Inspection on 15/05/05 for Peel Way

This inspection was carried out on 15th May 2005.

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 21 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 15/12/06

Peel Way 05/10/05

Peel Way 14/06/05

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 15th May to 18th July 2006 10:00 Peel Way DS0000015599.V295107.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 Peel Way DS0000015599.V295107.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. Peel Way DS0000015599.V295107.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 No registered manager. Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Peel Way DS0000015599.V295107.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 visit. Information about the service provided is contained in the service users guide. Peel Way DS0000015599.V295107.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 seven hours and took place from 10 am. 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. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector also attended a staff meeting and met with the regional manager to give some feedback about the inspection and to discuss concerns highlighted during the inspection. Residents have profound disabilities and have a limited capacity After the visit relatives and other professionals were contacted and asked for their opinions of the service. Feedback was received from six relatives and one professional. 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? The monthly monitoring visits have been taking place regularly and reports are now far more detailed and show that the organisations monitoring of the home has improved. The Statement of Purpose and complaints procedure had both been updated so that residents know about the home and also about how to make a complaint. Staffing levels are better than at the time of the last inspection. Peel Way DS0000015599.V295107.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. Peel Way DS0000015599.V295107.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 Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is poor. 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. Residents receive appropriate information about what the home provides and the service that they could expect to receive. The home is not able to meet the assessed needs of all of the residents as identified in pre-admission information. EVIDENCE: The Statement of Purpose and the Service User Guide were examined. The Statement of Purpose has been amended and updated as required by the previous inspection. The Service User Guide has been produced using symbols to make it more accessible to residents than the written version. Therefore appropriate information about the home is available to prospective residents and their relatives. There have not been any new residents admitted since the last inspection. 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 Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 9 using the company standard format. Therefore sufficient information was gathered on a prospective resident to enable the staff team to identify their needs. 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 reviews. Although the staff team have experience of working with people with learning disabilities they have not received training in working with people with mental health problems. In addition the service is not registered to meet the needs of people with mental health problems. Therefore the service was unable to satisfactorily demonstrate that it was able to meet the assessed needs of all of the residents. The registered persons must arrange multi agency reviews to determine if the placement is appropriate for residents with mental health problems. If this is the case the registered persons must apply to be registered for people with mental health problems. See also the section in the report with regard to staffing for more information and requirements for staff training. The newest resident visited the home with his mother before he moved in and he had the opportunity to look around and to meet other people living at the home. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service. Residents’ plans contain detailed information about their needs but these are not always reviewed regularly and therefore residents cannot be sure are all of their current needs will be met. Risk assessments are not always comprehensive or reviewed regularly and therefore residents’ needs may not be being met as safely or as appropriately as needed. Residents’ personal information is safely stored to maintain confidentiality. EVIDENCE: Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 11 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. Three care plans were examined. These contained a lot of information about the individuals needs, likes and dislikes. From these it was apparent that the staff team know the residents well. For example one care plan contained a communication profile that states, “if I refuse to leave my bedroom it means I want to be on my own. If I make loud vocal sounds and jump around it probably means that my pad needs to be changed.” The care plans seen were in different formats. One of these was more detailed and far more person centred. It contained photographs and pictures to assist the person to understand the plan. There was sufficient information available for staff to work with the residents and plans show that staff know the residents well and that they are trying to meet individual needs. However there were gaps and information had not been fully completed or dated. The information in individuals’ plans needs to be fully completed, signed and dated. This will ensure that all staff have correct and full information about individuals. Person centred planning and active support is being rolled in as part of the organisations business plan. However in the interim there does not appear to be a consistent method of developing care plans or of reviewing them. In some cases the support plan is reviewed yearly, others have had person centred planning meetings, CPA (Care Programme Approach) meetings or care management reviews. There was no clear indication that residents and their relatives were involved in these processes. The plans must be reviewed with the resident and other significant people at least every six months and updated to reflect changing needs. This will ensure that up-to-date information is available about residents’ needs. Daily recordings are made about what each person has done and support that they have been given. In some cases these recordings were detailed but others did not give a clear picture. For example “interacted well with staff, in a settled mood.” Daily recordings need to be more specific and detailed and linked to individual plans. This will ensure 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. 