Inspection on 25/10/05 for Reddown Road (37)

This inspection was carried out on 25th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 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) 23/06/06

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 Unannounced Inspection 25th October 2005 1:20 Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 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.V256618.R01.S.doc Version 5.0 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.V256618.R01.S.doc Version 5.0 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) 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.V256618.R01.S.doc Version 5.0 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. 28th June 2005 Date of last inspection Brief Description of the Service: 37 Reddown Road is a residential care home that is owned, managed and staffed by Milbury Care Services a public limited company that specialises in providing accommodation and personal care for younger adults with learning disabilities. The home is registered with the CSCI to take up to eight service users at anyone time. There are seven male service users all aged between 50 and 70 years of age currently residing at the home. Gavin Ainslie continues to be the registered manager of the service, a post he has held since June 2003. The home itself is a large detached property situated in a quiet residential street in Coulsdon, a suburb to the South of Croydon. The home is within fifteen minutes walk of a variety of amenities, including local shops, resturants and pubs. The home also has its own transportation and is within a few hundred yards of a small local train station and several bus stops. The premises comprises of eight single occupancy bedrooms, a large L shaped open plan lounge/dinning area, new kitchen, sensory room, laundry facilities, and first floor office. The vacent space which the former kitchen occupied is to be turned into an enlarged activity/games room for the service users. There are sufficient numbers of toilets and bathrooms located near service users bedrooms and communal areas. The garden at the rear of the property has a raised lawn which can only be accessed by steps. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 13.20 on the afternoon of Tuesday 25th October 2005 and took three hours to complete. Since the homes last inspection, carried out in June 2005, the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the senior in charge of the late shift and another member of staff on duty at the time. During the course of this inspection the manager of another Milbury care home who had come for a visit, was also met, albeit briefly. This visit was part of Milbury cares temporary arrangements for running Reddown Road in the registered managers absence, who remains on sick leave. As part of the Commissions inspection process, one of the homes immediate neighbours was also spoken to at length about their views on the homes operation. The rest of the inspection was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although three vulnerable adult strategy meetings have been convened by the Local Authority since April’05 to discuss two separate incidents of alleged abuse at the home. What the service does well: What has improved since the last inspection? Since the home’s last inspection carried out in June 2005 all the requirements identified in the subsequent report have either been met in full or the previously prescribed timescale for action not expired at the time of this inspection. Areas of practice that have improved include record keeping, and in particular the maintaining of medication administration sheets by staff. In addition, the home physical environment has been significantly altered with a new fitted kitchen moved to the former games room ensuring extra space is now available for a new activities/games room. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 6 What they could do better: The positive comments made overleaf notwithstanding, the home in conjunction with the registered providers must improve in a number of key areas of practice. Firstly, it was disappointing to note that only one service user was out with staff on arrival, while the rest, all of whom seemed quite content, were nevertheless either just sitting or wandering around the home not engaged in what could be described as any particularly ‘meaningful’ activities. The television was on in the main lounge, but none of the service users seemed to be particularly interested in watching it. Service users daily diary notes and activity schedules sampled at random, as well as some of the comments made by staff, all indicated that the number and variety of community based activities the service users were being actively encouraged and supported to participate in on a regular basis was an area where the home could and should be doing better. Secondly, although the home has previously been commended for ensuring all the relevant authorities, including the Local Authority’s (the host Borough of Croydon) Vulnerable Adult Protection Team and the Commission, were always notified without delay about alleged incidents of abuse within the home, Milbury Cares multi-agency working practices need to be improved. Senior managers representing Milbury care acknowledge that the internal investigation into these alleged incidents of abuse was abnormally protracted and that mistakes were made. Furthermore, all the relevant agencies and other interested parties were not always kept informed about any progress being made, or lack