Inspection on 15/12/06 for Peel Way

This inspection was carried out on 15th December 2006.

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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peel Way 18/09/07

Peel Way 05/10/05

Peel Way 14/06/05

Peel Way 15/05/05

Peel Way 24/02/05

Peel Way 26/08/04

Peel Way 19/03/04

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 Peel Way 6 Peel Way Harold Wood Romford Essex RM3 OPD Lead Inspector Jackie Date Key Unannounced Inspection 15 – 18th December 2006 10:30 th DS0000015599.V323485.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 DS0000015599.V323485.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. DS0000015599.V323485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peel Way Address 6 Peel Way Harold Wood Romford Essex RM3 OPD 01708 386 478 01708 345 478 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) The Avenues Trust Limited *** Post Vacant *** Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000015599.V323485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: 6 Peel Way is a purpose built home for six adults with learning disabilities, situated in Harold Wood, Romford. It is a detached two-storey house with parking space to the side, and an enclosed garden to the rear. There is an open plan lounge/dining area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, both of which have ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each have an ensuite toilet, and share a bathroom. There is a ramp to both front and back entrance, but no lift to the upper floor. The Avenues Trust, a company that has similar homes, both locally and in Kent, runs the home. There are good local transport links, and the home has its own minibus. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, or staff accompanying residents to appointments. At the time of the visit there were 6 men living at the home. Some residents have profound disabilities and limited ability to communicate verbally, whilst others are more independent. The scale of charges is between £1,403 & £1,423 per week. This information was provided in the pre inspection questionnaire received at the time of the previous visit. Information about the service provided is contained in the service users guide. DS0000015599.V323485.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 lasted for about nine hours and took place over two days. The staff and the residents were spoken to. All of the shared rooms and some of the bedrooms were seen. Staff, care and other records were checked. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Other professionals were contacted and asked for their opinions of the service however no feedback was received. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? There has been a lot of improvement since the last inspection. 15 of the 21 requirements from that visit have been met and it is evident that the manager and staff team have been working very hard to improve the service and to meet the requirements from the previous inspection. There is now a new manager in post. The manager and the staff team are working together to develop and improve the service. The organisation are supporting them to do this. Activity plans have been introduced to give residents a more structured day and staffing arrangements have been changed to facilitate the activities. Personal plans have been completed and are up to date as are risk assessments. Therefore staff have current information to enable them to meet residents needs as safely as possible. All of the health and safety checks are being done and therefore the service users live in a safe home. DS0000015599.V323485.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000015599.V323485.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 DS0000015599.V323485.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): 2&3 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The required information is gathered on prospective residents and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. The home is not able to fully meet the assessed needs of all of the residents as identified in pre-admission information. EVIDENCE: There have not been any new residents admitted since 2005. At that time the inspection found that in-depth reports were received from members of the specialist multidisciplinary team for people with learning disabilities. The manager had also carried out a pre admission assessment using the company standard format. Therefore sufficient information was gathered on a prospective resident to enable the staff team to identify their needs. However the information obtained indicated that the individual concerned had, in addition to a mild learning disability, mental health problems, challenging behaviour, and was subject to ongoing CPA (Care Programme Approach) reviews. Other residents also have mental health problems and ongoing CPA DS0000015599.V323485.R01.S.doc Version 5.2 Page 9 reviews. The staff team have experience of working with people with learning disabilities and since the last inspection have received a one day introduction to mental health training course. The service is not registered to meet the needs of people with mental health problems and this has been discussed with the registered provider. Therefore the service was unable to satisfactorily demonstrate that it was able to meet the assessed needs of all of the residents. The registered providers have requested multi agency reviews to determine if the placement is appropriate for residents with mental health problems. However these have not yet happened. The registered provider is following up the request and in the interim an appropriately qualified senior manager carried out an assessment on one of the residents and concluded that he did have a dual diagnosis but that at that time his mental health problem was stabilised. He also concluded that this resident is capable of functioning at a more independent level. The registered provider has decided to apply for registration to provide a service to people with a dual diagnosis of learning disability and mental health problems. Advice on how to do this was given to the manager during the visit. The requirement with regard to multi disciplinary reviews and a change in registration have therefore been restated in this report and the timescale for completion extended to allow for this process to be completed. DS0000015599.V323485.