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. However some of the risk assessments are not comprehensive and others have not been reviewed regularly. Risk assessments must be comprehensive and must be reviewed regularly to ensure that they are up-to-date. This will mean that risks can be reduced and that the residents’ needs can be met as safely as possible. The previous inspection required that “ where restraint and/or restrictions form Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 12 part of the residents care plan there must be evidence that this has been agreed by professionals who have responsibility for that person, such as a GP or clinical member of the multidisciplinary team. There must also be evidence of the agreement of the next of kin. The registered manager must be able to demonstrate that the use of restraint and restrictions is kept under regular review, and that alternative interventions are considered on an ongoing basis”. Examination of this person’s file found that there was no evidence that this had been done and staff stated that this person has always had these restrictions placed upon him and this has just continued. The requirement has therefore not been met and this must be addressed to ensure that residents are not subjected to restrictions unnecessarily. Residents’ records and other information are stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Therefore residents’ personal information is appropriately kept and their confidences maintained as required by the previous inspection. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12, 13, 14, 15, 16 &17 Quality in this outcome area is adequate. 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 but this is sometimes limited by staffing levels. 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 each week. During the course of the visits some residents had been out for Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 14 lunch and on another occasion to the local stables. Five of the six residents went on holiday to Southern Ireland and said that they enjoyed this. However feedback from some staff was that at times, particularly during the late shift, staffing levels limited activities. See the section on staffing later in this report for a requirement. Residents have been paying staff expenses for some activities and trips and further information about this is in the section on concerns and complaints. 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. 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 as required by the previous inspection. 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. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. 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 needs to be improved to ensure that the service users are given 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. On the day of the visit residents seen looked clean and well dressed. During one visit the majority were wearing their football shirts as England were playing in the World Cup that day. Residents’ personal care needs are 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. A specialist pharmacist inspection was carried out in October 2005 and at the time of this inspection medication records and the Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 16 medication were checked. Medication is stored in an appropriate lockable cabinet in the main office. Examination of the MAR (Medication Administration Record) found any handwritten amendments or additions to Medication Administration Records (MAR) sheets had been signed and dated by the person making the entry as required by the previous inspection. In addition bottles of liquid medication had their opening date written on them also as required by the previous inspection. No medication is covertly administered and references to this had been removed from medication records. Some residents receive PRN (as required) medication and protocols/guidelines are needed for all of these to ensure that all staff know when to give this medication and for what purpose. There are not any detailed guidelines in place on the action to be taken in the event of a medication error occurring and these are needed to ensure that staff are quite clear on the action that must be taken. Specific advice on this was given to the senior at the time of the visit Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is poor. 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. Staff have not received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. Therefore residents are not adequately protected from abuse. Residents’ finances have not been adequately managed or 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. This has been updated to contain details of the Commission as required by the previous inspection. There was one recorded complaint that was made by a resident. This was taken seriously and addressed by the manager. The organisation has recently agreed funding 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 Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 18 stored and checks are made at each handover. However examination of records found that residents are routinely paying for staff meals and other staff expenses. This is not acceptable and must be stopped, as residents do not necessarily have the capacity to make informed decisions about how their money is spent. There should be a