Inspection on 06/09/05 for Repton Drive

This inspection was carried out on 6th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Repton Drive 22/11/07

Repton Drive 07/12/06

Repton Drive 09/05/06

Repton Drive 28/11/05

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 Repton Drive 13a Repton Drive Gidea Park Romford RM2 5LP Lead Inspector Edi OFarrell Unannounced Inspection 06 September 2005 10:35 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 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 Stationary 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. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Repton Drive Address 13a Repton Drive, Gidea Park, Romford, Essex RM2 5LP. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 308 2900 0208 308 2999 The Avenues Trust Limited CRH - Care Home 6 Category(ies) of LD Learning Disability - 6 registration, with number PD Physical Disability - 6 of places Within a total number of 6 Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection This is the first inspection of this service. Brief Description of the Service: 13a Repton Drive is a six place care home for adults with severe learning and physical disabilities, situated in a residential part of Romford. It was opened in December 2004 and is a purpose built bungalow set behind other detached houses in Repton Drive, and is a short walk to public transport links. There are six single bedrooms, each with ensuite toilet, shower and wash hand basin. There is an additional communal shower and bathroom. There is a domestic style kitchen/diner and utility room, and a lounge to which a conservatory is currently being added, so as to increase the amount of communal space. There is parking to the front of the building, and a small enclosed garden to the rear. The home provides 24-hour personal care, with health needs being met by visiting professionals, or care staff supporting service users to attend outpatient clinics. The home is currently developing Person Centred Planning in line with Valuing People the national policy for people with learning disabilties. As the current communal space does not meet the National Minimum Standards the providers have agreed to accommodate only four service users until the conservatory is completed. All areas of the home have full disabled access, and there is fixed overhead tracking in two bedrooms for specialist hoists. The home is operated by The Avenues Trust Ltd, a private company which operates several other similar homes in the area, and in Kent. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from mid morning to late afternoon, and was the first inspection since the home was registered in December 2005. The three service users who currently live at the home use mainly non verbal communication so obtaining their views was difficult, though they were observed interacting with staff. This was supplemented by examination of care plans and other records. All areas of the building were toured, and two members of staff were asked about the care provided, training opportunities and some policies and procedures. The home does not have a Registered Manager, and a Regional Manager is currently covering these duties. The findings of the inspection were discussed, by phone, with that manager the day following the visit. Staff and service users are thanked for their hospitality and in-put to the inspection. As is common at the first inspection following registration a number of Requirements have been set, which the organisation should be able to meet within the timescales once there is a permanent manager in post, and the person centred planning has been fully implemented. What the service does well: This home has been purpose built for six adults with severe learning and physical disabilities, and has full disabled access. It has been designed to be as homely as possible, and has the type of furniture that you would find in an ordinary house. Where people have to use wheelchairs and/or need help in moving from place to place specialist equipment has been built in. All the bedrooms have an ensuite toilet, shower, and washbasin, and there is a bathroom for people who prefer a bath. This has a special hoist, so people with mobility problems can use it. The bedrooms and bathroom are big enough for any other specialist equipment to be used in. The home is slowly building up a permanent staff team, who are becoming knowledgeable about the needs of both the current three service users, and two prospective service users. They have started using a new system of care planning, which is person centred; this means that each service user is at the centre of all assessments, plans, and reviews, and that it builds on strengths, rather than weaknesses. Once completed, and implemented, service users living at this home should enjoy a high quality of life. Staff met during the inspection displayed a very caring and warm approach to the service users. The current service users are mainly non-verbal so getting their views was difficult, but one lady very obviously enjoyed spending time in the kitchen with one staff member. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 & 4 Written information is not useful to this group of prospective service users, but needs to be accurate for use by their representatives in making decisions about placements. The current Statement of Purpose contains several inaccuracies, and the Service User Guide is not yet completed. Prospective service users’ individual aspirations and needs are currently being assessed, using a person centred approach, so that by the time they move into the home comprehensive plans will be in place. Prospective service users, and their representatives, are visiting the home to ‘test drive’ the service, so that their eventual move is as smooth as possible. EVIDENCE: The Statement of Purpose was examined and found to have several inaccuracies, for example stating that the home provides nursing, when it does not. The Service User Guide was not available during the visit. Both these documents must be accurate and available for service users’ representatives in order that are clear as to what services the home can offer. This is Requirement 1. As written information is not useful to this group of service users, due to their level of disability, the home needs to consider other formats for these and other documents about the home e.g. video/DVD/audio tape. This is Requirement 2. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 9 There are currently two prospective service users, and one of the files was examined. This young lady visits the home every weekend, during day time hours, and has an allocated bedroom, which already contains some of her belongings. Staff have been working with her family and the placing authority to gather information about her needs and aspirations. They are using a standardised format to develop a person centred plan; this incorporates elements of good practice in learning disability services, such as circles of support, short, medium and long-term goals, and building on strengths, rather than weaknesses. Once completed a comprehensive care plan will be in place, with a keyworker system that includes regular in-house review. The other prospective service user has also been allocated a bedroom, and is making short visits with her relatives. The needs of both service users were discussed with one staff member, who demonstrated knowledge and understanding of their needs. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Service users’ needs are currently being re-assessed using a person centred approach, which, once completed and fully implemented, will meet their needs and aspirations. In the interim some needs could be missed due to the recording and filing systems. Service users are assisted to make decisions, as far as possible, but the level of disability limits this. The use of person centred planning should, over time, increase each service users’ capacity to make decisions, with staff assistance. Service users are supported to take risks, and there has been an improvement in this aspect of care over recent weeks. This improvement needs to be built upon so that the quality of service users’ lives is maximised. EVIDENCE: The home provides a service for very severely disabled adults, two of whom spent many years living in hospital. Prior to admission, comprehensive assessments were carried out by the multi-disciplinary team, including community care assessments. These are available on file and the information is now being used to complete person centred plans. The system uses the first tense, e.g. ‘I avoid artificial colouring as it makes me hyperactive’. This is Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 11 excellent as it places the service user at the centre of the process, rather than as a passive recipient, as in more traditional approaches. The staff team are currently receiving training in this method of assessment and care planning, so the plans are at different stages of development. In the case of the prospective service user one-month, three-month, one year, and five-year goals have been identified, and include planning a birthday celebration, a trip to a fruit farm, a holiday in the UK, and a later holiday abroad. The other plans are not yet as well developed. As this is work in progress no Requirement has been set, but the plans and their implementation will be checked on at the next inspection by examination and discussion with staff, and service users’ representatives. Whilst the new plans are being developed staff work to care plans based on pre-admission assessments, in-house assessment, and assessments carried out by visiting professionals, such as physiotherapists. All this information has recently been brought together in one file for each service user, and a ‘This is me’ sheet is now at the front of each file. This gives a snapshot of needs, and how these should be met on a day-to-day basis, which is very useful for agency or bank staff, who may not know the service users well. It includes each service user’s means of communication, which is very important for this group of service users. If staff do not know how each service user communicates wishes and moods then they may inadvertently upset them, and create challenging behaviour, putting the service user at risk. What the ‘This is me’ sheet does not do is provide staff with a comprehensive list of all tasks associated with the care plans. For example, each service user has a bowel chart and a pad-changing chart, but these are not mentioned, so a new member of staff, or agency would only know if they were verbally informed. Care plans must be comprehensive and available to staff to follow on a day-today basis, so as to ensure that all identified needs are met. This is Requirement 3. Some risk assessments are in place, particularly for behaviour in which service users may harm themselves. Information from pre-admission assessments in relation to communication has been incorporated into the ‘This is me’ sheet, and into the sections of the person centred plans that have been completed. This is important as the service users are mainly non-verbal, and often use their behaviour to make their feelings known. Further risk assessment is being carried out as part of the new system of care planning, and must include all identified risks. For example, a recent incident report noted that one service user climbed on the wall in the garden, and was at risk of falling, and this must be included in the new care plan. This is Requirement 4. Information supplied by staff and written records demonstrated that there has been a recent increase in managed risk-taking within the home. For example, one service user is prescribed PRN medication for self-harming behaviour. Until recently this medication was given on a regular basis, but staff now use a more diversionary approach, such as offering a cup of tea, or one-to-one in his Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 12 room, at the onset. This approach appears to be working as the PRN medication has not needed to be given since 23 August 2005. Management and staff demonstrated a commitment to continuing with this type of approach as they get to know how the service users behave in their relatively new home. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 & 17 Service users have opportunities for personal development, and take part in appropriate activities within the home, and in the local community. These may be curtailed at times due to staffing levels. Their rights and responsibilities are recognised and respected, and the new care planning system will enhance this. Service users are offered a varied diet, which takes account of their preferences, and health and cultural needs. EVIDENCE: Records were examined and discussed with staff. Activities that have taken place are recorded on a daily log sheet, and these were examined for the month of August for the three service users. Activities included going for walks, to the pub, shopping for the house, meals out, use of sensory equipment, attending a thanksgiving service, a trip to Malden, tidying bedrooms, dance, massage, and a BBQ in Maidstone. These activities were interspersed with days spent in the home, and on the morning of the inspection the three service users spent all morning in the lounge with a member of staff. The shift leader reported that they would usually have gone Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 14 out, but as, due to sickness, there were only two members of staff on duty this was not possible. In the afternoon there were three members of staff on duty, and the two service users were taken out in their wheelchairs, after having tea at 3.00pm. The pre-admission information on one of these service users is very specific about him needing a structured day programme, and it is concerning that the structures that have been put in place get disrupted due to lack of staff. This is an important aspect of care as a lack of stimulation often leads to challenging behaviour in this group of service users. Recent improvements have been made by the home providing new sensory equipment in service users’ bedrooms, which may both stimulate, and calm people. This still requires sufficient staff to be on duty to encourage the service users to use the equipment. The home must provide sufficient staff for the identified needs of service users to be met on a day-to-day basis. This is Requirement 5 and also relates to Standard 33. Each service user has a weekly activity plan, and these are being built on during the re-assessment process. This should mean an increase in the range of activities being offered, and this will be checked on at the next inspection by examination of records and discussions with staff and service users’ representatives. The menu for the past four weeks was examined, and the fridge, freezer, and kitchen cupboards were checked for their content. There was salad, fresh fruit and vegetables, as well as food for snacks and main meals. The service users indicate their preferences by non-verbal communication, such as pointing to tea, rather than coffee, when being offered a drink. Meals are a mix of convenience food, such as ready-made pies and frozen chips, and made from fresh, such as pork stir fry, and roast dinners. Fresh fruit, vegetables, and meat, are purchased from the local market and shops on a twice-weekly basis, and service users accompany staff on these shopping trips. Preferences and cultural needs and wishes are noted in the care files, as are special dietary needs, such as no artificial colourings. A full record of all food taken is recorded for each service user on a daily basis. Takeaways, such as Chinese and Indian are provided on a regular basis. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18, 19, 20 & 21 Service users generally receive personal care and support in the way they prefer and require, and their physical and emotional health needs are generally met. The current methods of recording and filing information on needs could mean that some do not get met, particularly if a bank or agency member of staff does not know people well. Staff at the home are not following correct procedure in relation to medication, and therefore service users may not be fully protected. Ageing, illness and death are handled with respect and as the service users would wish, but support for staff needs to be provided following such events. EVIDENCE: Personal and health care needs are well documented in each service user’s file, but because there is currently no overall care plan, needs could get missed by staff, such as bank or agency, who do not know the service users well. In addition visiting health professionals could think that their advice/instructions are not being followed. Some information is on the ‘This is me’ sheet, but some is not, and some is reported on in the daily log, but, again, some is not, though it is recorded on a weekly plan. For example, the physiotherapist has devised a programme for one service user; this involves hand splints, and leg exercises. Neither of these is recorded in the daily log, though the splints are Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 16 on the weekly plan, but this means that there is no record that staff are doing this on a daily basis. This is Requirement 3. It took about ¾ hour to read through each file, and to get explanations for some sections from staff, or from other documents, such as staff meeting records. Neither staff nor visiting professionals have the time to do this on a day-to-day basis, so a summary sheet is needed. Sleep, food, bowel, and pad-changing charts were in place, but there were omissions, lack of explanations and codes, and inconsistencies in the use of 24 or 12 hour clock. Where charts are being used they must be accurate and consistent. This is Requirement 6. The medicine cabinet was examined, along with the medication charts (MAR), and the findings were discussed with the morning shift leader, and by phone the following day with the current manager of the home. Three Immediate Requirements (IR) were issued, and a further inspection by one of the Commission’s Pharmacy Inspectors has been requested. The cupboard contained medicine that is no longer prescribed; the frequency of prescription had been handwritten on