of, by Milbury care in following these matters up. The whole process lacked openness and transparency. Thirdly, although the alterations made to the homes physical environment since the last inspection have benefited the service users, there are still some outstanding maintenance issues that need to be addressed. The offensive smelling carpet in one service user’s bedroom needs replacing and curtains rehung in another bedroom on the first floor. Furthermore, despite assurances given at the last inspection that the registered providers had set aside some money to re-landscape and erect a far more suitable fence in the rear garden, it was evident during a tour of the external grounds that no progress had been made since June’05. Finally, although sufficient numbers of staff on duty at the time of this inspection were on the whole suitably experienced and competent, more staff still need to attend recognising, preventing and reporting abuse; working with adults with autism; understanding epilepsy; and cultural awareness training courses. Furthermore, the interim arrangements made by the service providers for a suitably qualified manager from another Milbury care home to be on call while the homes registered manager remains on sick leave, although adequate, the Commission is nevertheless concerned about the lack of suitably Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 7 qualified and experienced senior staff currently working at the home who are able to take charge of the day-to-day running of the establishment in the managers absence. This sentiment was echoed by many of the staff on duty at the time and filling the vacant deputy managers position should be made a priority. 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.V256618.R01.S.doc Version 5.0 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.V256618.R01.S.doc Version 5.0 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): 2 Prospective and existing service users have access to all the information they need to know about the homes operation. EVIDENCE: The homes Certificate of Registration was conspicuously displayed in the office and accurately reflected its current conditions. There have been no new admissions or discharges since the homes’ last inspection, consequently, it remains fully occupied by the same seven service users who were residing at the home at the time of the its last inspection. The homes two most recent referrals appear to have settled-in and this all male service user group seem compatible with one another and appear to get on quite well. . Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 10 Care plans accurately reflect service users personal, social and health care needs, ensuring staff can plan for and met them. Suitable arrangements are in place to ensure so far as reasonably practicable confidential information held about service users is appropriately handled and kept secure. EVIDENCE: The senior in charge of the late shift said there have been no significant changes made to the homes care plan format in the past twelve months. The three care plans sampled at random were very detailed and contained up to date information about every aspect of the service users individually assessed personal, social and health care needs, as well as their preferences and aspirations. Some of the topics covered in one service users care plan sampled at random contained details about the individuals unique living and domestic skills; specialist communication needs and comprehension; food and drink preferences; social interests; spiritual needs, and sexuality. The two care plans sampled had both been reviewed in the past six months and updated accordingly to reflect changing needs. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 11 All the service users have specialist communication needs, which as previously mentioned, is well documented in each of their care plan. As most of the service users communicate non-verbally it has been agreed that group meetings are ‘probably’ not the most effective method of ascertaining their wishes and supporting them to make informed decisions about their lives. Nevertheless, the home does have arrangements in place that ensures the views of the service users are, so far as reasonably practicable, ascertained and expressed. Records of the homes last two team meetings, held on a bimonthly basis, revealed the agenda, which staff help set, enables them to raise specific issues on behalf of the service users they keywork. The shift leader said each service user has a designated keyworker who must attend their key service users annual review meetings and hold one to one sessions with them at regular intervals. Staff currently keeps no records of service users regular one to one sessions with their keyworkers. It is recommended that these sessions are documented; especially as the service users do not have their own group meetings. It was positively noted that the first floor office, which was not being used at the time if this inspection, was locked. A keypad device had been fitted to the office door to ensure only staff ‘authorised’ to access this area unsupervised could do so. These arrangements are adequate to ensure confidential information stored in the office, much of which is kept on open shelving, remains secure. The shift leader was aware when he must share information given to him in confidence and with whom this information should be shared. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 16 Arrangements to ensure the social, leisure and recreational interests of the service users are identified and met are in the main sufficient, although this could be improved upon to enable the service users to have far greater opportunities to engage in appropriate activities in the wider/local community. EVIDENCE: On arrival only one service user was out with their keyworker. The shift leader said they had gone out for lunch and planned to see a film afterwards. The majority of the service users who were in at the time were either sitting or wandering around the main lounge. None appeared to be engaged in any particularly ‘meaningful’ or stimulating activities. Having examined daily diary notes at random, the document used by staff to record all the social, leisure and recreational activities service users participate in each day, it was disappointing to note that according to these records a couple of service users had only been out less than half a times each in the past thirty days. Activities consisted of mainly drives and walks to unspecified destinations, although there had been other trips to the cinema and shopping. Very few of the service Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 13 users planned activity schedules matched what the majority of the service users were suppose to be engaged in at the time of this inspection. The shift leader acknowledged that the number and variety of community based activities the service users had the opportunity to engage in was an area, which the home could improve upon. Furthermore, the minutes of the homes last staff meeting revealed that one senior member of staff had already raised the lack of activities the service users were currently undertaking, especially at the weekends, as an issue. Duty rosters sampled at random indicated that sufficient numbers of staff are on duty at the weekends to enable service users to engage in community based activities and that sufficient numbers of staff are ‘authorised’ to drive the homes vehicle. As discussed with the manager at the homes last inspection, the shift leader was unaware that any members of the current staff team have been assigned the task of coordinating the homes activities. The home should consider employing an activities coordinator/s and establish strategies to ensure planned activity schedules are implemented. These comments notwithstanding it was evident from service users daily diary notes that staff continue to actively encourage and support the service users to engage in in-house activities of their choice, although as previously mentioned, there was a distinct lack of participation on arrival. Nevertheless, records sampled at random revealed that art, sensory and music sessions continue to be popular with the service users and the shift leader believed the new games/activities room would be ready for use by 2005. Progress on this matter will be assessed at the homes next inspection. During the course of this visit all three members of staff on duty at the time of this visit were observed interesting with the service users in a very friendly and respectful manner. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 Suitable arrangements are in place to ensure the service users physical and emotional health care needs are identified, planned for and met. The homes policies and procedures for dealing with medicines ensure the service users are, so far as reasonably practicable, protected from avoidable harm. EVIDENCE: Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 15 The homes accident book revealed that there had been one major accident involving a service user since their last inspection, which had resulted in the individual being admitted to casualty. No injuries were sustained and the record shows staff on duty effectively dealt with the incident at the time. There have also been ten other significant incidents involving service users, two of which pertained to windows being smashed. Guidelines are in place to minimise the risk of these type of incidents reoccurring and the Commissions database shows the home continues to notify us without delay about these events. It was however disappointing to note that a member of staff had recently recorded a significant incident involving a service user in the homes communication book. The shift leader has agreed to remind all staff about the importance of recording significant incidents on the correct documents. Medication administration sheets sampled at random were all meticulously maintained and no recording errors were noted where staff had failed to sign for medicines handled. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has suitable arrangements in place to ensure complaints are handled objectively and the views of service users listened to and acted upon. The homes vulnerable adult protection procedures, although in the main sufficiently robust to protect the service users from abuse and/or harm, more staff still need to receive suitable training in recognising, preventing and reporting abuse. EVIDENCE: According to the homes complaints log no formal complaints or concerns have been made about the homes operation in the past six months. Since March 2005 two separate incidents of alleged abuse have been reported to the Commission and Croydon’s Joint Community Learning Disability Team. In both instances the homes registered manager was swift to notify all the relevant authorities, including the host borough (Croydon SSD) for the home, the placing Authority’s for the service users involved, and the Commission, about these allegations. Croydon JCLDT convened two separate