Inspection on 07/01/08 for Pinfold Home

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinfold Home 14/03/07

Pinfold Home 12/12/05

Pinfold Home 11/08/05

Pinfold Home 10/11/04

Pinfold Home 27/07/04

Pinfold Home 25/03/04

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

CARE HOME ADULTS 18-65 Pinfold Home 35-37 Pinfold Road Streatham London SW16 2SL Lead Inspector Lynne Field Unannounced Inspection 7th & 11th January 2008 10:00 DS0000022748.V353710.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 DS0000022748.V353710.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. DS0000022748.V353710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinfold Home Address 35-37 Pinfold Road Streatham London SW16 2SL 020 8769 7869 020 8677 9529 info@astrahomes.co.uk www.astrahomes.co.uk Mrs C Freeman 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) Marie Veronica Stuart Agwunobi Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places DS0000022748.V353710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2007 Brief Description of the Service: Pinfold is a care home set in a large Edwardian building converted from two houses. They have been specially adapted and are connected internally to form spacious accommodation. The home is laid out over three floors. It is located in a residential street within a short walking distance of full community facilities in Streatham and very close to public transport. There is limited parking space available in the area. It is a privately owned home first registered in 1989 to provide long-term residential care for people with mental health problems. The home is registered for 21 residents, but now accommodates 18 residents because rooms that were double rooms have been converted to single bedrooms. There are four communal areas, several toilets and bathrooms/showers, a large dining room/conservatory with wide terrace, and a well maintained secluded back garden that includes a patio, lawn and flowerbeds and an abundance of mature trees. The home has it’s own transport. The home is not designed to cater for people with physical disabilities and does not include a passenger lift. The ground floor is wheelchair accessible. The registered provider has recently purchased the house attached to the home and it is internally connected to the main home. It has been completely redeveloped to create seven small bed-sits with a small kitchen bathing facilities. This in the process of being registered by the registration team. The registered manager said the current fees payable for each resident is in the range of £450-00 to £750-00 per week according to the assessment of needs of the resident. DS0000022748.V353710.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was unannounced and was carried out over two days in January 2008. The registered manager was present on the second day of the inspection. On the first day a senior support worker who facilitated the inspection and showed me around the home. This included the new part of the home that is not occupied at the present time. I spoke to ten residents and three support staff, one domestic staff and the cook. Residents and staff files were viewed and two residents were case tracked. On the second day I met the registered manager. I checked records on care plans, medication records and the complaints book and was able to access confidential documents the senior carer did not have access to on the first day of the inspection. The registered manager told me about the recent developments in the home and how the service was being developed. The increased staffing levels were still in place to ensure residents are able to access the community activities with support when necessary. During a tour of the home the residents told me they liked living at the home. One resident said it had taken him some time to settle in but he “liked it here”. All the communal areas and bedrooms have been redecorated in the last year and are now no smoking areas. This had been discussed at a number of residents meetings and staff meetings before the decision was made to go ahead with this. What the service does well: The service continues to promote independence and provides good support for residents who have mental health problems. The registered manager is enthusiastic and hard working and motivates the staff team. All residents are admitted with a full assessment of care needs and only admitted if the home feels they are able to meet the service user needs. Residents are encouraged to participate in the running of the home and are consulted on issues that are relevant to them through service user meetings. DS0000022748.V353710.R01.S.doc Version 5.2 Page 6 Staff have or are working towards NVQ level 2 or 3. What has improved since the last inspection? 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. DS0000022748.V353710.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 DS0000022748.V353710.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good effective assessment methods, which allow essential information for each new resident to be obtained so that staff can go on to provide a service geared to their needs. The residents who are new to the home are introduced gradually and are carefully assessed in such a way that a service tailored to meet their needs is provided through a trial system and via communication with relevant professionals. EVIDENCE: The home has a statement of purpose and a service users’ guide, which includes the complaints procedure in the service users’ guide. I was given a copy and saw this had been reviewed and up dated in April 2007. The registered manager said each person is given a copy before they are admitted to the home and there is a copy in their room. The home’s admissions procedure states: “care management assessments are required for all prospective residents including personal and medical histories before residents are