the MAR charts, without being signed or dated; and there were three bottles of Diazepan (Valium) none of which matched the date or the amount recorded on the MAR chart. This is Requirements 7, 8 & 9. Wishes in the event of illness, dying and death are being recorded as part of the new care planning system, and this will be checked on at the next inspection. There has recently been an unexpected death at the home, and evidence was looked for that staff had received appropriate support following this. Deaths in this type of home are not common, so may impact on staff more than in other types of homes, where death is more common. Staff have to support the remaining service users, and be aware of their possible reactions, even where the service users are severely disabled, and may have a limited understanding of the death of another service user. There was no mention in the records of staff meetings that this event had been discussed. This is Requirement 10 and also relates to Standards 31, 32, 33, 35 & 36. This does not indicate that staff did not deal with the recent death appropriately, but the Commission is aware that this subject is often given a low priority in homes for younger adults. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 17 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 standard(s) 23 Service users may not be fully protected from abuse, but strategies are in place to reduce self-harm. EVIDENCE: The home’s abuse and whistle-blowing policies and procedures were examined, and briefly discussed with one member of staff, who was very clear what action to take if she suspected any form of abuse. There is a current adult protection investigation underway, and some documents were examined during this inspection that related to this. The information has been passed onto the officer within the Commission who is dealing with this matter. Training records were examined, and the two shift leaders who were on duty during the visit were asked about this training. Neither has yet attended a course, but hope to do so in the near future. This is Requirement 11. Adult protection training is important when working with this service user group, as they are vulnerable due to their level of disability. Behavioural programmes are in place, and are recorded as being followed where service users are at risk of self-harm. As stated earlier in this report the use of strategies that divert service users have reduced/contained incidents over recent weeks. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 The current communal space is sufficient for the number of people who live in the home, but not for six people, until the conservatory is completed. Service users’ bedrooms suit their needs and lifestyles and promote their independence. Toilets, showers and the bathroom meet service users’ needs. Specialist equipment is provided to meet service users’ needs. The home is clean and hygienic. EVIDENCE: The home was toured at the start of the inspection, and then revisited during the day; this included going into the bedrooms that are currently being used, or are allocated to prospective service users. The home is purpose built, and was opened in late December 2004. It is registered for 6 people, but currently cannot take more than four, due to the fact that the communal space is below National Minimum Standards. A conservatory is currently being built, which Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 19 will more than double the size of the lounge. All the bedrooms have an ensuite toilet, shower and washbasin, and two have overhead tracking for specialist hoists. There is a separate bathroom, with an assisted bath, and a separate toilet and shower. All areas have full disabled access. The construction of the conservatory has presented some Health & Safety issues, such as bricks and rubbish outside the front, and reduced access to the garden, but these have been adequately dealt with by the home, so no Requirement has been set. Fixtures, fittings and furniture is domestic in nature, and gives the building a homely feel. Once the conservatory is completed the home will be revisited by the Commission before agreement is given to all the places being filled. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 & 36 Staff on duty during the visit demonstrated knowledge of the needs of service users, and how these should be met. They were professional and there was evidence of warm relationships between service users and staff. There is a comprehensive staff training programme, which is provided by the organisation on an annual basis, but some thought needs to be given to the special training needs of staff in a newly opened home. EVIDENCE: Training records were examined, and the two shift leaders were asked about some aspects of training. Service users’ files were examined in order to compare the training provided with the needs of service users. The event log, maintained by the Commission, was examined for relevant information, as were accident and incident reports. Please refer to Requirement 10 and standard 21. The two shift leaders were very professional and balanced the needs of the service users with providing information to the inspector during the visit. Other staff members were observed, indirectly and directly, providing care, as per the care plans. The manager was not at the home during the visit, but all staff, including bank staff and agency were clear as to their roles and Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 21 responsibilities. Looking at records this appears to have vastly improved since the introduction of shift plans, which the shift leader compiles at the start of each shift. It was not possible to look at staff files, but the two shift leaders stated that they receive regular supervision. The records will be checked at the next inspection. Staff training records showed that the organisation has a commitment to a formal induction programme, covering such things as moving and handling, first aid, and introduction to the company. Once this is completed other basic training is offered, such as adult protection and food hygiene. The company needs to consider the special training needs of new projects, such as team building, formal and informal communication, and the special needs of the service user group. Some of the teething problems that this home has experienced may have been avoided if this had been thought of. This is Requirement 12. Please also refer to Requirement 11 in relation to the need for adult protection training, and to Requirement 5 in relation to the numbers of staff on duty on each shift. Examination of previous months’ rotas showed that there have been several occasions when there have only been two staff on duty. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 The current quality monitoring and assurance systems may not be adequate to ensure that service users and staff are always safeguarded. The health, safety and welfare of service users is generally promoted and protected, but the lack of fire drills, and alarm testing may place them and staff at risk. EVIDENCE: The home does not have a Registered Manager, so most of these standards were not fully assessed. An area manager is covering the duties, and there is ample evidence that she has introduced several changes for the better, e.g. shift plans, person centred planning, and reduction in PRN medication. Staff spoke highly of the value of her support, but also of looking forward to having a new permanent manager. The organisation is currently in discussion with the Commission about this appointment, as they are keen to move this home forward as soon as possible. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 23 The Commission, and the placing authority, have some concerns about the adequacy of the systems used by the company to monitor the quality of the service provided. This has been discussed directly between those agencies and the company, who are currently introducing a new system where the Registered Managers will be responsible for producing regular reports for their line manager and the Commission, using such things as incident and accident, and complaint statistics. As this is work in progress no Requirement has been set, but it will be checked at the next inspection. During this visit Regulation 37 notifications (notification to the Commission of certain types of events, such as falls), Regulation 26 reports (monthly reports by someone external to the home that have to be sent to the Commission), and incident/accident reports were cross-referenced. There were several events, such as falls where some injury had occurred, but not resulted in attendance at A & E, that had not been reported to the Commission. This is Requirement 13, which was discussed with the current manager, by phone, following the inspection. These reports are important as they allow the Commission to monitor, and keep in touch with, services between inspections. A sample of Health and Safety records was examined, and all were up to date, these included: Electricity; gas; water; and fire. Whilst the last inspection by the fire authority was fine, no records of fire drills or alarm testing could be found. This is Requirement 14 Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 2 2 2 2 3 3 3 Standard No 31 32 33 34 35 36 Score 2 2 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Repton Drive Score 2 2 2 2 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 25 N/A 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 1 Regulation 4&5 Requirement Timescale for action 31/10/05 2. 3. 4. 5. 6. The Statement of Purpose and the Service User Guide must be accurate, and be available for service users and their representatives. 1 4&5 The Service User Guide must be made available to service users in a format that is suitable for them. 6, 9, 18 & 12, 13 & Care plans must be 19 15 comprehensive and be available to staff so that all needs are met on a day-to-day basis. Records of all care given must be accurate and readily accessible. 9 15 & 13 c Care plans must include full risk assessment and risk management plans for all identified risks. When new risks are identified these must be incorporated into the plans. 11, 12, 13, 15, 12, 16 The lifestyle of service users 14, 15 & 33 (2) (m) & must not be disrupted by a lack (n) & 18 of staff. The home must provide sufficient staff for the identified social, developmental, and leisure needs of service users to be met. 18 & 19 12, 13 & Where personal or health care 15 charts are being used they must be accurate, up-to-date, and G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc 31/12/05 31/10/05 31/10/05 31/10/05 31/10/05 Repton Drive Version 1.40 Page 26 consistent. 7. 8. 20 20 13 (2) 13 (2) Only medication that is currently prescribed must be stored on the premises. Where prescriptions, including the frequency of administration, are handwritten on the MAR chart the person doing so must sign and date the entry. The Registered Provider must ensure that the amount of prescribed medicine corresponds with that recorded on the MAR chart. Staff must be equiped to deal with illness, dying and death. This must include support for the staff team following death, so that they can in turn support the remaining service users. All staff must have attended training on the protection of vulnerable adults. The Registered Provider must ensure that all staff working in the home have the appropriate training for the job that they are expected to do. This must include skills to work in a newly formed staff team and new project. The Registered Provider must ensure that all significant events are reported to the Commission as required by Regulation 37. The Registered Provider must ensure that regular fire drills and fire alarm testing is carried out and recorded. 09/09/05 09/09/05 9. 20 13 (2) 09/09/05 10. 21, 31, 32, 12, 15 & 33, 35 & 36 18 31/10/05 11. 12. 23 31, 32, 33, 35 & 36 13 (6) 18 31/12/05 31/12/05 13. 39 24 31/10/05 14. 42 23 (4) 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 27 Repton Drive Standard 1. Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Repton Drive G55 S0000060783 Repton Drive V247472 060905 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!