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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents’ plans contain detailed information so that staff can meet their needs. Risk assessments have been reviewed and therefore contain up to date information about residents needs. EVIDENCE: Each resident has an individual plan covering all of the necessary areas. These include health, finance, communication, domestic skills, activities, mobility, diet, personal care, religion and culture. The plans give details of how each person likes and needs to be supported. The degree to which some of the residents can be involved in the development of the plan is very limited due to their profound learning and communication difficulties. Others are able to take an active part in this process. Two care plans were examined. These contained a lot of information about the individuals needs, likes and dislikes. They also had photographs and symbols DS0000015599.V323485.R01.S.doc Version 5.2 Page 11 throughout to make them more user friendly. From these it was apparent that the staff team know the residents well and that a lot of work has been done to develop person centred plans. The plans clearly described how to support the person and what good support would be like. There was sufficient information available for staff to work with the residents and both plans show that staff know the residents well and that they are working to meet individual needs and to provide a more person centred service. In both cases the personal planning books had been updated, fully completed and information dated and signed as required by the previous inspection. This ensures that all staff have correct and full information about individuals. There was evidence that personal planning meeting had been held with the residents and of keyworker meetings. One of the staff has received training to be a PCP (Person Centre Planning) facilitator and other staff will be doing this training in the new year. Although individual plans have been reviewed internally with the residents there has not been reviews with the resident and other significant people as required by the previous inspection. The manager has contacted social services to request the reviews but has been informed that there is a shortage of people available to carry out the reviews. The manager was advised to go ahead, organise reviews and to invite the relevant people. If placing authority/s do not attend minutes should be sent to them along with details of any required action. The timescale for the completion of this requirement has been extended to allow time for this to happen. Daily recordings are made about what each person has done and support that they have been given. Separate night logs are also kept. Daily recordings have been changed in an attempt to reflect what residents have been doing and the care provided to them. A lot of the recording is in the form of tick boxes with additional information being added when needed. The daily records seen gave far more of a picture of what each resident had been doing. For example “assisted with laundry, went to the shop to get his paper”. This should mean that there is detailed information about each resident, which can be used as part of the review process and to identify ongoing and changing needs. Residents meetings have started again and there was also minutes available of a meeting with an independent advocacy service. These show that residents are consulted about what happens in the home and to them. There are risk assessments in place. These identify risks for the residents and staff and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Risk assessments seen were detailed and had been reviewed to ensure that they are up-to-date. This means that risks can be reduced and that the residents’ needs can be met as safely as possible. In some cases restraint and/or restrictions form part of the residents care plan and these have all been reviewed and signed by the manager. For example one resident is offered low alcohol alternative drinks instead of alcoholic drinks, another has his cigarettes “managed” by the staff DS0000015599.V323485.R01.S.doc Version 5.2 Page 12 team. The reasons for this are recorded and have been agreed with the individuals concerned as far as is possible. A third resident has got a full body suit restraint that can be used when required. However the manager said that this has not been necessary for a long time and will ask for this to be reviewed again at his next review to ensure that he is not subjected to restrictions unnecessarily. DS0000015599.V323485.