considered”. DS0000022748.V353710.R01.S.doc Version 5.2 Page 9 The registered manager told me she visits a prospective resident who had recently been admitted to the home to carry out a full assessment before they decided to live at the home. The home has a meeting to discuss whether they can meet the resident’s needs. The registered manager said she might visit the prospective resident several times to make sure the home could meet their needs before agreeing to admit them to the home. The registered manager again said she “would not agree to a block booking contract because she would not take anyone just because they were sent”. Copies of the assessments were seen on each residents file. The residents are invited to visit the home with family members or friends to help them decide if the home could meet their needs. The resident is initially accommodated on a trial period basis of three months. During this time there would be monthly reviews and if at or before that time either the resident or the home decide a permanent residency would not be satisfactory, the residency would be would be terminated in writing. One resident had been admitted recently and their file had copies of the assessment based on personal history and a full needs assessment. The resident said he like the home and had settled in now. The home holds assessments by health and social services professionals which it uses to demonstrate how needs can be met, and plan the care of the resident. DS0000022748.V353710.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are detailed, flexible and regularly reviewed care plans which set out how they are working with residents to meet their needs but these need to be reviewed within the appropriate time scales. Residents living in the home are included in the process of compiling care plans and risk assessments where possible as well as in decision making. EVIDENCE: I chose three residents to case track and looked at their files. One was of a resident who has been admitted since the last inspection in March 2007. Care plans give a thorough description of residents’ behaviours, reactions and preferences and how the resident was to be treated but needed to be updated. The registered manager said she was in the process of doing this. Other residents care plans and risk assessments were due to be reviewed and up dated but this had not happened. The registered manager had just come back DS0000022748.V353710.R01.S.doc Version 5.2 Page 11 from holiday. As there is no deputy manager this had to wait until the registered manager had come back from holiday. I was told that where appropriate the specialist rehabilitation team would be involved in setting up the care plans. OnThere were copies of the social history on file, the resident’s psychological state and triggers of identified behaviour problems. There were copies of risk management on files of the residents inspected. The registered manager told the inspector the residents’ assessments identified their needs such as one to one support where challenging behaviour may occur or they need to be supported to go to activities outside the home and an extra member of staff would be needed to take them. Care plans that were inspected gave a thorough description of residents’ behaviours, reactions and preferences and how the resident was to be treated. There were written agreements on file that staff could monitor their money and medication. The resident and the registered manager had signed this. The registered manager and the resident had signed all the care plans that I viewed. The registered manager told me that a best interest meeting had been held for one resident. This had been called because the residents mother did not want certain information to be passed on to them by the home but wanted the resident to return to their home so the information could be given to them there. A copy of the out come was seen on file. I spoke to ten residents during the course of the inspection. One who had recently moved in said “it had taken some time for him to settle in but he liked the home very much”. He said it “was a lovely home”. Another resident who had lived in the home for a number of years said, “he had all he wanted” and “the food was good”. DS0000022748.V353710.R01.S.doc Version 5.2 Page 12 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): 11,12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff allow and encourage people living at the home to take part in a range of activities both internally and externally. They also support people to maintain contact with friends and relatives and to start to develop independent skills. EVIDENCE: The home employs an activities coordinator to help residents plan their day who was on leave during the inspection. I was told that staff also get involved with planning or taking part in activities but the activities coordinator oversees the activities and makes sure they take place and are appropriate for each resident. The home has an art room and a manual therapist who comes in to do art therapy and exercises with the residents. One resident was given the opportunity to be supported to do work experience but he did not want to go. DS0000022748.V353710.R01.S.doc Version 5.2 Page 13 Another resident refuses to go out. This is documented and a record of this is kept on the residents file. I noted that other residents attend a local day centre where they take part in cookery and art therapy sessions. Residents have individual activities programmes and take part in the running of the home, which includes household chores and responsibilities. The residents are encouraged to develop daily living skills and social skills in an enjoyable way. They clean their bedrooms, change their bed linen, do their laundry and sometimes cook themselves a meal with the support of the staff team. One resident has an eating disorder and the psychologist continues to work with