Inspection on 23/06/06 for Reddown Road (37)

This inspection was carried out on 23rd June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 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) 02/07/07

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 23 & 28th June 2006 09:40 rd Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 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.V293457.R02.S.doc Version 5.1 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.V293457.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Reddown Road (37) Address 37 Reddown Road Coulsdon Surrey CR5 1AN 01737 559 309 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 Limited Mr Gavin Ainslie Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 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. 25th October 2005 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 recently been re-landscaped and is far more accessible. The home ensures prospective service users and their reprensentatives are supplied with all the inforamtion 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 £1,200 - £1,300 per week. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered the Commission for Social Care Inspection (CSCI) considers this service to have substantially more strengths than weaknesses and the overwhelming number of key National Minimum Standards inspected were assessed as met. Nevertheless some ‘serious’ concerns relating to the safety of the service users and quality assurance matters were noted and the providers are required to supply the Commission with an action plan setting out how they intend to improve their service. The Commission is confident the providers will acknowledge all the weaknesses identified in this report and will have little difficulty resolving them in a timely fashion. The initial unannounced site visit to the home was carried out on Friday 23rd June 2006 between 9.45am and 2.15pm, which was closely followed up by a one and a half hour announced visit five days later on 28th June 2006. During the course of these two visits six service users; the homes Registered and Deputy managers; and two support workers, were all met. Prior to the site visits taking place one service users relative was contacted by telephone and their opinion sought about the quality of the care provided. A total of three comments cards were also received by the Commission about the home, all of which had been completed by the relatives of service users. The registered manager also contributed to the inspection process by completing preinspection questionnaire and an equalities survey about his staff team and residents. The remainder of these site visits were spent examining the homes records and touring the premises. What the service does well: The feedback received from service users relatives about the home was in the main quite favourable. One service users relative wrote they were ‘very pleased at the care (their loved one) was receiving’, whilst another relative said they ’were generally satisfied with the standard of care provided’. The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Each resident has a plan that has been agreed with them and the home ensures they are continually reviewed to reflect changes in need. In the main the providers recognise the importance of training and delivers where possible a programme that ensures staff are competent to carry out their duties and meet the collective and individuals needs of the service users. As the home has experienced relatively low levels of staff turnover in the past twelve months the service users have also benefited from being supported by an experienced staff that are familiar with their unique needs and preferences. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The positive comments made above notwithstanding both the manager and his deputy acknowledged the home, and in some instances the providers, could do better in a number of clearly identifiable ways: During the initial site visit it was noted that the temperature of hot water emanating from a first floor bath was dangerously high and records revealed this particular water outlet was not being checked by staff a regular intervals. An Immediate Requirement Notice was served at the time for appropriate action to be taken to resolve this major breach of health and safety regulations. It was confirmed five days later during the second site visit to the home that all the required action had been taken in a timely fashion to make the bath safe again for residents use. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 7 All the staff met, which included the management team, felt that overall the range of social, leisure and recreational opportunities available to service users had significantly improved in the past twelve months, although the deputy conceded that was always room for improvement and said all the new in-house activity facilities could be much better utilized by staff. The providers have introduced a professionally recognised self-monitoring system, which uses satisfaction questionnaires to seek the views of service users, their relatives, and professional representatives, as a means of improving quality. The providers findings were last published at the end of 2004, but due to circumstances beyond the provider’s control, no results have ever been published since. While the Commission accepts that the results of any quality assurance surveys undertaken in 2005 were lost when the providers computer system crashed, it does not explain why no action has been taken since to rectify this on going matter and plans made for the results of surveys undertaken in 2006 to be published. The providers are reminded that the results of quality assurance surveys should be published at regular intervals to enable any interested parties to evaluate how successful or not the service has been at archaising its stated aims and objectives. Finally, the deadline for at least 50 of support workers to have achieved or be at least be working towards obtaining a National Vocational Qualification in care Level 2 or above expired at the end of 2005 and the providers are now required to produce a time specific action plan setting out how they intend to meet this minimum training target. 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. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 8 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.V293457.R02.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using all the available evidence. The home has produced an up to date residents guide that ensures prospective service users and their representatives have the vast majority of information they need to make an informed choice about whether or not to move in. Sufficiently robust arrangements are in place to ensure no prospective service users are admitted without their unique aspirations and needs being thoroughly assessed to determine whether or not the placement is capable of meeting their needs. Service users and their representatives are supplied with written contracts that sets out in detail their individual terms and conditions of occupancy, including the fees they can expect to be charged, which ensures this process remains open and transparent. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 10 EVIDENCE: The deputy manager was able to produce a copy of the homes most up to date Service users guide on request that had been reviewed in the past twelve months and contained the vast majority of information prospective service users and the representatives needed to know about the home. The Guide does not contain any of the residents or their representatives views about the standard of care provided, which should be included in the document as a means of assuring quality. The new deputy manager said the service had not received any new referrals in the past six months and was fully aware of the provider’s admissions procedures and the specific criteria used by the home for accepting new referrals. The files of two service users sampled at random both contained up to date Service Agreements that set out in detail these individuals terms and conditions of occupancy, which included the range of fees they and their representatives would be charged for facilities and services provided. These contracts had both been signed and dated by all the relevant parties. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Quality in this outcome area is good. This judgement has been made using all the available evidence. The homes arrangements for developing care plans are sufficiently robust to ensure each service users unique needs and personal goals are identified, met, and continually reviewed to reflect any changes. EVIDENCE: Three service users care plans inspected at random had each been formally reviewed in the past twelve months and up dated accordingly. The service users, their next of kin, independent advocates, Care managers, designated keyworker and the homes manager are always invited to attend these annual review meetings. In addition to these formal meetings care plans had also reviewed in-house on both a monthly and bi-annual basis to ensure they continually reflect service users constantly changing needs and aspirations. All three plans inspected had been up dated in the past six months, although not all of them had been reviewed each month by their designated keyworkers, in accordance with the provider’s policies. Records indicated that while one service users plan had Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 12 been reviewed by their designated keyworker six times since the beginning of the year another plan had only been reviewed once during the same period. Each service user has an assigned a keyworker. A comprehensive list of assessments that set out in detail the action to be taken by staff to minimise identified risks were available from the three care plans inspected and covered guidance to help staff deal with epilepsy, bullying, accessing the wider community, and unplanned absences by service users. The new deputy was fully aware of the importance of these risk assessments and the need to kept them under constant review. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. Social, leisure and recreational resources available to service users has significantly improved in the past twelve months, especially those in the wider community, although staff could be more proactive when it comes to encouraging service users to pursue a more meaningful and stimulating inhouse activities on a daily basis. Suitable arrangements are in place to enable service users to maintain good links with their families and friends. Dietary needs are well catered for and the meals nutritionally well balanced, providing daily variation and interest for the people living at the home. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 14 EVIDENCE: One service users care plan referred to the individuals spiritual needs and it was clear from their daily diary notes that staff supported them to attend Sunday Services held at a local church each month. Having arrived at 9.40am the vast majority of service users were either sitting relaxing in the main lounge or the back garden. Three daily diary notes sampled at random indicated that service users are accessing more social and leisure facilities in the wider community, which included walks in local parks, shopping in Croydon and trips to the cinema. Just before lunch a couple of staff used their initiative and decided to take two service users out for a drive to buy a Chinese takeaway meal for lunch. However, it was disappointing to observe while on several tours of the premises that none of the other service users who had remained at home seemed to be engaging in what could be described as any ‘meaningful’ or ‘stimulating’ activities. The one member of staff who had clearly been assigned the task of supervising all those service users who were at home appeared to spend most of the duration of the site visit sitting in the main lounge with service users watching daytime television. The service users who were in the lounge were clearly not watching the television and this is lack of staff interaction was particularly surprising since the service has made significant progress in recent years to improve its in–house activity facilities, which now includes a new games room that is better resourced, a sensory room and far more user friendly and accessible rear garden. These comments not withstanding it was still positively noted that the main lounge was adorned with flag bunting representing all the nations competing in the World cup and the new enlarged games room was suitably well-equipped with all manner of educational, art and craft, and leisure materials. Whilst informally interviewing another member of staff in the games room one service user came in to use some building blocks. The deputy manager said none of the service users have been on any day trips this year although arrangements were currently being made for this to be rectified. Progress on this matter will be assessed at the homes next in inspection. Records showed that three service users have already been on holidays this year. The home has an open visitors policy and none of the staff met said they were aware of any restrictions on visiting times. One service users next of kin spoken with on the telephone said they regularly visited their loved one at the home and quite often took them and some of the other service users out for a meal. It was positively noted that staff had arranged a trip for a service user to Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 15 visit the grave of one of their recently deceased relatives whom had lived some distance from the home. The two members