strategies to be used to prevent any escalation of challenging behaviours. As far as it went, the inspector considered it to be a helpful and relevant document. However, it made no mention of the use of restraint, or that on occasions this was to be used as part of the strategy to manage this individuals behaviour. It is required that where there is the potential for staff to use restraint, details of this are clearly recorded in any guidelines around managing their behaviour. Through observation and discussion there was evidence that service users are involved in the day to day routines of the home, for instance keeping their bedrooms tidy, helping with their laundry and preparing meals. This is in line with their care plans. Service users have a large measure of control over their daily lives, for example when to get up, what to wear etc. On the day of inspection two service users indicated that they would like to go out, and staff were then seen to facilitate this. All service users have a designated keyworker in place, the acting manager informed the inspector that they will try to match keyworkers with service users whom the share similar interests with. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 12 There was evidence that service users are involved in the day to day running of the home. Service users have weekly one to one meetings with their keyworkers, where they are able to discuss any issues of interest or importance to them. The home holds occasional service user meetings, the acting manager informed the inspector that it is planned that these will happen monthly, although only one has taken place since march of this year. Meetings include discussions on activities and menus. It is recommended that the home holds regular monthly service user meetings, which are minuted. The acting manager informed the inspector that it is planned that service users will be involved in choosing new décor for the home. The home has a confidentiality policy in place, this makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Confidential records are stored in a locked filing cabinet, staff and service users can have access to these records as appropriate. Pathways DS0000065292.V349119.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): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives. Service users have regular access to the local community, and the quality of food provided is satisfactory. EVIDENCE: There was evidence that service users have routine access to the local community. One service user attends a local college, where they study daily living skills including cooking and gardening. Another service user attends a day service, where they have access to music therapy and sensory sessions. Service users use public transport, including buses and trains, and the home has its own unmarked vehicle that service users use to access the community. Service users also access various other community facilities, including shops, parks and a leisure centre, where service users use the trampoline. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 14 Service users have access to a variety of social and leisure activities, both in house and in the community. In the community service users visit cafes and restaurants, go swimming, attend festivals and go to pubs. It is planned to start taking one service user to a Greek pub, which has traditional Greek music nights, to help meet his needs with regard to equalities and diversity issues. This service users needs are also met by his family supporting them to attend a Greek Orthodox Church. They are also supported to visit a nearby Greek record store to buy CD’s of Greek music. The home arranges various day trips, and recent trips have been to Alexander palace, Hampstead Heath and London Zoo. Service users are supported to go on holidays, two service users went to Centreparks, the home was able to demonstrate that this holiday had been planned around the needs of the service users. On the day of inspection, two service users went out for lunch, while another went horse riding. In house, service users have access to a visiting aromatherapist (who visited the home on the day of inspection), and a visiting music therapist. One of the staff at the home is trained in massage, and provides massages to two service users. Service users have access to TV, videos, music, and various puzzles. The home arranges various parties, including birthday parties and various themed parties, recent parties have included a Caribbean party and a valentines party. Visitors to the home are welcome at any reasonable hour. Service users are also able to visit their families in their family’s homes. Service users can see visitors in private if they so wish, and have access to a telephone. Where service users are unable to read, their keyworkers will go through their post with them. There was evidence that service users are treated with respect and dignity, staff were observed to knock and wait before entering bedrooms, and were seen to interact with service users in a respectful and friendly manner. At times service users made it clear that they wished to be alone, and staff were seen to respect this. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved in choosing the menu, and in food preparation, including buying the food. Menus indicated that the home is able to meet service users equality and diversity needs through food, for example traditional British and Greek meals are offered to service users. Service users are offered three meals a day, including the choice of a cooked breakfast. Drinks and snacks are offered throughout the day, and fresh fruit was available. The kitchen was clean and tidy, and food was appropriately stored. The home tests fridge and freezer temperatures on a daily basis. On the day of inspection, the homes freezer was broken, but the Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 15 acting manager was able to demonstrate that it was planned that a new freezer would be purchased in the near future. The kitchen was kept locked, and service users are not provided with keys. The acting manager informed the inspector this was in part due to the risk of service users injuring themselves or others with kitchen appliances. All food stored in the home is stored in the kitchen. Therefore, service users are denied access to some communal areas of the home, and to their food. It is required that if the home imposes a denial of service users rights, it has a clear written record of why this decision has been taken, and this decision must be subject to regular review. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet the personal and health care needs of service users. Service users have access to health care professionals as appropriate, and medications are administered in line with the homes policies and procedures. EVIDENCE: Care plans indicated that service users are encouraged and supported to manage their own personal care as much as possible. They are able to choose their own clothes to wear, although staff will offer advice on what is appropriate. There is a health action planning in place for all service users, which sets out how the home is to meet their health needs. All service users are registered with a GP, and all have an annual review of their medication in conjunction with their consultant psychiatrist. Records are maintained of medical appointments, including details of any follow up action. Records indicated that Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 17 service users have access to health professionals as appropriate, including members of the Learning Disability Team, including speech and language therapists, occupational therapists and behaviour therapists. Used continence products are disposed of appropriately. The home has a comprehensive policy in place around medication. All staff with responsibility for administering medications must first undertake training. Medications are stored securely in a locked cabinet. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record charts are maintained, those checked by the inspector appeared to be accurate and up to date. Clear protocols are in place for the use of any medications prescribed on a PRN basis. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints procedure in place. This has been produced in both written and pictorial form, to help make it more accessible to service users, and to meet there needs with regard to equalities and diversity issues. The procedure includes timescales for responding to any complaints received, and contact details of the CSCI. All service users are given their own copy of the complaints procedure. However, it is not on display anywhere within the home, and it is recommended that it should be. The home has an adult protection procedure. This was in line with current legislation. However, the home did not have a copy of the Local Authorities adult protection procedure, and must obtain one. All but one of the current staff team have attended adult protection training, the acting manager informed the inspector that it was intended that this person would be taking adult protection training in the near future. Staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Pathways DS0000065292.V349119.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): 24,25,26,27,28,29 and 30. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspectors that the homes physical environment is in a very poor state. It is bleak in appearance, and in some instances it is potentially dangerous. EVIDENCE: The home is located in a quiet residential street in the Finsbury Park area of the London Borough of Hackney. The home s close to shops, public transport networks and other local amenities. The home is built over three floors, and is in keeping with other homes in the vicinity. Communal areas consist of a quiet room, dinning room, two small outdoor areas at the rear of the property, (one of which contains garden furniture), and the kitchen. The home has eight bedrooms, although only four of them were occupied at the time of inspection. One of the bedrooms is ensuite. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 20 Externally, the home appeared reasonably well maintained. However, internally the home’s environment was in a very poor state. This has been highlighted in previous inspection reports, in monthly Regulation 26 visits and by service users through their meetings, and their one to one meetings with their keyworkers. Throughout the home, communal and private spaces are very sparsely decorated, and beak in appearance. There is also a large number of cracks in walls and ceilings, and there were found instances of holes in the walls. Some elements of the environment are potentially unsafe, the carpet is loose at the top of the stairs outside the office, this must be repaired urgently. The home has adequate natural light and ventilation throughout. However, there were no curtains up in the sitting room, which faces out onto a public road, this must be addressed. All service users have their own bedrooms, which have a hand basin fitted. Bedrooms all have central heating, although throughout the home there are several radiators that do not have any protective coverings, and this must be addressed. Bedrooms meet NMS on room size. As already mentioned, the kitchen is kept locked, and the home must