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 &17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The residents are encouraged to take part in activities and to be part of the local community and staffing levels have been adjusted to allow for this. Residents are supported to keep in contact with their relatives and relatives are welcomed at the home. Residents are given meals that meet their needs and individual preferences. EVIDENCE: Four of the residents are more independent than the other two and they assist with chores and with the cooking. The washing machine controls have been colour-coded to assist residents to do their own laundry. One of the residents can travel independently but the others require support from staff. Residents go to a variety of activities and these include a computer club, bowling, pool and out for meals. One resident uses the sensory room at a local day centre. DS0000015599.V323485.R01.S.doc Version 5.2 Page 14 Another resident had been to the Natural History museum. Since the last inspection activity plans have been introduced to give residents a more structured day. The rota is then arranged to facilitate the activities. For example two of the men now go to the sauna and two male staff are rotered to go with them. During the course of the visit some residents went out Christmas shopping and an extra member of staff was on duty to help facilitate this. Five of the six residents went on holiday earlier in the year to Southern Ireland and said that they enjoyed this. They have started to talk about the next holiday when they have decided to go away in smaller groups. Therefore the residents are participating in more activities and having a more interesting lifestyle and staffing levels are now sufficient to allow for this. Most residents have contact with their families in varying degrees. One resident’s mother visits regularly. She said that the staff were very helpful and had helped her son to settle in. Another residents file contains details of family birthdays and there is a note in his individual plan to remind him to send cards. Therefore the residents are supported to maintain their contact with their families. A record is kept of the food that is offered to residents and of what they choose. One of the residents said that the food was good. During the course of the visit some of the residents who were able to, were observed to be encouraged to make their own drinks. In the kitchen there were guidelines for different religions’ foods. For example Hindu, Sikh, Jewish. Some residents are able to indicate what they would like to eat and staff are aware of others preferences. The menu seen appeared to be appropriate and nutritious. DS0000015599.V323485.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 judgment has been made using available evidence including a visit to the service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. The administration and recording of medication is satisfactory and improved guidelines for “when required” medication will ensure that the residents are given any prescribed medication safely. EVIDENCE: The residents require differing amounts of support with their personal care. Some are quite independent but others are dependent on staff to meet their personal care needs. Details of the help that they need and how they prefer to be supported are in their individual plans. The plans also contain information on how to recognise what a resident wants or needs. For example “if I strip off I want attention” “if I gurgle and smile I am happy”. Residents’ personal care needs are met. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular DS0000015599.V323485.R01.S.doc Version 5.2 Page 16 access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. Four of the residents have had “annual health checks” and the home is waiting for the GP or nurse to visit the other two residents at home to carry out their checks. Therefore residents’ health care needs are being met. None of the residents are able to self medicate and medication is administered by staff that have been trained and deemed capable to do this. This is usually a senior or a shift leader. Medication is stored in an appropriate lockable cabinet in the main office. Avenues Trust have developed a new medication policy in consultation with one of the Commissions’ specialist pharmacist inspectors but a copy of this was not available in the home. A copy was given to the manager during the course of the visit. Examination of the MAR (Medication Administration Record) found that these had been appropriately completed and that the medication file contained photographs of each individual and a description of how their medication needed to be administered. It also showed how residents are supported to be a bit more independent by applying cream themselves with support rather than staff automatically doing this. Some residents receive PRN (as required) medication and protocols/guidelines have been developed for these to ensure that all staff know when to give this medication and for what purpose. Some of these guidelines were not clear and contained some ambiguities. For example 5-10 mls, 1 or 2 tablets. Some specific advice about this was given to the manager at the time of the visit and she is know in the process of amending the guidelines. The timescale for completion has been extended to allow for her to liaise with various GP’s and amend the documents. Guidelines are now in place on the action to be taken in the event of a medication error occurring as required by the previous inspection. These are needed to ensure that staff are quite clear on the action that must be taken in the event of an error and were followed by staff when a medication error occurred recently. Overall, medication is appropriately stored and administered and the amended guidelines for the administration of PRN medication will improve safeguards to residents and lessen the risk of error. DS0000015599.V323485.