them. There is a programme in place to try to minimise their food intake and the agreement is recorded and signed by the resident and manager. The inspector met ten residents during the inspection. Some were in the tearoom, where they have access to tea and coffee making facilities. There are cold drinks available there too. The registered manager said other residents were out following their activities programmes either on their own or with the support of staff. The home has a board in the hall that indicates who is in and who is out. I noticed four residents were out when I arrived and observed residents changing the board when they came in. Five residents were in the lounge. All said they liked living at the home and felt comfortable there. The home had a lively feel to it and there was lots of coming and going. One resident who has relatives who lived abroad, had stayed with at Christmas time. I was told arrangements had been made with the airline and the member of staff who took the resident to the airport stayed with the resident until the flight was called. Risk assessments were on file for this and it was agreed with the relevant professionals. I asked how the implementation of the no smoking rule in July 2007 and restricting smoking to designated areas in the home was going. The registered manager told me residents on the whole have a positive attitude about this but some residents were not keen to go out side to smoke. She hoped this would improve when the weather was better and said they continued to discuss this at resident meetings. Residents said they were able to choose what they wanted to eat. Each week the residents are asked to make suggestions for next week’s menu. The inspector was shown the copy of the menu suggestions that residents wanted to be included on next week’s menu. The inspector noted the meals are nutritious and well balanced with lots of choice to suit the diverse range of residents living at the home. Several residents are part of the healthy living group that promotes healthy eating. Menus are discussed at the residents meetings and at team meetings and all residents get a chance to comment on the food. DS0000022748.V353710.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. The manager and staff have been successful in making referrals to other professionals and specialists who can provide additional support. Residents administer and control their own medication where appropriate and are protected by the homes policies and procedures for dealing with medicines. Medication administration was found to be properly documented and is handled safely. EVIDENCE: I checked three residents care files. These contained all the information staff would need to support the residents in their preferred personal care routines and there are details of how much help an individual requires with different personal care tasks. DS0000022748.V353710.R01.S.doc Version 5.2 Page 15 In each residents file there is a copy of their medical history, a health assessment that has been done by the home and health action plan kept on file. There is a record of health appointments attended that indicates that the resident is supported by staff, if this is what the resident requires, to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. This included the outcome of the appointment. There are records of weekly blood tests and other medical conditions that require appointments a various hospitals for a number of residents. The All three residents files checked had placement reviews on file by the placement and monitoring service team at appropriate intervals. They deal with assessing and reviewing the home and residents care and support offered and given by the home then follow through any needs that are highlighted as not being met by the home at the reviews. The registered manager told me all residents are in the process of having their placement reviewed as part of the local authority’s mental health strategy. I was told the local optician comes into the home to test resident’s eyes and the residents visit the dentist when they need to. Records of these visits and outcome are recorded in the resident’s medical notes. Resident medication is stored securely in a locked medication cabinet in the staff office. One resident gets his own medication prescriptions from his GP and fills his own dosset box. Another resident has a weekly blood test and gets a weekly supply of medication, which he collects. The GP and the supplying pharmacist monitor this. The inspector checked two residents’ medication with the registered manager and all were found to be correct. All medication coming into the home is recorded. The registered manager audits PRN medication, general medication stock records and disposal of medication on a weekly basis. DS0000022748.V353710.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views are listened to and acted upon and there are safeguards in place to protect them from abuse, neglect and self-harm. EVIDENCE: The home has a complaints policy, a copy of which is in the residents’ guide. The inspector saw the complaints book and one complaint had been recorded. This was made by one resident about another resident’s behaviour. The registered manager described how she dealt with it by speaking to the resident the complaint was made against. A copy of the outcome was recorded in the complaints book and in the resident’s file. I noted that the complaints book is checked during the registered persons visits and they as well as the registered manager follow up any complaint. One resident told me they had made a complaint to the manager about an incident that had happened when the manager was on annual leave. The manager said she was investigating the complaint by speaking to the staff and the resident about what had happened and would record the outcome. The inspector was told the home’s administrator is the appointee for two