Inspection on 15/10/07 for Radcliffe House

This inspection was carried out on 15th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Radcliffe House 23/06/06

Radcliffe House 18/11/05

Radcliffe House 28/04/05

Radcliffe House 06/04/04

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

CARE HOME ADULTS 18-65 Radcliffe House 11 Radcliffe Road East Croydon Surrey CR0 5QG Lead Inspector Peter Stanley Key Unannounced Inspection 15th October 2007 9:00 Radcliffe House DS0000025828.V352514.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 Radcliffe House DS0000025828.V352514.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. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radcliffe House Address 11 Radcliffe Road East Croydon Surrey CR0 5QG 020 8680 4586 020 8680 4586 NO EMAIL 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) Quality Care Choice Limited James Oseya Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 23 Date of last inspection Brief Description of the Service: Radcliffe House is set in a large well-maintained garden and has nineteen single and two double bedrooms, in addition to a communal lounge, smoking and dining room. It is a large, converted period mansion, which consists of three floors, plus an attic conversion. The home is conveniently sited for local transport (buses and trams) and is within walking distance of the centre of Croydon. The nearest mainline station is East Croydon with easy access to London and the South Coast. The home provides care for up to 23 service users with long-term mental health needs. Some residents have a history of additional problems including alcohol or substance abuse. If these continue once they are admitted to the home they would be asked to leave. Whilst the home aims to rehabilitate residents so that they can live more independently, in independent or supported accommodation, most have had significantly severe mental health problems which has made rehabilitation difficult, and which has resulted in them living long-term in the home for many years. The home aims to reassess the appropriateness of each placement within a two to three year period. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over half a day and involved discussion with the home’s registered manager, James Oseya. The inspector met with both staff and service users, had wide-ranging discussion regarding the home, and examined both service user and staff records. The case records of four new admissions were case-tracked. These included residents’ assessments, risk assessments, care plans, medication records and review minutes.. Staff records examined included staff rotas, supervision, appraisal and training records. The inspector examined recruitment records and criminal records checks, for three new staff recruited since the last inspection. The inspector also looked at documentation relating to the day-to-day running and management of the home. This included quality assurance questionnaires and records, policies and procedures and records relating to the logging of any accidents or incidents (3 recorded) and complaints (none recorded). Documentation relating to health and safety including the home’s risk assessments, servicing and maintenance certification, were also examined. The inspection was assisted by the involvement of a layperson, an ‘expert by experience’, who has relevant insights and knowledge regarding users’ experience of mental health services. She spent about three hours talking individually with a number of residents to ascertain their views regarding the home and the support provided. Of seven residents with whom she spoke, one was female, most were in their late forties/early fifties with one young man being only thirty four. Within the report reference is made in italics to the observations made. The main areas which the ‘expert by experience’ were asked to look at were: The quality of care and support provided, choice and individual needs, and developing independence. This inspection follows a random inspection that took place on 4 January 2007. The reason for this inspection was to follow up concerns that had been expressed regarding practice and procedures at the home, and to check progress in meeting outstanding requirements. The concerns related to health and safety, and to the physical health care needs of residents, and followed both a coroner’s inquest and an adult protection investigation regarding the circumstances relating to the death of a resident at the home. Seven new requirements were made as a result of this visit, with 4 of the 15 requirements from the previous key inspection remaining to be met. On the basis of this inspection, the inspector is satisfied that those concerns identified have been appropriately addressed, and that residents’ health and safety is now being appropriately safeguarded. Feedback from the residents at this home has been generally favourable, with individuals presenting as being settled and secure, and well supported by staff. File checks indicate that residents are being consulted individually by their key workers, and within reviews, regarding their health, personal welfare and wellbeing. There are also residents’ meetings, in which residents are being Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 6 collectively consulted regarding their day-to-day living and routines, proposed activities, outings and events, and the planning of menus. Planned activities and outings are publicised in advance. Generally, staff were observed to be caring and skilled in their interactions with residents, with some appreciative comments being received from residents. There is also evidence of good support and regular supervision for staff and of a comprehensive and ongoing programme of staff training and development. Generally, there is evidence of regular daily activities and flexibility of routines, with residents being able to exercise a significant level of choice and control over their day-to-day lives. However, the ‘expert by experience’ identified an ‘institutional feel’ to the home, with most residents being observed to be present around the home. From her discussions with residents, she felt that there should be more attention given to engaging in and developing individual recreational or social interests outside of the home, and for developing individuals’ abilities and potential. The inspector has made a number of recommendations to assist in addressing these concerns. The ‘expert by experience’ also identified a concern relating to the individual right of a resident to have his or her own individual front door key, a right which is presently withheld. Whilst acknowledging that there are considerations of risk, any such restriction should be subject to a risk assessment for each individual, and should only be applied where there is a significant assessed risk to the individual or to other residents. A requirement applies. Of 15 requirements from the previous key inspection, on 23 June 2006, 4 remained outstanding at the last (random) inspection on 4 January 2007. These have now been met. From this inspection, there are 7 new requirements and 9 recommendations. The inspector would like to extend his thanks to the manager, James Oseya for his assistance in helping to facilitate this inspection. He would also like to extend his thanks to the deputy manager and to those staff and residents who spoke with the inspector and the expert by experience. The inspector would also like to extend his thanks to the expert by experience, Hilary Hawking, for her valued assistance in helping to carry out this inspection. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 7 What the service does well: Prospective residents are provided with all the information they require, and the opportunity to visit, and stay overnight if they wish, before deciding whether the home is likely to meet their needs. Generally, the home is able to demonstrate that the range of needs presented by residents are being properly assessed, and appropriately met. Each resident is provided with a service user agreement. This is written in a format which is appropriate to residents living at the home. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. Residents are enabled to participate fully in daily routines and activities, and are supported to make decisions that affect them and their day-to-day lives in the home. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Residents are encouraged to maintain contact with their family and friends, and to maintain links with the local community. There is choice and flexibility with meal arrangements. The quality of food is wholesome, nutritious and varied, with meals being taken in a pleasant and congenial setting. Generally, residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Clear information for raising complaints is made available, and residents and their relatives/friends are encouraged to raise any concerns they may have. Access to independent advocacy would, however, assist in addressing any unresolved concerns, and protecting the rights and interests of residents. The home’s policies, procedures and practice indicate that residents are being protected from abuse and are living in a safe environment. Generally, residents are living in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents’ rights and best interests are being safeguarded by the home’s record-keeping policies and procedures. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 9 While residents’ are being provided with a range of opportunities for leisure and social activities, more could be done to increase activities within the home, and to extend individuals’ involvement in community-based leisure and social activities. While residents are being encouraged to participate, and to exercise choice and control, in their daily routines and activities, more could be done to develop individuals’ abilities and potential. The inspector recommends that a vegetarian option should be offered at mealtimes to all residents. Whilst, generally, residents’ rights and responsibilities are being respected and recognised in their day-to-day lives, this needs to include the right to hold a front door key. The inspector would like to see the home develop a health action plan for each resident, detailing his/her physical, mental and emotional health care needs, indicating how these can best be met in accordance with the individual’s assessed needs, wishes and preferences. Carpeting was found to be in need of cleaning or replacement in two of the bedrooms inspected. The home has sufficient bathing and toilet facilities, which generally meet individual needs. However, two toilets were found without any paper towels in their dispensers. While, historically, residents have been protected by the home’s recruitment policy and procedures, their protection has, within the last 12 months, been compromised by the failure to have completed enhanced CRB checks for three new staff, prior to their appointment. While procedures have now been tightened, the home will need to evidence, over time, that enhanced CRB checks are being completed prior to all new staff appointments. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. However, risk assessments covering Fire, and Health & Safety, need to be reviewed and updated. 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. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 10 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 Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 11 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 to 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with all the information they require, and the opportunity to visit, and stay overnight if they wish, before deciding whether the home is likely to meet their needs. Generally, the home is able to demonstrate that the range of needs presented by residents are being properly assessed, and appropriately met. Each resident is provided with a service user agreement. This is written in a format which is appropriate to residents living at the home to ensure that they understand what services they will be receiving. EVIDENCE: The home has compiled a statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. The Statement of Purpose includes all the relevant information. The home has developed an excellent service user’s guide, which is written in a format/language suitable for the service users and contains all the essential Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 12 information. The inspector evidenced that these documents have been reviewed and updated within the last 12 months, on 24/8/07. The inspector noted the reference to the stated aim, included within the Statement of Purpose, for residents to be enabled to move on to lower supported or independent accommodation within a three-year period. Whilst the home aims to rehabilitate residents so that they can live more independently, in independent or supported accommodation, very rarely is this being achieved. This is due, in part, to the prevalence of significantly severe long-term mental health problems amongst the resident group, and the apparent shortage of supported living options, which has made the prospect of rehabilitation difficult to achieve. Given that most residents have been unable to move on, and have been living long-term in the home for many years, this aim is consistently not being achieved, and needs, therefore, to be removed from the Statement of Purpose. The manager agreed to remove this wording with immediate effect. Following referral, Care Programme assessments, risk assessments and care plans are obtained from the referring agency. Admission to the home is carefully planned. The manager or deputy manager visit the potential service user and complete an initial assessment and risk assessment of the individual. He/she is then encouraged to visit the home, with short visits being followed by overnight and weekend stays, prior to a decision being made. Following admission, an assessment meeting, involving the service user, his/her relatives/friends/representatives, and the care coordinator, is then arranged. At this meeting, a detailed assessment is undertaken and a plan of care drawn up. The assessment focuses on the individual’s needs for their mental health and well-being, medication, personal care, physical health, dietary needs, social interests and hobbies, religious/cultural needs, family involvement and social contacts. Placements are then reviewed on a regular basis, with weekly meetings taking place between the service user and his/her key worker. Placements and are not confirmed as permanent until a CPA review meeting has taken place after the first three months of placement. The home only admits emergency or short-term placements if the service user meets the homes admission criteria. There have been six new admissions since the previous key inspection on 23 June 2006, three of which have taken place since the last inspection on 4 January 2007. Following recruitment checks at the last inspection, and on this inspection, a care programme assessment has been obtained for an admission on 20.12.06, and for all subsequent admissions. All of the home’s assessments and risk assessments are in place. The inspector found that a photograph of the resident had not been included on any of the six files examined. A requirement has been made in respect of this. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 13 The home has a service user agreement that is issued to each resident who is admitted to the home. The agreement refers to a three-month ‘trial period’, and is written in an appropriate format for residents living at the home. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 14 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 to 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. Residents are enabled to participate fully in daily routines and activities, and are supported to make decisions that affect them and their day-to-day lives in the home. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. EVIDENCE: Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 15 The home has a comprehensive and thorough approach to care planning, with care plans being based on the Care Planning Approach. Generally, files include comprehensive service user plans, which provide detailed information evidencing how residents’ needs are being addressed, and the involvement of residents in contributing to their care plans. Risk taking plans (based on risk assessments) have been drawn up, with any restrictions being clearly identified and agreed by the resident. Contingency and crisis plans are also in place. The inspector looked at the files for three recent admissions. These evidenced that care plans had been developed, involving the resident in a person-centred approach. The registered manager has introduced a new care plan format, which is clear and user-friendly, placing more emphasis on the resident’s involvement. The care plan is evaluated on a weekly or monthly basis depending on the needs of the individual. There is regular monitoring of each resident’s care plan, with weekly meetings taking place between each resident and their key worker. In line with the development of a more person-centred approach, staff are undertaking training in person-centred planning. The inspector found that two service user files did not include any evidence of a review having taken place following their admission. Though assured by the manager that reviews had taken place for these two residents, he was unable to evidence these; a requirement therefore applies. Residents are being consulted in a variety of ways during their stay in the home. This includes service user meetings, key-worker meetings, care reviews and through questionnaires completed for quality assurance purposes. Residents are encouraged to be as independent as possible in their day-to-day living and, with the support of their key workers, to be fully involved in making decisions relating to their daily recreation and activities. There has, however, been very little progress in enabling residents to make the transition to more independent life-styles within the community. This is, in part due to the longevity of residence for many residents, which has historically developed in this home, and to the significantly high levels of mental vulnerability which most residents present. Following a previous concern, from the last key inspection, regarding the frequency of residents’ meetings, these are now being held on a regular monthly basis, with issues discussed being fully recorded. Meetings are being chaired by the manager or deputy manager. There is evidence that residents are supported to take risks in developing independent skills and abilities. One of the stated aims of the home is to enable service users to take responsible risks wherever possible. Prior to their admission prospective service users are thoroughly assessed regarding potential risks relating to their day-to-day living inside and outside the home. Risk assessments and care plans evidence that individuals are being encouraged and assisted to participate fully in daily routines and activities. This Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 16 includes using public transport, and accessing local recreational and shopping facilities. Residents are also encouraged to look after their own monies and to collect their own benefits. The inspector examined a sample of risk assessments that have been completed for residents living at the home. These provide a comprehensive risk assessment of each individual, with risk-taking plans and individualised care plans having been developed to detail the actions required to minimise risks and hazards. The home has a comprehensive ‘missing persons’ policy/procedure document. This clearly states the actions which staff are required to take in the event of an unplanned absence of a service user. A monitoring system has been put in place whereby residents’ movements in and out of the home are recorded. Hourly checks are completed by staff to ensure the safety of residents. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 17 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 to 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. While residents’ are being provided with a range of opportunities for leisure and social activities, more could be done to increase activities within the home, and to extend individuals’ involvement in community-based leisure and social activities. While residents are being encouraged to participate, and to exercise choice and control, in their daily routines and activities, more could be done to develop individuals’ abilities and potential. Residents are encouraged to maintain contact with their family and friends, and to maintain links with the local community. Whilst, generally, residents’ rights and responsibilities are being respected and recognised in their day-to-day lives, this needs to include the right to hold a front door key. There is choice and flexibility with meal arrangements however residents would have greater choice if vegetarian options were offered. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 18 EVIDENCE: The ethos of the home, as outlined in the Statement of Purpose, is very much orientated towards promoting independence and maximising individual choice and opportunities. Staff at the home work with residents with the aim of increasing their motivation and confidence, and developing their independent living skills. Residents are encouraged to take responsibility for undertaking daily tasks such as tidying their rooms, doing their laundry, and preparing drinks, food and snacks. As evidenced in daily logs, care plans and review notes, the daily routines of the home are observed to be flexible and accommodating of individual needs and preferences. The ‘expert by experience spoke with a number of residents and identified an ‘institutional feel’ to the home, which she felt was linked to the lack of opportunity for transferring to independent living or supported living units within the community. Most residents have lived in the home for more than two years, and some for up to 10 years. Whilst acknowledging that the home has links with employment, welfare rights and other support services, it was felt that more could be done to encourage independence through developing individual skills, abilities and potential, and by seeking opportunities through part-time work, for increasing personal income and choices. The inspector spoke with a number of residents during the inspection and received feedback that indicated that that there is flexibility in their daily routines and that they are able to engage in a range of in-house and community-based activities. Activities and events are publicised on the home’s notice board and at service users’ meetings. Each resident has an individual daily activities programme, a copy of which is kept in their own room. The programme is agreed with the individual and reflects his/her interests and needs, and is monitored by the key worker and at reviews. Whenever possible, residents are encouraged to develop their learning and work-related skills. One resident has his own computer in his room, while others are able to access the home’s computer if they wish. Another resident has an interest in photography and attends courses in this, and computer studies, at Croydon College. While residents are encouraged to access local educational facilities including basic literacy and numeracy classes and vocational/skills-based courses, there has, however, been little take-up of these courses. Activities within the home include regular twice-weekly art and pottery sessions, which are well attended. These sessions have aimed to develop creative self-expression, and a sense of personal fulfilment, and have proved to be very popular with residents. The inspector has previously observed one of these sessions and was impressed with the level of personal involvement and satisfaction achieved. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 19 The ‘expert by experience’ noted that an art therapist visits the home each week and that this seems to be a popular activity with quite a few of the residents with whom she spoke. She observed that residents take pride in developing their skills and talents in this area, and noted that an exhibition of their work is to be held in an art gallery, within the community where members of the general public will be able to view it. In her own words, “ I feel that that the empowering and confidence building for those who will take part speaks for itself”. There is a wide range of games and activities both within and outside of the home, including table football. Some residents go swimming once a week, or play golf with their key worker, whilst others have gym equipment in their room. Activities and events are publicised on the home’s notice board and at service users’ meetings. Views expressed by residents have indicated that while there are opportunities available for social and leisure activity, with individual needs and choices being accommodated, more could be done in the way of encouraging individual interests and developing recreational and leisure activities. The ‘expert by experience’ felt, however, that residents could be challenged a bit more to draw out and encourage their abilities and to learn some new ones. One resident to whom she spoke had been a champion discus thrower when young, while another resident had excelled at table tennis and chess. Another resident expressed an interest in making jewellery, which the expert felt could involve other residents in a group session, and be accommodated by the purchase of a jewellery kit and small enamelling oven. The expert also felt that studying above basic literacy could be encouraged for some individuals who presented as being “bright” and “capable of learning and doing more then at present”. The ‘expert by experience’ noted that there could be more community-based leisure and social activities for residents. While residents are able to access the local leisure centre, and other facilities, there was little evidence of any group bookings that could help facilitate an improvement in the level of interest and participation. The inspector recommends that this possibility is explored, and discussed with residents, with view to having regular weekly group bookings for activities such as swimming and badminton and the use of the gym. The ‘expert by experience’ also identified the need for more leisure activities within the home such as a proper full-size pool table and a table tennis table. The therapeutic value of these activities, in encouraging individuals’ social interaction and participation, cannot be underestimated, and should be given a higher priority. The inspector therefore recommends that the home’s providers Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 20 and manager consult with residents with view to providing these activities within the home. Occasional bingo sessions are organised, and staff play dominoes and board games with residents. One staff member plays the saxophone keyboard and trumpet, and occasionally plays these for the enjoyment of residents. Daily papers and magazines are available, and information is provided regarding the availability of activities in the area. Residents visit the shops, cafes and cinema, while some residents attend local day centres, where they are able to participate in activities and enjoy social contact. The home has a mini-bus and organises day trips to seaside resorts such as Bognor Regis, Brighton or Bournemouth. These do not involve any additional cost to the residents and, from the views expressed, are very much looked forward to by both the residents and staff who accompany them. The home actively encourages residents to maintain family links and friendships both inside and outside of the home. Residents can see visitors in their rooms and in private, and are encouraged to maintain friendships and personal relationships. Family and friends can be invited to barbecues and other events that take place at the home. Views expressed by residents indicate that they are encouraged to maintain contact with their family and friends, and that staff are welcoming to visitors and respectful of their privacy when they receive visits. The rights and responsibilities of residents are generally being well respected and recognised in their daily lives. All residents are encouraged to register on the electoral role and, if they wish, are assisted to exercise their right to vote. Residents are encouraged to handle their own finances, and to be consulted and involved in any decision that affects their personal or collective welfare. All residents are informed of their right to access information that is kept about them if they wish to do so. Religious and cultural needs are respected, with the right of individuals to worship in their own faith being assisted to make this possible. One resident, from a Muslim religious background, is assisted to practice his religious beliefs and maintain his faith. From her discussion with one resident, the ‘expert by experience’ identified an issue relating to the right, presently denied, to have a front door key. The manager confirmed that residents are not presently issued with a key to let themselves in. When discussing this, the manager’s concern was that the security of the home, and the safety of other residents, could potentially be compromised if this right was abused and strangers were able to gain access. This concern has Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 21 to be balanced, however, against the right of the individual to have a key to the front door of their home, as with any person living in the community, and in keeping with the need to develop the individual’s independent living skills. Following discussion with the manager, it was agreed that, subject to a risk assessment, residents should be afforded the right to have their own key, the only exception being if there were specific behavioural or other concerns that had been risk assessed, which involved a high level of risk to the individual and/or other residents. A requirement applies. Mealtimes are flexible and take account of individuals’ work and activity schedules. Menus evidence a wide choice of foods offering a varied and nutritional diet. Residents are consulted as to which foods they would like purchased, and are able to have an alternative dish provided if the menu options do not appeal. A detailed record is kept of the food provided. The dining area is pleasantly laid out and provides a relaxed and congenial setting for taking meals. Residents are encouraged to prepare their own breakfast, and to assist with food preparation and other tasks if they wish. Lunch and an evening meal are provided. Comment received indicates that the food, which the home provides, is good and varied, and that it accommodates individual tastes. One resident is of the Muslim faith, and has his dietary needs respected. The ‘expert by experience’ noted that, from her discussions, residents are being encouraged to shop and cook for themselves, and to assist with peeling potatoes and washing up. She also observed that the choice of food cooked is provided from a menu book kept in the dining room, and that there are two different options for each mealtime. She identified a complaint, voiced by some residents, for a vegetarian choice for those residents who are not identified as being “vegetarian”. The inspector recommends that a vegetarian option should be offered at mealtimes to all residents. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 22 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 to 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The personal support, health care, and emotional health needs of residents are generally being well met in this home. However, following a concern regarding a lack of awareness of a resident’s physical health care needs, policies and procedures have been reviewed, and relevant training arranged for all staff. The inspector would like to see the home develop a health action plan for each resident, detailing his/her physical, mental and emotional health care needs, indicating how these can best be met in accordance with the individual’s assessed needs, wishes and preferences. Generally, residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. EVIDENCE: Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 23 The inspector examined a random sample of service user files and evidenced that both personal support and general health care needs are being generally well met. As detailed in assessments and care plans, the range of personal support needs presented is varied, with support being tailored according to individual needs and goals. Staff provide very flexible support with the focus being on encouraging and assisting individuals to undertake tasks such as maintaining personal hygiene, preparing their own breakfast and doing their own laundry. The inspection of residents’ files indicates that there is regular contact with health care professionals, and that personal support and healthcare needs are generally being addressed. The person’s mental and physical health needs are closely monitored, with individuals being reminded to receive visits and attend appointments as and when these are required. Residents are able to receive visits from visiting professionals in the privacy of their own rooms. Concerns regarding the circumstances relating to the death of a service user at the home in 2006 were discussed on a random inspection on 4/1/07. Arising from the report from an NHS Trust, regarding a coroner’s investigation, the physical health needs of service users were identified as an area of particular concern, with two recommendations being identified. The first recommendation referred to the need for physical health care needs of residents to be addressed more assertively, whilst the second referred to the need for residential care homes to improve their skills and knowledge in addressing physical health care needs. On the basis of the inspector’s review of the evidence presented in the report, and from his discussion held with both the home and the Manager of the Rehabilitation and Recovery Team in Croydon, the inspector issued two requirements. Firstly, for the home to review and update its policy regarding the physical health care needs of residents, including how these needs are addressed and monitored, and how procedures can be improved so as to promote more positive practice in this area. A further requirement was made for all care staff to be provided with up-todate training relating to the physical health care needs of residents, and associated good practice. The manager, James Oseya, confirmed that both these requirements had been met, and the inspector evidenced the necessary documentation to support this. The physical health care needs of residents will, however, need to be closely monitored so as to ensure the delivery of good practice in meeting these over time. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 24 Following on from this recent concern, and the need for developing good practice, the inspector would like to see the home develop a health action plan for each resident, detailing his/her physical, mental and emotional health care needs, indicating how these can best be met in accordance with the individual’s assessed needs, wishes and preferences. The plan should reflect a personcentred approach, fully involving the individual and his/her relatives or representatives, and should be drawn up in consultation with the GP, community psychiatric nurse and any other relevant health care professionals. The health action plan should record details of medication, how and when this is administered, and should be reviewed annually, or more frequently as required. A recommendation applies. The home has appropriate medication policy and procedures in place. A visiting pharmacist completes a medication audit every three months. Medication charts are maintained, together with records relating to receipts and returns of medication. The home uses the Monitored Dosage System for administering medication, with blister packs being used. All medication is kept securely in an appropriate medication cabinet. All staff who administer medication receive accredited medication training. Three residents have been risk assessed as being safe to administer their own medication, with support and training being provided. This includes showing residents how to maintain their own medication charts. These are monitored to ensure that they are being appropriately completed. At the time of writing this report, a concern has been expressed by social services regarding medication practice in regard to a resident’s medication. The inspector was informed that this concern is currently being investigated, under adult protection procedures, by social services. The inspector is awaiting more information, and is unable at this time to make any judgement regarding this matter. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 25 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear information for raising complaints is made available, and residents and their relatives/friends are encouraged to raise any concerns they may have. Access to independent advocacy would, however, assist in addressing any unresolved concerns, and protecting the rights and interests of residents. The home’s policies, procedures and practice indicate that residents are being protected from abuse and are living in a safe environment. EVIDENCE: The home has an appropriate complaints policy and procedure in place. A summary is included in both the service user guide and the statement of purpose. There have been no complaints since the last inspection. The inspector spoke with a number of residents, no concerns being expressed. Residents are able to raise any concerns or grievances with their key worker, other staff on duty, the manager or registered provider, or with their care coordinator. When complaints relating to the users’ mental health needs are made these are recorded in his/her care notes and discussed with the C.P.N. Feedback indicates that residents feel that they are being listened to, and that when problems or concerns arise, they are able to get these addressed. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 26 In discussion with the manager, the inspector enquired as to whether the home has any access to independent advocacy, and was advised that there are no formal arrangements in place. The inspector would like to see the home obtain the services of an advocacy organisation to provide any resident who has an unresolved concern or grievance with access to an independent advocate. A recommendation applies. No allegations of abuse have been recorded since the last inspection. The home has an appropriate adult protection policy and procedure, for the protection of vulnerable adults. This is in line with local statutory procedures, with all staff being familiarised with the home’s policy and procedures. The manager has advised that all staff are provided with ongoing supervision, support and training regarding the nature of abuse and the protection of vulnerable adults. Following a requirement from the last key inspection, all staff have now completed local statutory adult protection training. A recommendation, for the registered manager or deputy manager, to attend the three day ‘training for trainers’ course in adult protection has yet to be implemented, but the manager confirmed that both the deputy manager and himself are on the Croydon waiting list for places. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 27 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 to 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally, residents are living in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents’ rooms are comfortable and reasonably well decorated, being suited to individual needs. Following a serious incident at the home, the safety of residents is now being assured with the completion of a regular monthly audit of residents’ furniture and possessions. The home has sufficient bathing and toilet facilities, which generally meet individual needs. EVIDENCE: Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 28 The premises were inspected and found to be homely, comfortable and safe. Fittings, adaptations and equipment are of good quality, and domestic in scale. The home has a health and safety policy, with staff receiving training in this area and being supported to maintain a safe and secure environment. The home has a large well-maintained garden with a patio area and lawn. Residents presented as being settled and satisfied with the home and facilities provided, with several positive comments being received. The home is decorated to a reasonable standard throughout and presented as being comfortable, bright and warm. There is a planned programme of maintenance for the redecoration and renovation of the home, including plans to redecorate all residents’ rooms, and the communal areas, within the next 12 months. The home has 19 single rooms and 2 double bedrooms. The inspector viewed a number of bedrooms. Generally, the rooms inspected presented as being reasonably decorated and furnished to required standards. Residents are consulted regarding their choice of colour scheme and décor, and are able to bring their own items of furniture if they wish. Residents were observed to personalise their rooms with photos, personal mementoes and possessions including personal stereos, CD players and TV sets. One resident has his own personal computer in his room. Doors to rooms are fitted with locks suited to individuals’ capabilities, and each resident is provided with his/her own keys. Staff are able to access any room in an emergency. Following a requirement from the last key inspection, all residents’ bedrooms now include a lockable drawer or facility. A major concern from the last (random) inspection, on 4/1/07, regarding the build-up and hoarding of possessions in residents’ rooms, which contributed to a serious health and safety incident, has been addressed. This related to the excessive build-up and hoarding of possessions in a resident’s room, which was felt to have been a significant contributory factor in leading to the individual’s death. Whilst acknowledging the right of residents to have their own possessions in their rooms, this must be balanced against the risks to safety when a build-up of possessions is in danger of becoming a potential hazard or fire risk. In line with a requirement, an inventory of all furniture and possessions was completed following the incident, and a regular monthly audit, monitoring any build-up that may occur, is now being completed on a regular monthly basis. The inspector observed carpeting, which was dirty and stained in two rooms (Rooms 12 and 20); this was drawn to the attention of the registered manager. The carpeting needs to be thoroughly cleaned or replaced. A requirement applies. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 29 The home has a bathroom on both the ground floor and on the first floor. The existing ground floor bathroom has been renovated, with a new bath having been installed. The home also has three shower units, and seven toilets all near service user’s bedrooms and communal areas. Some bedrooms have ensuite washing and toilet facilities. While toilets and bathrooms were found to be clean and safe, the inspector was concerned to find that two toilets (on the ground and top floors) did not have any paper towels in their dispensers; a requirement applies. The laundry room was renovated and refitted in 2006, and provides safe, hygienic and efficient laundry facilities. Both staff and residents use this. The laundry facilities are suitably positioned so as to ensure that any soiled laundry is never carried through areas where food is stored, prepared or eaten. Heating is being maintained at a comfortable temperature throughout the home, with individual thermostats to regulate the temperature in all rooms. The manager advised that a new boiler has been installed in the home, in August 2007. Radcliffe House has several communal spaces for residents’ use, and the house has a very homely feel. There is room for all the home’s residents to sit together, or to receive visitors in private, in either of the home’s two lounges. There is also a pleasant, spacious dining room, which includes an area where residents can sit in easy chairs. Details of the menu options for the day are chalked up on a blackboard. The home has a small smoking room for the use of those residents who wish to smoke; this is situated well away from any of the communal areas. There is also a conservatory, adjacent to the main lounge, where residents can sit and look out across the garden. The kitchen area is clean and domestic in scale, and residents are encouraged to make use of the facilities if they wish. The inspector did, however, notice a build-up of loose items of rubbish just outside of the kitchen; this is not acceptable, and the area must be kept clear with any loose items being properly bagged up. A requirement applies. The home does not accommodate people with significant physical disabilities and is not suitable for people who are wheelchair dependent. There are, however, a number of older service users who have some physical impairment. The home has been assessed (on 29/3/06) by an Occupational Therapist for any adaptations or aids that would assist in meeting the residents’ collective needs. The home presents as being clean, hygienic and free from any offensive odours. The home complies with food hygiene and environmental health regulations, and has had a recent inspection, on 30 July 2007. The home’s policies and procedures manual contains various policies for the prevention and control of infection including dealing with spillages, HIV and Hepatitis B. Staff receive training in food hygiene, health and safety and infection control. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 30 Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 31 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 to 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing has been increased so as to provide more comprehensive cover throughout the day, and at night. This, together with clearly defined roles and responsibilities, are assessed to be meeting the needs of residents. Regular staff meetings are now being held. The effectiveness of the staff team has been improved by regular staff meetings and by the introduction of improved methods of communication. While, historically, residents have been protected by the home’s recruitment policy and procedures, their protection has, within the last 12 months, been compromised by the failure to have completed enhanced CRB checks for three new staff, prior to their appointment. While procedures have now been tightened, the home will need to evidence, over time, that enhanced CRB checks are being completed prior to all new staff appointments. With appropriately trained and qualified staff, who are now being supported through regular one-to-one supervision, residents can feel more assured that their needs will be met. This improvement must be sustained. EVIDENCE: Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 32 The inspector examined the staff rotas. These indicated that the home is maintaining more realistic staffing levels. During the day, the home now has 3 care staff on duty throughout the day, from 7.30am to 10pm. There are two seven-hour shifts, with a half-hour formal handover session taking place prior to each new shift. The night duty rota has been adjusted so that there are now two waking staff on duty at night (instead of one waking and one sleep-in as had previously been the case). In addition, the home employs one full time domestic cleaner and a cook. The last key inspection report identified the need for good communication and support of staff, and for regular one-to-one staff supervision. The inspector had been concerned to find that there had been very infrequent staff meetings. This situation has been addressed by the new manager, James Oseya, with staff being supported through supervision and training to take more responsibility for communicating effectively with residents and with each other. The introduction of staff handover sessions between shifts, and weekly key worker meetings with each resident, has helped in this regard. Also, by regular staff meetings, which are now being held on a monthly basis, and chaired by the manager or deputy manager. The inspector examined records of staff supervision, appraisal and training, and found these to be satisfactory, with evidence of staff being supported to improve their performance and achieve their targets and goals. All staff are receiving an annual appraisal. Following concerns from the last key inspection, regarding the irregularity of supervision, the new manager has been ensuring that staff receive regular supervision, with sessions taking place on at least a two-monthly basis. Since his appointment, the manager has been undertaking all staff supervision, but he advised the inspector that is intending to delegate some of this to the deputy manager and a senior care worker. To this end, the inspector recommends that supervision and appraisal training should be provided for both the deputy manager and the senior care worker, so as to ensure that they have developed the requisite level of knowledge, awareness and skills required for supervising staff. The home has a comprehensive induction programme in place, with all new staff receiving induction training within six weeks of appointment. This includes training on the principles of care, safe working practice, health and safety, communication, confidentiality, and maintaining a safe environment. The induction programme is signed and dated on completion. There is an ongoing staff training programme, with each staff member agreeing a personal training plan that meets their individual needs and learning objectives. Staff are encouraged to study for their NVQ care qualifications. The registered manager indicated that of 13 care staff, 9 have achieved an NVQ Level 2, of whom 3 staff are studying for their NVQ Level 3. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 33 The deputy manager, Keith Nicholas, has completed studies for the NVQ Level 4 and RMA (Registered Manager’s Award). There is an ongoing staff-training programme, with statutory training taking place in mental health, food hygiene, health and safety, medication and infection control. Following the death of a resident at the home last year, the inspector identified a need for staff training in bereavement and loss. This training has since taken place. Following a concern, identified at the last (random) inspection on 4/1/07, regarding the apparent lack of monitoring and awareness of residents’ physical health care needs, a requirement was made, requiring staff to undertake training in this area. The manager confirmed that all staff have now completed this training, with two training sessions having taken place within the last six months. The home has appropriate recruitment policy and procedures in place. Since the last inspection, there have been one new staff appointment of a cook at the home. The inspector checked the staff file and found that the CRB (Criminal Records Bureau), identity and employment checks had been satisfactorily completed. On the last (random) inspection, on 4/1/07, the inspector was concerned to find that three staff had been recruited without an up-to-date CRB certificate having been obtained. CRB certificates on file were from previous care settings. The manager and deputy manager were advised that portability does not apply between homes and that the three staff had to be supervised at all times by an experienced staff member until such time as the enhanced CRB checks had been completed and the CRB certificates obtained. The manager, Mr James Oseya, who had just recently started, was warned that any further transgressions in this area would result in statutory notices being served. A further concern identified was the absence of two appropriate references for one staff member recently transferred from another care home owned by Mr Philipides. As a result, two requirements were made which have both been met. The manager confirmed that new enhanced CRB checks are being made prior to all staff appointments, and that CRB certificates and references are being obtained. The inspector completed checks on two staff who have been recently recruited, and found CRB certificates, references, evidence of qualifications, identity and health checks to be in place. The home must ensure that all recruitment checks are completed for all future appointments, and that this can be evidenced over time. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 34 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 to 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Following a period of downturn, residents are now living in a home that is being generally well managed and run in their best interests. The home is beginning to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is meeting its aims and objectives. Residents’ rights and best interests are being safeguarded by the home’s record-keeping policies and procedures. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. However, risk assessments covering Fire, and Health & Safety, need to be reviewed and updated. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 35 EVIDENCE: From 3 January 2007, the home has been managed by Mr James Oseya, becoming the registered manager. Mr Oseya has had extensive previous experience in the mental health field and in residential care management. His appointment followed a period of nine months when the home did not have a registered manager, and which adversely impacted on the management and day-to-day running of the home. Since being in post, Mr Oseya has demonstrated his commitment to raising standards at the home by introducing a number of changes to improve practice, systems and staff working. Feedback from residents and staff, regarding the day-to-day running of the home, has been generally positive, with favourable views being expressed regarding the home environment and the support provided by staff. The evidence from this inspection indicates that there is an open and inclusive style of management in the home, with residents being consulted and involved in decisions affecting their individual and collective welfare. Regular monthly meetings for both residents and staff are being held, these being chaired by the manager or deputy manager. The home has been developing its quality assurance processes over the last three years with questionnaires having been developed by the managing company for canvassing the views of residents, relatives, friends and visiting professionals and other interested parties. These are designed to ensure that the home is meeting its aims, objectives and statement of purpose. A service user satisfaction survey has been completed, and an audit report completed. The manager confirmed that he has been reviewing the homes policies and procedures, this being evidenced in the AQAA and in the home’s checklist, detailing when these were last reviewed (in 2007). From the evidence of this and previous inspections, residents’ and staff records are generally being well maintained. A policy is in place that informs residents on how to gain access to their records and any information held about them. All records are being kept securely, with confidentiality being respected. The home has a health and safety policy, and a fire safety policy, which were both last reviewed in August 2006. The inspector noted that the fire risk assessment was last completed on 28/6/06; this needs to be reviewed and updated. The home was also unable to evidence an up-to-date health and safety risk assessment. This needs to be evidenced. A requirement applies. All health and safety checks are evidenced to have been completed within the last 12 months. Fire drills take place on a regular, weekly basis, with these being recorded in a written record. The home has 3 monthly inspections of fire alarms and equipment, and arranges six-monthly fire safety training for all Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 36 staff. Water testing for legionella is being carried out each year, together with the testing of gas and electrical appliances, boilers, heating systems and fire alarms. Water temperature checks are being completed weekly, and fridge/freezer temperatures are checked daily. The home has policies and procedures covering the control of substances hazardous to health (COSSH and RIDDOR), with the home maintaining safe storage and disposal of these substances. A health and safety concern identified from the last key inspection, relating to the issue of smoking in the home, has been addressed. In line with a requirement, the home has reviewed its policy on smoking, with smoking being restricted to a designated smoking room located well away from the other communal areas. Residents are no longer permitted to smoke in their rooms or in any other part of the home. Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 37 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 3 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 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 3 3 3 2 X Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 38 Are there any outstanding requirements from the last inspection? No 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 17(1)(a), Schedule 3, No 2 Requirement A photograph of the service user must be included on all service user files. As detailed in Regulation 17(1)(a) Schedule 3, No 2 photograph of the service user must be provided. 2 YA6 15(2)(b) Reviews for two recently admitted service users (CW and JH) must be evidenced. A copy to be forwarded to the CSCI, Croydon office. 3 YA16 12(1)(a) Residents should be afforded the right to have their own front door key, the only exception being if there are specific behavioural or other concerns that have been risk assessed, and which involve a high level of risk to the individual and/or other residents. The home must ensure that paper towels are provided for hand drying, in all toilets DS0000025828.V352514.R01.S.doc Timescale for action 30/11/07 a 30/11/07 31/12/07 4 YA27 12(4)(a) 16/10/07 Radcliffe House Version 5.2 Page 39 within the home. 5 YA26 16(2)(c) The carpeting in Rooms 12 and 20 is dirty and stained, and needs to be thoroughly cleaned or replaced. All other carpets in residents’ rooms need to be checked and cleaned, or replaced if required. The area just outside of the kitchen must be kept clear of any loose items of rubbish, and these must be properly bagged up. The home needs to evidence up-to-date Fire Risk and Health and Safety assessments. A copy must be forwarded to the CSCI, Croydon office. 30/11/07 6 YA30 13(4)(a)&(c) 16/10/07 7 YA42 13(4)(a)&(c) 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations The home should develop a health action plan for each resident, detailing his/her health care needs, and how these can best be met in accordance with the individual’s assessed needs, wishes and preferences. The plan should reflect a person-centred approach, fully involving the individual and his/her relatives or representatives, and should be drawn up in consultation with the GP, community psychiatric nurse and any other relevant health care professionals. The plan should record details of medication, and how this is administered, and should be reviewed annually, or more Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 40 frequently as required 2 YA14 The inspector recommends that the home’s providers consult with residents with view to providing a proper fullsize pool table and a table tennis table within the home. These would provide the opportunity for more recreational and activity within the home. 3 YA14 More should be done to develop individuals’ abilities and potential through giving positive encouragement and assistance, and by accessing relevant leisure, learning and educational resources. The inspector recommends that access to the local leisure centre is explored, and discussed with residents, with view to having regular weekly group bookings for activities such as swimming and badminton and the use of the gym. The inspector recommends that a vegetarian option should be offered at mealtimes to all residents. The inspector would like to see the home obtain the services of an advocacy organisation to provide any resident, who has an unresolved concern or grievance, with access to an independent advocate. The inspector recommends that the registered manager, or deputy manager, undertake the Croydon 3 day adult protection training for trainers course in adult protection. The inspector recommends that there is some delegation of staff supervision and that accredited supervision training is provided. The inspector recommends that supervision and appraisal training should be provided for both the deputy manager and the senior care worker, so as to ensure that they have developed the requisite level of knowledge, awareness and skills required for supervising staff. 4 YA14 5 6 YA17 YA22 7 YA23 8 YA36 9 YA36 Radcliffe House DS0000025828.V352514.R01.S.doc Version 5.2 Page 41 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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