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): 22 & 23 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. There is a complaints procedure, available in a user-friendly format that would be followed in the event of any complaints being made. Residents can be supported to make any complaints by an independent advocacy service. All staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ bank accounts are not being adequately monitored and this places them at risk of financial abuse. EVIDENCE: The organisation has an appropriate complaints procedure and this is available in a user-friendly format. This is included in the service user guide. The organisation has arranged for Havering People First to facilitate advocacy sessions within the home and this will help to ensure that residents views are incorporated into the daily running of the home and service development and that residents are supported to express any concerns or dissatisfaction. A random selection of residents’ finances was checked and cash amounts held agreed with records. Receipts were on file. Residents’ monies are securely stored and checks are made at each handover. At the time of the last DS0000015599.V323485.R01.S.doc Version 5.2 Page 18 inspection it was discovered that residents were routinely paying for staff meals and other staff expenses. This was not acceptable and has been stopped, as residents do not have the capacity to make informed decisions about how their money is spent. There is a service budget to pay for staff expenses. In addition residents are going to be compensated for any expenditure on staff expenses or for any items that should have been purchased by the organisation. The timescale for completion of will be extended to allow for the manager to complete this piece of work. A record is kept of monies in residents’ bank accounts but these are not checked against statements and residents’ monies are not adequately monitored. The manager said that she had been unable to obtain information from banks but the bank agreed appointeeship on the day of the inspection. The manager said that she would now be able to access information about accounts and to introduce a monitoring system for bank accounts. The requirement that systems must be put in place to ensure that residents’ finances are recorded and monitored and that regular auditing is carried out therefore remains outstanding. The timescale for completion will be extended to allow for the manager to make the necessary arrangements and to put the systems in place. This will assist to protect residents from financial abuse. Staff have received protection of vulnerable adults training. They are aware of what constitutes possible abuse and of the action that needs to be taken. This offers more protection to residents who are unlikely to be able to indicate that they have not been treated appropriately and are relying on other people to keep them safe. DS0000015599.V323485.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 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The residents live in a purpose built home that is suitable for their needs. EVIDENCE: 6 Peel Way is a purpose built home for six adults with learning disabilities, situated in Harold Wood, Romford. It is a detached two-storey house with an enclosed garden to the rear. There is an open plan lounge/dining area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, both of which have ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each have an ensuite toilet, and share a bathroom. There is a ramp to both front and back entrances, but no lift to the upper floor. None of the residents require any specialist adaptations. Since the last visit a new fridge/freezer has been purchased as well as new pots, pans and crockery. Some new lamps have also been bought. The manager said that they are in the process of getting quotes to have the hallway painted. DS0000015599.V323485.R01.S.doc Version 5.2 Page 20 Bedrooms are personalised according to individuals likes. One resident is a Manchester United supported and his bedroom reflects this. The badly stained flooring in one room has been replaced as required by the previous inspection. At the time of the visits the home appeared to be clean and was free from offensive odours. DS0000015599.V323485.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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are receiving ongoing training to give them the skills to meet all residents’ current needs and provide an appropriate service for them. Staffing levels and arrangements have improved and do now allow for the development of appropriate activities. Staff are properly recruited and the necessary checks carried out. This helps to protect service users and keep them safe. Staff receive the supervision and support that they need to carry out their duties and to provide an appropriate service to the residents. EVIDENCE: Staff spoken to during this visit demonstrated a sound knowledge of the needs of the residents and were able to describe how they try to meet these on a daily basis. They also confirmed that, with the exception of the manager, there has been a stable staff team and that they are all clear as to their roles. Staff also felt that the residents were used to the staff and benefited from the DS0000015599.V323485.R01.S.doc Version 5.2 Page 22 continuity. Therefore the residents are receiving a service from a consistent group of staff that appear to know them well. One of the residents said, “I am settled here and I like it.” During the visit staff were observed to spend time with residents, talking to them and giving them the support that they needed. There are a minimum of three staff on duty during the daytime shifts and two staff during the night. Four staff are frequently on the shift and this is linked to residents activities. Staff spoken to said that that the staffing levels and arrangements are better and that there is more flexibility to work with residents both in the home and in the community. From discussions with staff it would appear that staffing arrangements and levels and are now sufficient to meet residents’ assessed needs. The staff team all have experience of working with people with learning disabilities. Staff on duty said that they had received training since they started work in the home and that the training programme for the coming year was available and that they have been booked on other courses. A staff training record was available and this showed courses completed and those that staff were booked to attend in the coming months. As stated earlier in the report at least one of the residents has mental health needs and the regional manager has said that one of the main priorities of the organisation’s business plan was the development and implementation of a comprehensive training strategy for staff working in mental health services and that this would include staff working at this home. In the interim staff have received introduction to mental health training. Staff spoken to said that this training had been good and was useful. Three staff are due to start NVQ 2 in January. Therefore the staff team are receiving the training that they need to meet residents’ needs. No requirements have been made at this stage in relation to training and the progress of the mental health training in particular will be monitored during future inspections. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. Staff records are held centrally at the organisations head office in line with an agreement made with the Commission. DS0000015599.V323485.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): 37, 39 & 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and provides a safe environment for the service users. The registered provider monitors the service appropriately to check the quality of the service provided to service users. EVIDENCE: A new manager has been in post since the last inspection and she has started the process to be registered by the Commission. The manager has experience of working with people with learning disabilities and has completed NVQ 3. She has been a senior and an assistant manager at a residential home and has also managed a supported living scheme. She will be undertaking the DS0000015599.V323485.R01.S.doc Version 5.2 Page 24 Registered Managers Award. Since the manager has been in post the requirements from the last inspection are being addressed. Staff feedback that “the service is improving and that staff are clearer where they are going and there is more structure for the residents.” “Things are better organised now”. Staff also said that they feel very well supported by the manager and that the service manager visits regularly and has acknowledged the work that the staff team have done to develop the service and to meet the requirements from the previous inspection. Therefore the service users are benefiting from a well run home. A representative of the organisation carries out monthly unannounced monitoring visits to the home and a report on this visit is left at the home and a copy of this sent to the Commission. The reports cover the necessary areas and indicate any action that is needed. Therefore the quality of the service provided to the service users is monitored by the organisation. The necessary health and safety checks are carried out and a safe environment is provided for the service users. Two fire drills were held in June 2006 but the organisations procedure is that fire drills are carried out monthly. A minimum of 4 fire drills must be held each year and this requirement remains outstanding. It is again recommended that the fire drill record sheet includes information about the time of the fire drill and who was present. This information can then be used to check that fire drills are being carried out at different times of the day and night and also that all staff and residents have taken part in fire drills over a period of time. Fire alarm call points are now tested weekly to ensure that they are working correctly. All of these actions are necessary to minimise the risks in the event of fire. Hot water temperatures are now tested each week to ensure that they do not exceed the specified 43°C. It is again recommended that the prescribed maximum temperature for the hot water and guidelines on what staff should do if the temperature is above 43° C. be on the record sheet. This will ensure that staff are clear about this and will further lessen the risk of scalding to residents. DS0000015599.V323485.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 X 2 3 3 2 4 X 5 X 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X DS0000015599.V323485.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 YA3 Regulation 12,18 Requirement The registered persons must arrange multi agency reviews to determine if the placement is appropriate for the residents living there. If this is the case the home must apply to be registered for people with mental health problems. (Previous timescale of 30/09/06 not met). Care plans must be reviewed with the resident and other significant people at least every six months and updated to reflect changing needs. (Previous timescale of the 31/10/06 not met). Individual protocol/guidelines must be in place for the administration of PRN (as required) medication. (Previous timescale of the 31/08/06 not met). Residents must be reimbursed for any staff expenses that they have financed. (Previous timescale of the 30/09/06 DS0000015599.V323485.R01.S.doc Timescale for action 31/03/07 2. YA6 15 31/03/07 3. YA20 13 31/03/07 4. YA23 13 28/02/07 Version 5.2 Page 27 not met). 5. YA23 13 Systems must be put in place to ensure that residents’ finances are recorded and monitored and that regular auditing is carried out. (Previous timescale of the 30/09/06 not met). A minimum of 4 fire drills must be held each year. 28/02/07 6. YA42 23 31/12/06 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 YA42 Good Practice Recommendations It is recommended that the fire drill record sheet includes information about the time of the fire drill and who was present. It is recommended that the prescribed maximum temperature for the hot water and brief guidelines on what staff should do if the temperature is above 43° C. be on the water temperature record sheet. 2. YA42 DS0000015599.V323485.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000015599.V323485.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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