residents. Two other residents have independent trustees. Each resident has a separate account and a record of his or her money is kept. The inspector observed how staff and residents recorded financial transactions and noted the financial records and money are locked away. All receipts are kept. Residents DS0000022748.V353710.R01.S.doc Version 5.2 Page 17 are able to access their money at any time should they wish to do so. One resident has a financial agreement on in their care plan that was agreed and signed by the resident and appropriate professionals as well as at the residents review meeting. There is an adult protection policy and procedure in the home as well as a copy of the local authorities POVA policy and procedure. All staff has been trained in adult protection in the past and the home has refresher training in adult protection on the training programme. DS0000022748.V353710.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A pleasant, welcoming and comfortable home is provided for the residents. Recent redecoration and adjustments have improved the facilities and further improvement work is planned. The home is bright, clean, comfortable and safe. Residents’ rooms are comfortable and are decorated to reflect their personalities. The ground floor communal areas and bedroom are accessible to people with mobility needs. EVIDENCE: The home originally consisted of two large adjoining Edwardian houses. The home is laid out over three floors. All the stairs and landings have recently DS0000022748.V353710.R01.S.doc Version 5.2 Page 19 been redecorated and carpets have been replaced making the home look warm and homely. The home has a communal lounge on the ground floor and a lounge in the basement that is used by the smokers of the home. There is a small kitchen in this area where residents can make a drink and another small kitchen just off the dinning room that is used by residents when they want to cook themselves a meal. Next to this is the activities room that is used for meetings and art projects as well as other activities, such as games. The large conservatory at the rear of the home is used as the dining room and I noticed all the dining tables and chairs have just been replaced. The proprietor has recently purchased a third house that is adjoining the home. I was given a tour of the building including the new part. This has been developed to provide accommodation for seven extra residents. Each resident could live independently and would have bedroom with a sitting area, kitchen and bathing facilities. The new part of the home has been taken back to the shell of the building and completely redesigned and rebuilt to a very high standard. Furniture and fittings are of a high quality and the decoration is stylish. This is the process of being registered by the registration team. In the original part of the home the resident’s bedrooms are comfortable and individually decorated and furnished. All the bedrooms have been redecorated in the last year. All the toilets and bathrooms have been redecorated in the last year. Three residents bedrooms have been completely refurbished to include en suite facilities. There are two bathrooms/shower rooms and toilets on each of the three floors. The home is clean and bright. All the bedrooms seen during the tour of the house were individual and homely. The home is unsuitable for individuals with impaired mobility, except the ground floor. One resident with restricted mobility has been allocated a bedroom on the ground floor. Suitable adaptations in the form of handrails have been provided to ensure and enable residents to mobilise independently. I was told there is a rolling programme of maintenance and re-decoration of the premises. A more powerful kitchen hood extractor fan was installed to help improve the heat and smoke extraction from the kitchen and cut down the false fire detection incidents. The LFEPA visited the home in October 2007 found the home to be satisfactory. DS0000022748.V353710.R01.S.doc Version 5.2 Page 20 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): 31,32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels have been reviewed to ensure there is enough staff on duty to meet the assessed needs of the residents. Recruitment arrangements are good and residents individual and joint needs are met by appropriately trained staff. There is a friendly, motivated and competent staff team and staff has regular supervision and are supported in their work. EVIDENCE: I met three support staff, one domestic staff and the cook during the course of the inspection. The staff I met told me they like working at the home and felt the management were very supportive. On the first day of the inspection the registered manager was still on annual leave and the senior support worker who was on duty that day and was responsible for the running of the shift facilitated the inspection. I checked the rota and noted there is always three staff on duty at the home in the daytime. The home has not appointed a DS0000022748.V353710.R01.S.doc Version 5.2 Page 21 deputy manager since the previous deputy left. Although the registered person is available during this time and calls in regularly there is no other person on the premises who is officially accountable or whom the registered manager can hand over the day to day business of the running of the home to when she is away or on annual leave. Now the home is to have more residents who will have different care needs it would be good practice to appoint a deputy manager to share the responsibility of running and managing the home. See Recommendations. I noticed throughout the inspection staff were interacting well with residents and in a positive way. The qualities I saw included good listening skills, a calm and confident manner, and a good grasp of the basic areas of need they needed to meet, including communication. Four staff files were