Inspection on 02/07/07 for Reddown Road (37)

This inspection was carried out on 2nd July 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Reddown Road (37) 18/03/09

Reddown Road (37) 15/04/08

Reddown Road (37) 23/06/06

Reddown Road (37) 25/10/05

Reddown Road (37) 28/06/05

Reddown Road (37) 02/11/04

Reddown Road (37) 15/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Reddown Road (37) 37 Reddown Road Coulsdon Surrey CR5 1AN Lead Inspector Lee Willis Key Unannounced Inspection 2nd July 2007 11:10a Reddown Road (37) DS0000025829.V344614.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 Reddown Road (37) DS0000025829.V344614.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. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Reddown Road (37) Address 37 Reddown Road Coulsdon Surrey CR5 1AN 01737 559 309 F/P 01737 559 309 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) londonroad@tiscali.co.uk Milbury Care Services Ltd Mr Gavin Ainslie Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified resident over the age of 65 with a learning disability to be admitted. 8th February 2007 Date of last inspection Brief Description of the Service: 37 Reddown Road is owned by Milbury Care Services and is registered with the Commission to provide personal support for up to eight younger adults with learning disabilities. All the service users currently residing at the home are aged 50 and over. Gavin Ainslie, who has been the registered manager of the service since June 2003, remains in operational day-to-day control. This detached property is situated on a quiet residential street in the suburb of Coulsdon. The home has its own transportation, is on a main line bus route, and is also less than five minutes walk from a local train station with good links to central London and the surrounding areas. A variety of local shops, cafes, and pubs are also within fifteen minutes walk of the home. The property has two floors and comprises of eight single occupancy bedrooms; an open plan ‘L’ shaped main lounge/dinning area, a new enlarged activities room; two sensory areas; a new kitchen; laundry room, office, and staff sleep-in room. There are sufficient numbers of toilet and bathing facilities located throughout the home near service users bedrooms and communal areas. The garden at the rear of the property has been re-landscaped and is far more accessible. The home ensures prospective service users and their representatives are supplied with all the information they need to know about the services and facilities provided and how much they can expect to be charged for them. The fees currently charged ranges from £1,250 - £1,300 per week. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process the Commission for Social Care Inspection (CSCI) has judged the service as having a number of strengths, but also specific areas of particular weakness that require urgent action to be taken to address them. Most Key standards were almost met and overall we judge the service to be a safe one, although as mentioned we identified a number of potential risks to people who use the service during the site visit that staff had either not recognised or were managing particularly well. This unannounced site visit was carried out on a Monday between 11.10am and 3.40pm. During the course of this four and a half hour inspection three people who currently live at Reddown Road were met, along with the homes registered manager, and three support workers who were all on duty at the time of this site visit. The two people whose care plans had recently been updated to make them more person centred were selected for ‘case tracking’. The remainder of this site visit was spent examining the homes records and touring the premises. What the service does well: People who use service are able to enjoy stimulating lifestyles. Staff seek the views of residents and consider their varied social interests and hobbies when arranging activities both in the home and the community. There is evidence that service users are actively encouraged to get the most out of the homes relatively new and well equipment sensory and art/games rooms, as well as engage in all manner of leisure activities in the wider community. Activities participated in the last month include meals out, day trips to the coast, bowling, drives in the country and walks in a local park. The service also uses a number of innovative methods to ensure people who use the service have access to all the information they need to make informed decisions about what to eat or activities to engage in. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 6 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. Reddown Road (37) DS0000025829.V344614.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 Reddown Road (37) DS0000025829.V344614.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 Quality in this outcome area is good. This judgement has been made using all the available evidence. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: A copy of the homes Statement of Purpose was looked at. The manager told us the document had been reviewed in the past six months and updated accordingly to reflect any changes in provision. The date the Statement was last reviewed was not contained in the document, although it was illustrated with all manner of pictures, symbols, and photographs to enable it to be read by all the people who used the service. The outcome for key Standard No. 2 was not looked at on this occasion because the last full inspection of the service confirmed a suitable process was in place to assess prospective service users needs prior to their admission. The manager told us he had not accepted any new referrals since the home was last inspected despite having two places vacant. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using all the available evidence both during and before the inspection visit to this service. Care plans reflect what is important to the individual, their capabilities, and what support they need to achieve their personal aspirations. The home has a comprehensive set of assessments and management strategies in place to minimise any identified risk, but these are not always followed by staff, which puts people who use the service at risk. EVIDENCE: The individual care plans for the two people selected for case tracking were both examined. The manager told us that Milbury care had recently developed a new care plan format that was far more person centred than the homes previous version. The manager also told us that introducing the new person centred format was a work in progress and that he hoped to have completed this task by October 2007. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 10 The two care plans that have been made into draft versions of the new person centred format were made available for inspection on request. The manager told us Keyworkers are responsible for developing the new care plans whenever possible, with the service user, their relatives and professionals representatives. The two draft plans examined were a definite improvement on the previous format as they placed a greater emphasis on people’s unique strengths and personal preferences, as well as their goals and aspirations for the future. To help individuals understand the information contained in their care plan the new format is written in plain language and illustrated with all manner of pictures, symbols, and photographs. The manager told us he felt the new care plan format was a better working tool that would help staff deliver the support required by the people who used the service. The manager went onto say that once the new format was up and running there was an expectation that keyworkers would review them on a monthly basis and up date them accordingly to reflect any changes in provision. Another member of staff spoken with was also able to describe how the new care plan format would work in practice. The manager told us that people who live at the home do not have their own meetings because of peoples complex communication needs, although service users are encouraged to help plan the weekly menus at more informal gatherings held every Sunday. At these meetings staff use pictorial aids and photographs to represent a wide variety of different meals to help service users plan the forth coming weeks menu. Risk assessments were included in the two care plans being case tracked, which detailed any action to be taken to minimise identified risks and hazards. On arrival it was noted that three service users were left waiting unsupervised in the homes people carrier for just over a quarter of an hour. The manager told us that child safety locks prevented these individuals from leaving the vehicle and that they were being supervised from a distance by the member of staff working in the kitchen. The manager was reminded that under no circumstances should service users who require staff support in the wider community or experience epilepsy be left unsupervised in a locked vehicle, irrespective of whether staff can see people from the kitchen window. All risk assessments regarding how much staff supervision service users require in the wider community must be reviewed as a matter of urgency and up dated accordingly to prevent a similar incident reoccurring. The manager has also agreed to remind his staff team of their supervision responsibilities. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A good range of activities within the home and community mean service users have various opportunities to participate in stimulating and motivating activities. Dietary needs and preferences are extremely well catered providing daily variation, choice, and interest for the people who use the service. Furthermore, mealtimes appear to be less chaotic and more of a social occasion that service users and staff can both enjoy together. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 12 EVIDENCE: As previously mentioned in this report on arrival three service users were observed sitting the homes vehicle waiting to go out. The manager told us that these service users planned to go bowling and have lunch out afterwards. It was positively noted that staff had developed photographic representations of the various activities service users could choose to engage in each day, which are conspicuously displayed on the large notice board in the dining room. Daily diary notes examined for the two service users being case tracked revealed that in the past four weeks these two individuals had participated in a wide variety of social, leisure and recreational activities, both at home and in the wider community. Activities engaged in included day trips to the coast, walks in a local park, drives in the country, shopping, playing various games in the art room, and using both the homes sensory rooms. The manager told us that he planned to take a service to the bank that afternoon. The home has a visitor’s book which staff asked me to sign on arrival. A member of staff spoken with said they always made sure service users guests were made to feel welcome. The manager told us that service users are actively encouraged to participate in household chores and a section to include this expectation is contained in the new care plan format. Menus are varied and nutritionally balanced. As previously mentioned in this report it was positively noted that the weekly menus are available in pictorial format to enable service users to make informed choices about the food they eat. Staff maintain a detailed record of all the food consumed by service users as a means of determining whether or not peoples diets are satisfactory. The manager told us that advice had recently been sought from a nutritionalist about one service users diet and new guidelines established. These guidelines were conspicuously displayed in the kitchen and two staff spoken with were aware of their new responsibilities regarding this individual dietary needs. The two new care plans (draft versions) examined both contained detailed information about these individuals food and drink preferences, as well as their dislikes. Lunch was served at 1.30pm in the open plan lounge dinning room. It was positively noted that the member of staff who had prepared the meal sat down at the dinning table and joined three service users for their lunch. The meal of chicken stew, mixed vegetables, boiled potatoes, and gravy looked very appetising. Specialist equipment in the form of angled cutlery and non-slip mats were also observed being used over lunch to enable the service users to enjoy their meal without requiring any direct staff assistance. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 13 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. The home has suitable arrangements in place to ensure the people who use the service receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are always recognised and met. Overall the homes policies and procedures for handling medication are robust, but will still need to be improved to ensure people who use the service are not placed at risk of harm because they have not received all their prescribed medication. EVIDENCE: All the service users met during this visit were suitably dressed in wellmaintained clothes that were appropriate for the season. Staff maintain detailed records of all the health care appointments service users attend with various health care professionals, which includes the Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 14 outcome of these visits. One service users files examined in depth revealed they had seen their GP for a routine check up and a dietician in the past six months. One member of staff spoken with demonstrated a relatively good understanding of the two service users being case tracked unique personal and health care needs. The manager told us that individuals who require support to promote their continence receive regular input from community-based nurses. Staff spoken with demonstrated a good understanding of individual service users continence management routines, but the manager told us none of his staff team had received any training about continence promotion (See ‘Staffing’ outcome group NMS No.35). Staff maintain detailed records of all the accidents involving service users. There record showed that no accidents involving service users had occurred in the home since it was last inspected. Records revealed that staff on duty had appropriately dealt with all the incidents involving service users since February 2007. The homes manager was fully aware that he had a duty of care to notify the Commission without delay about the occurrence of any ‘significant’ incidents or event in the home. No recording errors were noted on the medication administration sheets in place for the two service users being case tracked. However, during a tour of the premises a capsule of medication was found under a sofa cushion in the lounge. The manager told us there is a person using the service who has a condition, which makes it difficult for them to hold things in their mouth and will therefore very occasionally drop oral medication prior to swallowing. The manager has agreed to establish a management strategy to minimise the risk of oral medication not being taken by this individual and will remind his staff team to be more diligent when administering medication to them in the future. All the medication currently held by the home on service users behalves is securely stored in a locked cabinet in the office. Protocols for the use of ‘As and when required’ (PRN) medication were made available on request, which set out in detail when and how staff should administer it, and who is ultimately responsible for authorising its use. It is recommended that staff write the reason why they administered PRN medication in the space provided on the reverse side of medication administration sheets. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes arrangements for dealing with complaints and allegations of abuse are sufficiently robust and understood by staff to ensure people who use the service feel listened to and safe. EVIDENCE: A copy of the homes complaints procedure is included in the service user guide and specifies who deals with them and how long a complainant can realistically expect to wait for a response (i.e. within 28 days). The manager confirmed that no complaints or allegations of abuse had been made about the homes operation in the past twelve months. The manager demonstrated a good understanding of the action he would need to take if an allegation of abuse was made within the home. The manager was able to produce a copy of the Department of Health’s ‘No secrets’ on request. Care plans being case tracked contained specific guidance to help staff minimise the occurrence, as well as deal with, incidents of challenging behaviour. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 16 The balances recorded on the financial sheets kept for the two service users being case tracked matched the amounts being held by the home on their behalves. The manager told us the providers have set a maximum limit regarding how much money can be kept in the home at anyone time to minimise the risk of theft. The money was individually stored in a secure place in the homes safe. Receipts are kept for all goods and services purchased by staff on service users behalves. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 17 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, 26, 27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall décor, and condition of the fixtures and fittings in the home ensures the service users live in a relatively homely and comfortable environment. The homes arrangements for keeping the premises hygienically clean and for despising of clinical waste need to be improved as a means of controlling infection. EVIDENCE: The manager told us there have been no significant changes made to the interior design or layout of the home since it was last inspected. On arrival three service users were observed relaxing on sofa in the lounge, and appeared to look quite content. During a tour of the premises the home was noted to be relatively clean, although a lot of left over food, paper, and other Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 18 items of rubbish, including a disregarded capsule of medication, were all found under a number of sofa seat cushions in the lounge. Furthermore, the fabric covers on all the lounge sofas looked rather ‘shabby’ and the manager conceded that they were not ideal for meeting the service users continence needs. More suitable sofa covers will need to be obtained that are fit for purpose. All the service users bedrooms that were inspected were decorated to a reasonable standard and contained all the furniture and fittings the occupant would require. The temperature of hot water emanating from the first floor bathroom was found to be a safe 40 degrees Celsius when tested at 14.10. The homes new washing machine is capable of cleaning laundry at appropriate temperatures and has a sluice programme for dealing with soiled laundry. Sufficient supplies of latex gloves and plastic aprons were found in this area for staff to wear as and when required. The manager demonstrated a good understanding of the homes arrangements for disposing of this clinical waste, although a number of used yellow and black clinical waste bags were found pilled up on top of a bin in the side alley contrary to infection control standards. The manager told us he would remind his staff team about their infection control responsibilities and arrange suitable training. The manager also told us that arrangements for the collection of all the electrical equipment and various items of furniture left out in the side alley had already been made with the appropriate authorities. Progress on this matter will be assessed at the homes next inspection. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 19 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): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, sufficient numbers of very experienced and competent staff are employed on a daily basis to support the needs, activities, and aspirations of the people who live at the home. The homes recruitment procedures are sufficiently robust to minimise the risk of service users harmed by people ho are ‘unfit’ to work with vulnerable adults. EVIDENCE: On arrival three support workers and the registered manager were all on duty, which matched the staff rota for that days early shift. The manager told us he had a full compliment of staff of which just over 50 had either achieved an National Vocational Qualification (level 2 or above) in care who were currently working towards this aim. The manager said he is confident that the four staff currently studying for their NVQ’s will have completed their training by the end of 2008. The manager is aware that all his staff team should be NVQ trained Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 20 and it is recommended the providers establish a time specific action plan setting out how they intend to achieve this aim. The manager told us that the home continues to experience relatively low rates of staff turnover and therefore he has only needed to recruit one new member of staff in 2007. The new member of staffs file was examined in depth and was found to contain a completed job application form, two written references, proof of their identity, and an up to date Criminal Records Bureau reference number. The manager told us that as agreed with the Commission all new staffs CRB’s and Protection of Vulnerable adults register checks are held at the providers central office. In accordance with this agreement documentary evidence to show that a protection of vulnerable adults check had been carried out in respect of the homes latest recruit was faxed threw to Reddown Road within minutes of the request being made. The homes latest recruit told us they had received a thorough induction, which was currently on going that had covered the homes fire safety arrangements, first aid, food hygiene, and abuse. The new member of staff was very clear what action they would need to take in the event of the fire alarm being sounded. Documentary evidence was produced on request to show this individual had received one formal supervision session since commencing work at the home. The manager also told us it was custom and practise for all new staff to receive at least three supervisions with a suitable qualified senior member of staff during their probationary period of employment. A member of staff who came on duty after lunch was very clear about their roles as a support worker and knew what was expected of them. The manager has carried out a training needs and strengths assessment of his entire staff team. The document revealed that sufficient numbers of staff were suitably trained in fire safety, first aid, food hygiene, managing challenging behaviours, adult protection, handling medication, and working with people with epilepsy. As previously mentioned in this report staff need to receive additional training in infection control and continence promotion. It is also recommended that in order to help staff implement the new care plan format sufficient numbers receive person centred care planning training. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Overall, the homes management arrangements are meeting the needs of the people who live at Reddown Road. The homes health and safety, and fire prevention arrangements are not sufficiently robust to safeguard the welfare of the people who use the service, their guests, and staff. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 22 EVIDENCE: The homes manager is suitably qualified to run a care home. The manager told us that since the homes last inspection he has received training in how to implement the provider’s disciplinary procedures. The manager was able to describe a clear vision of the home and able to evidence a sound understanding and application of ‘best practice’, particularly in relation to meeting service users needs. The manager was able to produce the minutes of three staff meetings that had been held since the beginning of the year. The minutes revealed these meetings were very service user focused and that keyworkers played a very active role in setting the agenda. The manager told us he believes the results of any stakeholder satisfaction surveys the home regular undertakes will continue to be published on an annual basis for any interested parties to view. This standard will be assessed in greater dept at the homes next inspection. A number of reports were produced on request to show that senior staff representing the providers continue to carry out unannounced monthly inspections of the home as part of Milbury cares quality monitoring system. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 23 The homes fire records revealed staff continue to test the fire alarm system every week and conduct fire drills on a regular basis. It was positively noted that a fire drill was recently carried out at night to test the night’s staff’s knowledge of the homes evacuation procedures. During a tour of the premises it was noted the front door, which should have automatically activated a security alarm when opened, failed do so because the override button had not been reset. The manager immediately rectified the problem and has agreed to remind his staff team about their health and safety responsibilities. On arrival it was noted the laundry room door was being inappropriately propped open by a coil of extension leads, which would prevent its automatic closure in the event of the fire alarm being activated. The laundry room door is fire resistant and the manager was reminded that under no circumstances must such doors be wedged open as they form an essential part of the homes fire containment arrangements. A member of staff on duty at the time removed the offending wedge when asked. Furthermore, the under the sink cupboard in the laundry room, which was full of chemicals and other substances hazardous to health (COSHH), was also found open. This was concerning as the only member of staff working on the floor at this time was in the kitchen leaving the three service users in the lounge unsupervised with open access to the laundry room and the COSHH cupboard within. Due to the serious nature of this health and safety breach of the Care Homes Regulations (2001) an Immediate Requirement Notice was issued at the time of this site visit. The same member of staff who removed the door wedge also locked the COSHH cupboard at the same time. Up to date Certificates of worthiness were in place to show that suitably qualified engineers had checked the homes gas (Landlords) and electrical installations, portable electrical appliances, passenger lift, fire extinguishers, and fire alarm system, in the past twelve months. The homes water heating was last checked for legionalla in October 2005 and is well over. Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 24 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 1 X Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 25 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 YA9 Regulation 12(1)(b), 13(4)(b), 15(2) & 18(1)(a) Requirement Timescale for action 09/07/07 2. YA20 3. YA24 4. YA30 5. YA35 Service users who have been assessed as requiring staff support whilst out in the wider community must never be left unsupervised in a parked vehicle. Staff must also be reminded about their supervision responsibilities and review risk assessments regarding the use of the homes vehicle. 13(2) & Staff must more vigilant when 18(1)(a) administering oral medication and associated risk assessments reviewed. 23(2)(d) All the ‘shabby’ fabric covers on sofas in the lounge must be replaced with more suitable covers that are fit for purpose. 13(3) & All the soft furnishings in the 23(2)(d) (o) home must be kept clean and clinical waste disposed off in accordance with basic infection control standards. 12(4)(a), Sufficient numbers of staff 13(3) & must be suitably trained to 18(1)(c)(i) control infection and promote continence. DS0000025829.V344614.R01.S.doc 09/07/07 01/10/07 09/07/07 01/10/07 Reddown Road (37) Version 5.2 Page 26 6. YA42 13(4) & 23(2)(c) 7. YA42 13(4) & 23(4)(c)(i) 8. YA42 13(4) (6) 9. YA42 13(4) (6) The front door must activate a security alarm every time it is opened to minimise the risk of unplanned absences of service users. All fire resistant doors must be kept shut and never be wedged open as they form an essential part of the homes fire containment arrangements. Chemicals and other substances hazardous to health (COSHH) must be kept securely locked away when these products are not in use to minimise the risk of service users being harmed. An Immediate requirement Notice was issued at the time of this visit. A suitably qualified engineer must test the homes water heating system for Legionella. 02/07/07 02/07/07 02/07/07 01/08/07 Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations The date the homes Statement of purpose was last reviewed should be included on the document in order to allow anyone reading it to determine how frequently it is updated. Staff authorised to handle medication in the home should always write the reason why they decided to administer ‘as required’ (PRN) medication in the space provided on the reverse side of medication administration (MAR) sheets. The providers should establish a time specific action plan setting out how they intend to ensure the homes entire staff team achieve an NVQ level 2 or above in care by an agreed date. Sufficient numbers of staff should receive person centred care planning to help them implement the new care plan format. 2. YA20 3. YA32 4. YA35 Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Reddown Road (37) DS0000025829.V344614.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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