vulnerable adult protection meetings, in accordance with their vulnerable adult protection protocols, to share information with all the relevant professionals and agree the most appropriate way to proceed with these matters. It was agreed at both these meetings senior managers representing Milbury care would carry out internal investigations into both these allegations as soon as reasonable practicable and keep all the relevant parties updated about progress being made. Therefore it was concerning to note that despite these reassurances from the registered providers it took over six months for the first of these investigation Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 17 to be concluded. Furthermore, the whole process had not been particularly open or transparent with no details about the lack of progress being made by Milbury Care ever shared with any of the interested parties, including the homes registered manager, Care managers representing the service users, Croydon vulnerable adults team, or the CSCI. The first investigation eventually took six months to complete. The Commission excepts that suitable arrangements had been made by Milbury care to ensure the service users were not placed in any immediate danger and the reason for some of the delay had been caused by factors beyond the service providers control. Nevertheless, this does entirely explain why all the relevant parties were not notified much sooner about all the subsequent problems, which were hampering the investigation. At a follow up case conference held in October 05 a senior operations manager for Milbury advised the meeting that both matters had now been fully investigated and none of the allegations made substantiated, although the member of staff who had been suspended without prejudice for the past six months had subsequently resigned from their post. Other matters arising from these matters are discussed in greater depth in the section of this report entitled ‘staffing’. Both members of staff interviewed at the time of this inspection said that had received training in the use of Non-Violent Crisis Intervention (NVCI) in the past twelve months. The shift leader went onto to say that the underpinning philosophy of NVCI training is to teach staff how to de-escalate potentially aggressive situations before they occur and to only to use this physical intervention technique as a ‘last resort’, in accordance with Department of Health’s guidance on these matters. Records revealed that there have been no incidents of staff using physical intervention techniques in the past twelve months. One member of staff said they have yet to receive training in recognising, preventing and reporting vulnerable adult abuse. All staff must attend suitable training in this area of practice as a matter of urgency. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 28 Overall, the size and layout of the home, which is generally furnished and decorated to a reasonable standard, ensures the service users have a homely, comfortable environment, however greater care must be taken to ensure their safety. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 19 EVIDENCE: As part of a rolling programme to improve the homes physical layout for the benefit of the service users the new fitted kitchen has been installed in the homes former activities/games room with the intention of using the space previously occupied by the old kitchen as a much larger activities area. This was clearly a work in progress, but there was certainly sufficient space and suitable equipment for the preparation and storage of food in the new kitchen. A suitable locking device still needs to be fitted to the cupboard under the sink where a number of COSHH products are being stored and advice sought from the Local Environmental Health Authority about the need for the new kitchen to be inspection. Several of the bedrooms viewed at random had all been decorated and furnished to a reasonable standard and looked quite personalised. New floor covering must to be fitted in one service users bedroom and new Curtains/blinds in another to ensure these spaces suit service users individual needs. Bedroom No#2 looked like it had recently been redecorated and some new net curtains had now been hung in a first floor bedroom, which overlooked some of the homes immediate neighbours. However, the damaged wall in this same bedroom had not been repaired as recommended and a suitable doorstopper device not fitted to the wall to prevent further damage occurring. Reinforced toughened glass has now been fitted in one bedroom where the occupant recently smashed the window, although no were curtains hung. Staff explained that the individual who occupies this room often pulls them down. The requirement is therefore made that the home considers alternative ways of hanging curtains and/or covering windows in this room. For example, securing curtains with re-attachable Velcro. The carpet in bedroom No#7 needs to be replaced with more suitable floor covering as the room is currently rather odorous, despite the best efforts of staff to keep the carpet clean. Having tested the temperature of water running from the hot tap attached to the first floor bath it was found to be a safe 41 degrees Celsius at 13.10pm. The toilet seat in this bathroom is loose and will need to be made secure. Since the homes last inspection in June’05 when assurances were given that money had been set aside for the rear garden to be landscaped and a more suitable fence erected, it was clear from touring the external grounds that no progress has been made on these matters. The time specific requirement is therefore made that work commences on both these projects before Spring 2006 when the service users and their immediate neighbours will no doubt start accessing their respective rear gardens on a more frequent basis. Progress on these on going environmental matters will be assessed at the homes next inspection. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 20 Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 36 Sufficient numbers of suitably experienced and competent staff are employed to meet the health and welfare needs of the service users. However, sufficient numbers of staff still need training to ensure they are suitably qualified and competent to meet all the service users specific autistic and epilepsy needs. EVIDENCE: In the absence of a senior manager with access to confidential staff files the number of staff with a National Vocational Qualification in care could not be assessed on this occasion. Consequently, the previous recommendation that 50 of the homes staff team achieve this award or the equivalent by the end of 2005 is merely repeated in this report. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 22 On arrival three members of staff were on duty in the home and a fourth was out having lunch with a service user. The three staff met consisted of an experienced senior who was in charge of the shift, a relatively new, but nevertheless experienced member of staff and the homes most recent recruit. This was reflected on the home’s duty roster for the day and sufficient to meet the assessed needs of all seven of the service users currently residing at the home. Duty rosters revealed that one member of staff had who had recently resigned, had done so voluntarily, and had no returned to work having been suspended from their duties without prejudice since March 2005. Allegations made against this individual were never substantiated, following an internal investigation carried out by Milbury Care. The two staff interviewed during the course of this inspection both said most staff had begun working together more as a team and both felt recent tensions and conflicts in the group had started to ebb. Senior managers representing Milbury Care acknowledge that the home still needs to focus on staff team building and would need to be tackled as a matter of urgency in group and one to one staff meetings. This is clearly an on going process and will be assessed at the homes next inspection. Since the home’s last inspection one new member of staff has been employed. The care staff team, excluding the manager, are now overwhelming made up of individuals from a wide range of different ethnic backgrounds, including Afro, Afro-Caribbean and Latin American cultures. This clearly does not reflect the cultural heritage of the service users, who are all white Caucasians. The Commission accepts the home can only recruit new members from the choice of candidates available. This point not withstanding, the registered providers should nevertheless be more mindful of the cultural and ethnic imbalance that now exists between the service users and staff team. In the absence of the homes registered and deputy manager none of the staff files were inspected on this occasion. The timescale for action to meet the one requirement identified in the homes last report, which pertained to staff training, had not expired at the time of this inspection and is therefore not considered unmet. The requirement is merely repeated in the main body of this report with an unchanged timescale for action. Progress on this matter will be assessed at the homes next inspection. The shift leader said he last had a one to one supervision session with the manager in Septermber’05. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 23 Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 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 & 42 The service users and staff team would all benefit from the appointment of a suitably experienced and qualified deputy manager to be in operational day to day control of the home in the registered managers absence. The health, safety and welfare of the service users could be compromised if some of the homes fire containment arrangements are not improved. EVIDENCE: The homes registered manager was still on sick leave at the time of this inspection. The service providers notified the Commission about the absence of the homes manager as soon as they realised that it would be for a continuous period of more than 28 days, in accordance with the Care homes Regulations (2001). In the interim, the service providers have arranged for the registered manager of another Milbury care home in the area to visit Reddown Road on a weekly basis. Furthermore, the homes Senior Operations manager remains on call in case of emergencies. Staff interviewed said Michael Lugnada, the registered manager from another Milbury care home, had been visiting them Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 25 every Monday for the past month. During the course of this inspection Michael arrived unannounced around 3.30pm for a visit. Nevertheless, these arrangements notwithstanding, the Commission is still concerned that the home has insufficient numbers of suitably experienced and qualified senior staff who are unable to take charge of the day-to-day management of the home in the absence of the registered manager. The staff interviewed at the time of this inspection echoed this sentiment. The requirement is made that a suitably ‘fit’ person fills the vacant deputy manager’s position as soon as practicable. Having telephoned Julie Goodyear, the homes Operations manager, she was able to confirm that Gavin Ainslie, the home registered manager, would be returning to work on Monday 7th November 2005. Milbury care is reminded that the Commission must be notified in writing of the return to duty of a registered manager not later than seven days after the date of their return. Furthermore, the Commission must also be notified in writing about any proposals to significant alter the layout of a care home. It was noted that the new fire resistant kitchen door was being inappropriately wedged open at the time of this afternoon inspection while a member of staff was preparing food. The home is reminded that fire doors are essential for containing fires and under no circumstances must they be wedged open. If the service providers considers it to be in the service users ‘best interests’ to have the kitchen door held open when this space is being used then a suitable holding device (e.g. magnetic or dorguard) needs to be fitted to the door, which will enable it to close automatically when the fire alarm is sounded. The emergency call bell/alarm located in the passenger lift was tested at 13.35 and was noted to be faulty. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 3 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Reddown Road (37) Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000025829.V256618.R01.S.doc Version 5.0 Page 27 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 YA14 Regulation 12(3) & 16(2)(m) Requirement Timescale for action 01/02/06 2 YA19 3 YA23 4 YA23 A member of staff must be assigned the task of cocoordinating activities on service users behalves and strategies established to ensure planned social, leisure and recreational activity schedules are implemented. 18.1&17.1(a) All staff must be reminded 15/11/05 Sch3.3j to record the occurrence of all significant incidents on the correct documents. 12(1),13(6) & All the relevant authorities 15/11/05 37 must be kept informed about delays encountered by the service providers when investigating alleged incidents of abuse, in accordance with the Local Authorities vulnerable adult protection protocols and multi-agency working practices. 13(6)&18(1)Sch All staff must be suitably 01/02/06 2.4 trained in recognising, preventing and reporting vulnerable adult abuse and documentary evidence of this training made available DS0000025829.V256618.R01.S.doc Version 5.0 Page 28 Reddown Road (37) on request. 5 YA24 13.4,16.2(h)& 23(5) A suitable locking device must be fitted to the cupboard under the sink in the new kitchen where a number of COSHH products are currently being stored. Furthermore, advice needs to be sought from the homes Local Environmental Health authority about the possibility of one of their officers inspecting the new kitchen. The damaged wall in bedroom No#6 must be repaired and a suitable doorstopper device fitted to the wall to prevent further damage occurring. This was recommended in the homes previous inspection on 28/06/05, but no action was taken. Alternative ways to hang curtains and/or blinds must be considered for the first floor bedroom nearest the bathroom. The carpet in bedroom No#7 needs to be replaced with more suitable floor covering to minimise offensive odours lingering in this room. Work to improve the layout of the rear garden to make it more accessible and safe for service users and a more suitable fence erected must have at least started be Spring’06. Sufficient numbers of the current staff team must be suitably trained to meet the autistic and epilepsy needs of the service users. A suitably ‘fit’ person must fill the vacant deputy 01/12/05 6 YA26 16(2)(c) & 23(2)(d) 01/01/06 7 YA26 12(4)(a) & 16(2)(c) 01/01/06 8 YA26 16(2)(k) & 23(2)(d) 01/01/06 9 YA28 12(4)(a) & 23(2)(o) 01/03/06 10 YA35 12(1) & 18(1) 01/01/06 11 YA37 18(1) & 19(1) (2) 01/02/06 Page 29 Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 12 YA37 38(5) 13 YA37 39(h) 14 YA42 23(4)(a) (c)(i) 15 YA42 12(1) & 13(4) manager’s position as soon as practicable. The Commission must be notified in writing of the return to duty of the registered manager not later than seven days after the date of their return. The Commission must be notified in writing about any proposals to significantly alter the physical environment of the home. lf it is considered to be in the service users best interests it is permissable for the new fire resistant kitchen door to be held open during the day providing a suitable holding device (e.g. magnetic or dorguard) is fitted, which enables it to close automatically when the fire alarm is activated. The passenger lift alarm is faulty and must be repaired as a matter of urgency. 15/11/05 01/12/05 01/02/06 15/11/05 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 YA7 Good Practice Recommendations The minutes of service users one to one sessions with their keyworkers should be recorded to enable anyone ‘authorised’ to inspect these records to determine whether or not they are being held at regular intervals. 50 of care staff to have achieved an NVQ level 2 or above in Care by the end of 2005. 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 DS0000025829.V256618.R01.S.doc Version 5.0 Page 30 2 3 YA32 YA33 Reddown Road (37) training courses. Reddown Road (37) DS0000025829.V256618.R01.S.doc Version 5.0 Page 31 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.V256618.R01.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!