service budget to pay for staff expenses. In addition residents must be reimbursed for any expenditure on staff expenses. Representatives of the organisation have stated that there is a separate budget for staff expenses and that residents should not have been paying. They also said that residents would be reimbursed. This will be monitored during future visits to ensure that residents’ finances are being appropriately managed and safeguarded. A record is kept of monies in residents’ bank accounts but these are not checked against statements and residents’ monies are not adequately monitored. For one resident the amount on the statement did not agree with the record sheet. Systems must be put in place to ensure that residents’ finances are recorded and monitored and that regular auditing is carried out. This will assist to protect residents from financial abuse. The previous inspection also required that the staff must have training on the protection of vulnerable adults. Staff spoken to all said they had no concerns about the way residents were treated and cared for but have not all received the adult protection training. This requirement has been made on 2 occasions and not met. This must be addressed by the organisation. Failure to meet unmet requirements impacts on the welfare and safety of service users. Failure to comply by the new date will result in the Commission considering enforcement action. Staff need to have a comprehensive understanding of what constitutes abuse and how to protect residents. A better understanding of this may have meant that staff would have raised concerns about residents’ finances and the appropriateness of residents paying for staff expenses. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is adequate. 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 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. None of the residents require any specialist adaptations. One relative said that the “home is a pleasant environment and is clean”. Bedrooms are personalised according to individuals likes but the flooring in one room is badly stained and needs to be replaced. Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 20 At the time of the visits the home appeared to be clean and was free from offensive odours. Most of the residents were due to go on holiday shortly after the inspection and staff were going to take this opportunity to carry out some “spring cleaning”. A satisfactory food hygiene report was received following an environmental health visit in June 2005. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service. Staff are not receiving all of the necessary training to give them the skills to meet all residents’ current needs and provide an appropriate service for them. Staffing levels do not 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 continuity. Therefore the residents are receiving a service from a consistent group of staff that appear to know them well. The seniors spoken to at the time of the visit were quite clear as to their role and responsibilities as seniors Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 22 but at the time of the first visit there were not any clear management arrangements in place as the manager had transferred to another home the previous week. The section on management gives more information and requirements about this. One of the relatives said, “the staff are very helpful to my son and helped him to settle in, the staff are very good.” One of the residents said, “it is okay here, the staff are okay.” 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 should be on the early shift but this is not always the case. The previous inspection required that staffing levels must be set based on individual care plans and assessed needs. Staff spoken to said that that the staffing levels had improved since last year. However one of the residents requires the support of two staff and therefore this affects staff availability and flexibility to work with other residents both in the home and in the community. From discussions with staff it would appear that staffing levels do limit the development of activities and are not always sufficient to meet residents’ assessed needs. Therefore this requirement remains unmet and the Registered Person needs to address this. 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. However as stated earlier in the report at least one of the residents has mental health needs and staff have not received training in this area as required by previous inspection. The regional manager 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 he said that he has asked the training department to prioritise mental health awareness training for the team. 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. Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 23 The previous inspection required that 50 of the staff team’ must achieve NVQ level 2 in care by the end of 2005. Information supplied in the pre inspection questionnaire indicated that none of the staff team actually have an NVQ qualification but that two staff are working towards this. Therefore this requirement has not been met and the staff team do not hold the required qualifications. Staff meetings have been taking place regularly and the Inspector attended a meeting in June 2006. At this meeting appropriate issues were discussed. Staff spoken to also said that they had been receiving supervision. This means that staff have an opportunity individually and collectively to discuss issues, concerns and the development of the service. Peel Way DS0000015599.V295107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service. The organisation has not robustly supported the manager and staff team to develop and improve the service. There has not been any stability or consistency in the management of the service and this has also affected the development of the service. A safe service is provided to residents. EVIDENCE: The registered manager for the service transferred to another home within the organisation a week before this inspection. Prior to this the home has had fragmented management arrangements. At the start of the