provide evidence for the reason for this denial of rights. It was noted that the light in the kitchen did not work, the only light in there was provided by a small lamp, which was wholly inadequate when there was no natural light, and this must be addressed. One of the windows in the kitchen was broken, this must be replaced. The bathroom on the second floor has on occasions flooded, and water has gone through the ceiling and flooded the bedroom directly underneath. This bedroom is currently not in use. On examination it was seen that the ceiling was bowed where it was stained by the flooding. The bathroom above is still in regular use, and the inspector had concerns that this was potentially unsafe. It is required that the home seeks advice from appropriate persons to verify that this bathroom is structurally safe for use. The toilet seat in the downstairs toilet was broken, and not all toilets had working locks with an emergency override device fitted. These issues must be addressed. The inspector was satisfied that the home has sufficient numbers of bathrooms and toilets to meet the needs of service users. It was noted that the home was generally clean and tidy, and that the home has taken steps to reduce the risk of infection, for example staff are provided with protective clothing, such as gloves and aprons. Laundry facilities are suitable in scale to meet the needs of service users, and hand washing facilities were situated around the home. COSHH products were stored securely. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 21 The area manager informed the inspector that funding had been agreed to completely renovate and redecorate the home, and that it was hoped that work would begin within this calendar year. It is required that this work is done, and that the home is in a good state of repair and decoration. Continued failure to comply with requirements around the homes physical environment may lead the CSCI to take enforcement action against the home Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have built up good relations with individual service users. However, service users would further benefit from staff receiving relevant training, for example around autism. EVIDENCE: The home provides 24-hour staffing, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection, and clearly identified who was in charge of the home at any given time. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities. All staff are provided with a copy of their job description. In addition to care staff, the home also employs designated cleaning staff and an administrative assistant. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 23 Staff were observed to interact with service users in a sensitive and respectful manner. Several service users have complex communication needs, including very limited speech. Staff were seen to be able to communicate with service users through various means, including sign language and the use of Makaton. Staff were seen to initiate positive interactions with service users, for example looking through a photo album that belonged to a service user. At times service users made it clear that they wished to be left alone, and staff were seen to respect this. The home has various employment policies in place, including on recruitment and selection and equal opportunities. Staff employment files were examined, these were found to contain references and proof of ID including passports. Files did not contain CRB checks. Some contained a CRB disclosure numbers, but not all. The acting manager informed the inspector that they thought CRB’s were stored centrally by the organisation. It is required that CRB checks are in place for all staff working at the home, and that these are available for the purposes of inspection. Of the eleven care staff employed at the home, four have achieved a relevant care qualification, although the acting manager informed the inspector that it is planned that more staff will be given the opportunity of completing such a qualification. To help ensure that service users are supported by appropriately trained staff, it is required that at least 50 of care staff working in the home achieve an NVQ Level 2 in Care or equivalent qualification. All staff undertakes a structured induction programme on commencing work at the home. This includes a period shadowing more experienced members of staff in a supernumery capacity. Recent staff training has included food hygiene, adult protection, health and safety and Non Violent Crisis Intervention. However, the inspector was disappointed to note that several staff have not had any training around epilepsy or autism. This is despite the fact that all of the current service users have autism, and three of the four have epilepsy. The acting manager informed the inspector that they have requested this training from the organisation that runs the home, but that they have as yet not been offered it. It is required that all care and senior staff in the home attend appropriate training around autism and epilepsy. All staff receive regular formal one to one supervision from one of the homes senior staff. Records are kept of supervision meetings, and staff have access to their records. Supervision records seen by the inspector evidenced discussions around performance, service user issues and training needs. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home has suitable management arrangements in place. EVIDENCE: The homes registered manager is currently on maternity leave. An acting manager has been appointed, who is supported by a deputy manager and two senior support workers. The management team have all individually had several years experience of working in a care setting. The management team presented as been approachable and accessible to both service users and staff. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 25 The inspector checked various policies and procedures, including medication, confidentiality and adult protection, all of which appeared to be in line with NMS. Record keeping within the home was generally of a satisfactory standard, and confidential records are stored securely. Staff supervisions, staff meetings and service user keyworker meetings all contribute to the quality assurance within the home. Copies of previous inspection reports are available to view in the home. The inspector was pleased to note that regular unannounced Regulation 26 visits are now taking place since the last inspection, indeed, one such visit was carried out on the day of inspection. The AQAA provided by the home states that the “Company has just recruited a quality and performance team who will undertake twice yearly assessments of the service and work with the manager to develop action plans to address issues raised from the assessment.” Fire extinguishers were situated around the home, these were last serviced on the 5/6/07. Fire alarms were last serviced on the 21/5/07, although they have not been tested by the home regularly. Records indicated that they were last tested in June 2007, and it is required that fire alarms are tested at least once a week. It is also required that the home holds regular fire drills, at least once every three months. Fridge/freezer and hot water temperatures are checked, and COSHH products were stored securely. The home had in date safety certificates for gas safety, PAT testing and electrical installation. The home had in date employer’s liability insurance cover in place. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 26 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 3 2 1 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 3 26 1 27 1 28 1 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 2 3 Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23 Requirement The registered person must ensure that all of the damaged areas of the home be repaired and decorated. (Timescale 30/11/06 not met) The registered person must ensure that comprehensive pre admission assessments are carried out on any prospective service users prior to them moving into the home, to ensure that the home is able to meet their needs. The registered person must ensure that all service users individual care plans are subject to regular review, at least once every six months. The registered person must ensure that clear guidelines are in place around the use of restraint, for all service users where it has been identified that this may form part of any strategies to manage their behaviour. The registered person must ensure that the reasons for any denials of rights, (including service users right to enter the DS0000065292.V349119.R01.S.doc Timescale for action 31/12/07 2. YA2 14 30/09/07 3. YA6 15 31/10/07 4. YA9 13 31/10/07 5. YA17 13 30/09/07 Pathways Version 5.2 Page 28 6. YA23 13 7. 8. YA24 23 13 and 23 YA24 9. YA24 13 and 23 10. YA24 13 and 23 11. 12. YA26 23 23 YA27 13. YA28 23 14. YA32 18 homes kitchen and help themselves to food) are clearly recorded. Any denials of right must be subject to regular review. The registered person must ensure that the home has a copy of the Local Authorities adult protection procedure. The registered person must ensure that all cracks and holes in ceiling and walls are repaired. The registered person must ensure that the loose carpet on the stairs outside the office is repaired. The registered person must ensure that the floor in the second floor bathroom is structurally safe, and that the bathroom is safe to use. The registered person must ensure that that all radiators in the home are fitted with a protective covering. The registered person must ensure that all bedrooms are decorated to a good standard. The registered person must ensure that the ground floor toilet is fitted with a seat, and that all bathrooms and toilets have working locks, which are fitted with an emergency override device. The registered person must ensure that curtains are fitted in the sitting room. The registered person must ensure that lighting in the kitchen is of an adequate standard. The registered person must ensure that the broken window in the kitchen is replaced. The registered person must ensure that at least 50 of care staff employed at the home have an NVQ Level 2 in Care or DS0000065292.V349119.R01.S.doc 30/09/07 31/12/07 14/09/07 14/09/07 31/12/07 31/12/07 31/10/07 31/10/07 31/12/07 Pathways Version 5.2 Page 29 equivalent qualification. 15. YA34 19 The registered person must 31/10/07 ensure that CRB checks are carried out for all staff working at the home, and that these are available for the purpose of inspection, by persons so authorised to do so. The registered person must 30/11/07 ensure that all care staff working in the home undertake appropriate training around epilepsy and autism. The registered person must 30/09/07 ensure that regular fire drills are carried out at least once every three months, and that the home tests its fire alarms at least once a week. 16. YA35 18 17. YA42 13 and 23 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 YA8 YA22 Good Practice Recommendations It is recommended that the home holds service user meetings at least once a month. It is recommended that the home has a copy of its complaints procedure prominently displayed within the home. Pathways DS0000065292.V349119.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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