of staff informally interviewed about meals said they both believed the service users were in the main satisfied with the food provided. The Chinese takeaway bought for lunch that day appeared to go down very well with both service users and staff, although it was concerning to note that for reasons unknown one member of staff insisted on eating their lunch whilst walking around the lounge after everyone else had finished theirs. This matter was raised with the registered manager and while it is appreciated that the high support needs of the services users make it impractical at times for staff to provide appropriate assistance at mealtimes and eat their food at the same time, there is no excuse for anyone to wander around the house whilst eating hot food. This poor practice is not only hazardous, but shows a lack of respect for the service users home. It was pleasing to note that the registered manager had already made this poor practice issue an agenda item to be discussed at the next staff meeting, which was due to be held the following week. During the course of this visit one service user was observed effectively using non-verbal communication to express their wishes to the deputy manager. The deputy clearly had a good understanding of this particular individuals unique method of communicating and promptly made the individual a cold drink as requested. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using all the available evidence. The home has sufficiently robust arrangements in place to ensure service users health care needs are continually recognised and met, and the occurrence of any significant accidents and/or incident appropriately logged and reported to the relevant professionals. Sufficiently robust systems are in place to ensure medication records are appropriately maintained and monitored to protect service users unnecessary harm. EVIDENCE: On arrival all five of the service users relaxing in the main lounge were wearing age appropriate clothing, including a variety of T-shirts and light summer trousers, suitable for the warm weather being experienced that day. All the services users had clearly been shaved and the deputy manager said she was not aware of any incidents when staff had inappropriately used one service users electric razors to shave everyone. The manager also said that all the service users were currently supported by staff to wet shave and therefore it was not necessary to keep electric razors in the house. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 17 All three of the care plans examined in depth revealed that staff ensure service users regularly attend appointments with local health care professionals, including community based GPs, dentists and opticians. These plans contained a comprehensive overview of each service users general health care needs, which are continually updated to indicate any changes. The homes accident book revealed that none of the service users had been involved in any serious accidents in the past six months or sustained a major injury in that time. Records of all the incidents that had occurred in the home in the past six months revealed that staff were fully aware when to log this information and to whom it should be reported. Two staff spoken with about the recording and reporting of accidents and significant incidents were clearly aware of the difference between an accident and a significant incident, and when the Commission must be notified about them. Records are kept of all medicines received, administered, and returned to the dispensing pharmacist by the home and no recording errors were noted on three service users Medication Administration sheets sampled at random. These records accurately reflected the current medication stocks held by the home on service users behalves, which are securely stored away in a locked metal cabinet in the first floor office. The deputy manager said that none of the service users were currently prescribed any ‘as required’ (PRN) or Controlled drugs. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using all the available evidence. The home has sufficiently robust arrangements in place to ensure service users have access to an effective complaints procedure, have their legal rights protected and so far as reasonable practicable, are protected from abuse. EVIDENCE: The home has a complaints procedure that is up to date and is available in a number of formats to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is widely distributed and copies are included in the new residents guide and pined to a notice board in the office. The homes complaints log revealed that no formal complaints or informal concerns had been made about the homes operation in the past six months. A copy of the homes Whistle blowing procedures for staff to follow in the vent of witnessing or suspecting abuse was conspicuously displayed in the office. Two members of staff informally interviewed said they had both recently attended training course of recognising, preventing, and reporting vulnerable adult abuse. The manager confirmed that sufficient numbers of his current staff team have received refresher training in the use of Non-Violent Crisis Intervention techniques. Staff interviewed were both aware that these techniques should only be used as a ‘last resort’ when all other methods had failed when dealing with an aggressive incident. The manager and his deputy both confirmed that on no occasion in the last six months had staff physically intervened to deescalate a potentially dangerous situation. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 19 Financial records sampled at random all contained up to date information about all the transactions taken by staff on their behalves, which tallied with the amounts of money in the homes safe for each service user. This money is individually stored and receipts are also kept of all the purchases made by staff on service users behalves. One wallet sampled at random, which was being held by the home for safekeeping, contained a huge amount of money that ran into hundreds of pounds. The deputy was not aware of any reason why such a large sum of money was being held in the home for this particular individual. To minimise the risk of theft large sums of money should not be kept on the premises. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including two site visits to this service. The recent changes made to the physical design and layout of both the external grounds and the homes interior ensures service users live in a clean and comfortable environment, which suits their needs and lifestyles. EVIDENCE: During a tour of the premises it was noted the home was very clean and free from offensive odours. The conservatory doors leading to the garden were open on arrival that made the main lounge/dinning area appear much bigger and brighter. The new layout of the rear garden, especially the sloping ramp and grab rail leading from the patio area to the raised lawn, has made the homes external grounds far more accessible for service users. The majority of service users were observed accessing this space at one time or another during the course of this two-day site visit. There is also a new bench for service users to sit on and a new wooden fence has replaced the old chicken wire one, which was unsuitable for its purpose. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 21 The internal layout of the home has also significantly altered in the past twelve months with the converting of the old kitchen into a much larger games/activities room. Work has also commenced on transforming a spare bedroom on the first floor into a second sensory area. Progress on this matter will be assessed at the homes next inspection. During a tour of the building it was noted that all the radiators on the first floor landing were on full blast making this confined space unbearable hot. The deputy manager turned all the radiators off at the time and said he would remind staff about leaving them on in the hot weather. A question mark was also raised about the reliability of homes boiler that the deputy said the manager was following this matter up with Milburys maintenance department. The furnishings and fittings in all the communal areas are of good quality, domestic in appearance, and seem to meet the service users needs. During a tour of several of the service users bedrooms it was noted that they were all decorated and furnished to a good standard, felt pleasantly warm, and looked quite personalised. One service user who resided on the first floor was very keen to show off their recently redecorated bedroom, which they were clearly very pleased with. It was positively noted that in the lounge and several of the bedrooms television had been encased in transparent cabinets that had been secured to the wall to minimise the risk of the sets being damaged. The homes washing machine is capable of washing clothes at appropriate temperatures and also has a sluice facility. Hand washing facilities are prominently sited in this area and adequate supplies of latex gloves were located at convenient places throughout the home. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using all the available. The home is clearly committed to training and in the main ensures that sufficient numbers of suitably qualified staff are on duty at all times to meet the individual and collective needs of the service users. However, the providers arrangements for ensuring at least 50 of the homes staff have either achieved or are working to obtain a National Vocational Qualification in care remain woefully inadequate and must be improved to ensure services users are supported by suitably competent staff. Service users do benefit from the fact that the current staff team is well supported and supervised by their line managers. EVIDENCE: Staff training records revealed that three members have achieved a National Vocational Qualification in care (Level 2 or above) and a fourth person is currently enrolled on a suitable NVQ course. The manager is acutely aware that the deadline to meet this National Minimum Standards of having at least 50 of a services support workers either NVQ trained or enrolled on a suitable course expired at the end of 2005. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 23 The number of staff on duty at the time of the first site matched the duty rosters for that morning. Four staff comprising of the deputy manager and three support workers were all on duty, which was adequate to meet the assessed needs of the service users. The deputy manager said that a minimum of three staff would always be on duty throughout the day that he felt was adequate to meet the service users needs. The home has experienced relatively low levels of staff turn over in the past twelve months and consequently the manager has not needed to recruit any new members of staff, although one member was recently promoted to cover the vacant deputy manager’s position. The new deputy was very enthusiastic about his new role and had clearly done a competent job running the home in the registered managers absence, which was still on annual leave at the time of this inspection. With the exception of NVQ’s the providers seem to recognise the importance of training, and in the main deliver a programme that meets the service users needs. Documentary evidence was available on request to show that sufficient numbers of the current staff team had received up to date training in a number of core areas of practice, including fire safety’ moving and handling; first aid; basic food hygiene; vulnerable adult protection and physical intervention techniques; and handling medication. In addition, the majority of staff had recently attended specialist training courses to improve their knowledge and understanding of autism and epilepsy. The manager is also committed to ensuring all his staff team, especially new members, are inducted using the Learning Disability Awareness Framework. The current staff team is culturally very diverse with the continents of Europe, Africa, and both Central and South America all represented, although the overwhelming majority are of black African origin. The manager conceded that while the ethnic diversity of his current staff was quite representative of Croydon as a whole, it did not accurately reflect the ethnic origins of the entirely white British service user group. The manager has agreed to be mindful of this ethnic and cultural imbalance when he next recruits. Three staff files inspected at random all contained documentary evidence to show they had each received at least three formal supervision sessions with a suitably qualified senior member of staff in the past six months, in line with this standard and the providers own supervision procedures. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is poor. This judgement has been made using all the available. The service users benefit from living in a reasonably well run home which two suitably experienced and competent individuals manage. The homes arrangements for assuring quality are currently inadequate. If satisfaction surveys are not undertaken at regular intervals and the results published at least annually then all the major stakeholders, including service users, their relatives and professional representatives, as well the providers themselves, will be unable to evaluate how successfully or not they have been in achieving the services stated aims and objectives. In the main the homes health and safety arrangements are sufficiently robust to ensure that so far as is reasonably practicable the service users and staff are protected from unnecessary harm, although procedures for ensuring hot water temperatures remain at a safe level were found to be woefully inadequate. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 25 EVIDENCE: The registered manager has achieved a National Vocational Qualification in management and care – Level 4 and has well over two years experience of working with adults with learning disabilities in a management capacity. Records showed that two staff meetings had been held since the beginning of the year and that another was scheduled to take place that afternoon. Topics covered were wide training and included staff morale, which everyone spoken with during the coursed of this six-hour inspection said had significantly improved in the last six months. The home has up to date equal opportunities and racial harassment policies and procedures in place that referred to all the relevant anti-discrimination legislation, (e.g. Race Relations, Sex, and Disability Discriminations Acts). The providers continue to carry out unannounced monthly inspections of the home and compile a written report of their findings, which are then forwarded to the Commission and the homes manager. The providers have a quality assurance system in based on seeking the views of all the major stakeholders in the service, which includes services users, their relatives, and professional representatives. However, the manager conceded that to the best of his knowledge the results of the homes last quality assurance review were published at the end of 2004. The Commission is fully aware of the mitigating circumstances beyond the providers control that meant the results of last years (2005) quality assurance surveys could not be published, but cannot understand why a time specific action plan to address this on going matter has still not been established. At the time of the first site visit to the home the temperature of hot water emanating from the shared first floor bath was found to be an unacceptable 57 degrees Celsius at 12.15, some 14 degrees over the recommended safe level. It was also noted that although staff continue to appropriately maintain water temperature records of the ground floor Parker bath no checks were being carried out in respect of the first floor bath. Consequently, the faulty thermostatic mixer valve attached to this bath had gone unnoticed. The deputy manager said all the service users that regularly used the first floor bath needed staff support with personal care and therefore would never be left unsupervised whilst in the bath. An immediate requirement notice was issued at the time for this ‘serious’ breach of health and safety to be resolved within the next five days. It was also agreed that the bath could continue to be used in the interim providing staff checked the temperature of the hot water being used. Having carried out a second site visit on 28th June 2006 it was noted that the temperature of hot water emanating from the first floor bath was a safe 42 degrees Celsius and staff were now checking the temperature at regular Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 26 intervals. During the course of the second site visit a member of staff from Milbury’s maintenance department arrived to check the homes water system. The homes fire records showed the alarm system is tested on a weekly basis and fire drills undertaken at least once every quarter. Since the beginning of the year two successful fire drills involving all the service users and the majority of staff have been carried out. Safety notices were conspicuously displayed throughout the home in easily understood formats and all the homes emergency procedures were pinned to the notice board in the office. The new kitchen door, which was propped open at various times during the site visit has been fitted with a suitable realise mechanism that ensured it would close flush into its frame when the fire alarm was sounded. The cupboard under the kitchen sink had been fitted with a suitable locking devise to ensure (COSHH) products stored there were kept out of harms way. Up to date Certificates of worthiness were available on request as proof that suitably qualified engineers had tested the homes passenger lift and fire extinguishers in the past twelve months. All food kept in the new fridge was correctly stored in line with basic food hygiene standards. An officer from the Local Environmental Health Department last visited the home in November 2005 and stated in their subsequent report that the service was operating to a good standard, although records of fridge and freezer temperatures were not always being consistently maintained. Records sampled at random revealed this previously identified shortfall had now been resolved. Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 27 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 X 4 X 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 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 1 X X 1 X Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 28 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 YA32 Regulation 18(1) Requirement Timescale for action 01/01/07 2. YA39 24(2) 3. YA42 13(4) & 23(2)(c) At least 50 of the homes support workers must have either achieved or at least be working towards obtaining an NVQ level 2 or above in care by an agreed date. The providers must seek 01/09/06 stakeholders views about the service provided and publish the results of their findings at regular intervals. The temperature of hot water 28/06/06 used in baths must never exceed 43 degrees. Staff must check this at regular intervals and keep a record of their findings. Immediate Requirement Notice served and appropriate action taken to resolve the matter in a timely fashion (i.e. within 5 days). Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 29 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 service users guide should contain stakeholders (e.g. service users, their relatives and professional representatives) views about the standard of care provided at the home. Care plans should be reviewed at least once a month by each service users designated keyworker and up dated accordingly to reflect any changes in need. Staff should actively encourage and support service users to pursue valued and fulfilling in-house activities whenever reasonably practical. Staff should sit and eat their meals with service users whenever practicable and should not wander around the house eating their food. ‘Large’ sums of money should not be kept on the premises. The service providers should be mindful of the cultural imbalance that exists between the current staff team and the service users when recruiting new members of staff. All staff needs to be culturally aware and attend suitable training courses. 2. 3. 4. 5. 6. YA6 YA12 YA17 YA23 YA33 Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Reddown Road (37) DS0000025829.V293457.R02.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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