visit the management arrangements had not been resolved. Subsequently the Commission was informed that the two seniors would have responsibility jointly for the day-to-day management of the home, but this would not be a formal acting management arrangement. They were to receive additional support from the service manager. The Commission did not consider these Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 25 arrangements to be adequate and following a meeting with the regional manager alternative arrangements were made. The service manager will spend time at the home and also the manager of another service will be based in the home for two days per week. The organisation anticipates that a new manager will be in post sometime in August. The Commission agreed these interim arrangements. However it is extremely important that the staff team receive appropriate and consistent support and that a new manager is in post as soon as possible. Feedback received from a professional connected to the service was “the home appears to be well-run and both staff and residents seemed happy. However I’m not happy with the regular management changes which interfere with consistency in management style”. Discussions with staff indicated that there have been several changes in management. This will have had a detrimental effect on the development of the service. Regular monthly monitoring visits have been taking place and reports of these visits have been sent to the Commission. These reports are now far more detailed and cover all of the necessary areas and show that monitoring of the home has improved. However feedback from a number of staff was that they did not feel that the organisation had given adequate support and that “they are quick to use the stick and not to support ”. The majority of the necessary health and safety checks are carried out and a safe environment is provided for the residents. A food safety inspection was carried out in June 2005 and a satisfactory report was obtained. There have not been any fire drills held since December 2005. The organisations procedure is that fire drills are carried out monthly. A minimum of 4 fire drills must be held each year. It is 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 tested on a monthly basis. Fire alarm call points must be tested each week 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 tested each month but must be checked each week to ensure that they do not exceed the specified 43°C. It is 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. Peel Way DS0000015599.V295107.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 3 3 2 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Peel Way DS0000015599.V295107.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 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. The information in individuals care plans need to be fully completed, signed and dated. Care plans must be reviewed with the resident and other significant people at least every six months and updated to reflect changing needs. Daily recordings need to be more specific and detailed and linked to individual plans. Risk assessments must be comprehensive and must be reviewed regularly to ensure that they are up-to-date. Where restraint and/or restrictions form a part of a residents care plan there must be evidence that this has been agreed by professionals who have responsibility for that person, such as a GP or clinical DS0000015599.V295107.R01.S.doc Timescale for action 30/09/06 2. 3. YA6 YA6 15 15 31/10/06 31/10/06 4. 5. YA6 YA9 15 13 31/10/06 30/09/06 6. YA9 15 & 13 (7) & (8) 31/10/06 Peel Way Version 5.2 Page 28 7. YA20 13 8. YA20 13 9. 10. 11. YA23 YA23 YA23 13 13 13 (6) member of the multi-disciplinary team. There must also be evidence of the agreement of the next of kin. The Registered Manager must be able to demonstrate that the use of restraint and restrictions is kept under regular review, and that alternative interventions are considered on an on-going basis. (Previous timescale of 13/11/05 not met) Individual protocol/guidelines must be in place for the administration of PRN (as required) medication. Detailed guidelines must be in place on the action to be taken in the event of a medication error occurring Staff expenses must be paid for by the organisation. Residents must be reimbursed for any staff expenses that they have financed. All staff must receive adult protection training. (Previous timescales of 25/05/05 & 31/10/05 not met). 31/08/06 31/08/06 31/08/06 30/09/06 31/10/06 12. YA23 13 13. 14. YA26 YA32 16 18 Systems must be put in place to 30/09/06 ensure that residents’ finances are recorded and monitored and that regular auditing is carried out. The stained bedroom carpet 31/10/06 must be replaced. The Registered Persons must 31/10/06 ensure that all staff have training in recognising the on-set of severe mental illness. (Previous timescale of the 31/01/05 not met). 50 of care staff at the home must achieve NVQ level 2 in care by the end of 2005. (Previous times of 31/12/05 not met.) DS0000015599.V295107.R01.S.doc 15. YA32 18 31/12/06 Peel Way Version 5.2 Page 29 16. YA33 18 17. 18. YA35 YA37 18 8 19. 20. 21. YA42 YA42 YA42 23 23 13 Staffing levels must be set based on the individual care plans and assessed needs. (Previous timescale of 30/11/05 not met.) Staff must receive the appropriate training to meet residents assessed needs. A permanent manager must be recruited and an application submitted to the Commission for the manager’s registration. A minimum of 4 fire drills must be held each year. Fire alarm call points must be tested each week Hot water temperatures must be tested each week to ensure that they do not exceed the prescribed safe temperature. 31/10/06 31/12/06 30/09/06 31/12/06 31/08/06 31/08/06 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. 2. Refer to Standard YA42 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 record sheet. Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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 Peel Way DS0000015599.V295107.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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