examined including two new members of staff. These included copies of the application forms, two written references, a signed copy of their contract stating terms and conditions and identification. All files were checked for CRBs and all had CRB checks and all were correct. New staff under went an induction program and this was recorded on their files. The homes staff team are continuing to make good progress in attaining the required percentage of NVQ qualified staff. Four staff has already achieved an NVQ in Care at level 2 or 3. Staff records showed three staff underwent staff induction for NVQ level 2. They started college in September 2007. Three staff attended a health and safety course. Training records are on file but a training matrix would be help the home have an over view of training that has been completed and when staff are due to have refresher training. Copies of certificates and confirmation of training, such as NVQ level 2 and 3 that has been undertaken and this was held on individual staff files. Staff had regular signed supervision every month and there were copies appraisals on file. I noted that there had been an impromptu staff meeting to gather staff views on some aspects of running the home. These included improvements to staff areas, holidays and training as well as precautions to be taken to prevent infections being carries from hospital to the home when a resident is discharged. I saw copies of staff meeting minutes that are held every two months. The registered manager told me they were planning to hold them every month in future. DS0000022748.V353710.R01.S.doc Version 5.2 Page 22 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): 37,38,39,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team is lead by a capable, experienced manager who runs the home well. The manager has brought continuity, leadership and good levels of communication to the work of the home and this benefits the people using the service. The formal appointment of a deputy manager would be of benefit and support to the registered manager and indirectly the residents. EVIDENCE: DS0000022748.V353710.R01.S.doc Version 5.2 Page 23 On the first day of the inspection the registered manager had not returned from annual leave. I returned the following week to see her and finish the inspection. I was unable to access confidential documents on the first day of the inspection because there was no one in the position of authority to allow me access. As stated above, in a home of this size there needs to be a formally appointed deputy manager to assist in the running of the home and is accountable for the management of the home when the registered manager is not available. The registered manager has strong leadership skills and this combined with her commitment and drive has ensured that policies and procedures of the home are adhered to and that the terms and conditions of the contracts issued to residents are fulfilled. Staff and residents continue to say they have confidence in the registered manager. I am always impressed by they way she is always professional and conscientious in her approach to her work and to the most difficult of residents. I was told that she prioritises her workload to ensure their needs are met. I was told senior staff have taken on more responsibilities within the home and this has eased the burden on the registered manager but I noted it would help to have someone formally in a position of authority who could develop professionally to fill the role of deputy manager. An appointment of a deputy is particularly relevant when the home is developing its service and increasing the numbers of residents living in the home. The residents meetings have lapsed in the past few months. These need to be reinstated. I was told the registered manager had asked key workers to set these up but it has not happened. I was shown the records of the home’s health and safety and equipment checks. The records the inspector viewed indicated the home’s health and safety services and equipment have been checked, serviced and maintained at the appropriate intervals apart from checking water temperatures. Each room has a risk assessment and this is reviewed every three months. The inspector checked the fire records and precautions. There was a copy of the fire certificate floor plan and risk assessment on file. The inspector noted the break alarms are being tested weekly and fire-fighting equipment has been checked regularly. Fire drills have been carried out with all the residents at various times of day on different days, ensuring all staff have taken part in fire drills over the course of six months and there is a record of the date and time drills have been carried out. The records of monthly visits by the registered provider have been submitted to the CSCI. The registered provider is doing these inspections and sending copies of the reports of monthly visits made to the home. DS0000022748.V353710.R01.S.doc Version 5.2 Page 24 DS0000022748.V353710.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 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 3 X X 3 DS0000022748.V353710.R01.S.doc Version 5.2 Page 26 No 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 YA6 Regulation 15 Requirement The registered person must ensure that all residents care plans are regularly reviewed and up dated on time. Timescale for action 28/02/08 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 YA35 YA43 Good Practice Recommendations A staff training matrix would help the registered manager and staff have an over view of training under taken and when refresher training is due. The home and registered manager would benefit from the appointment of a deputy manager. DS0000022748.V353710.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000022748.V353710.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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