Inspection on 10/11/05 for Roy Kinnear House

This inspection was carried out on 10th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roy Kinnear House 20/03/09

Roy Kinnear House 07/05/08

Roy Kinnear House 26/09/07

Roy Kinnear House 27/06/06

Roy Kinnear House 30/06/05

Roy Kinnear House 08/12/04

Roy Kinnear House 17/05/04

Roy Kinnear House 11/11/03

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 Roy Kinnear House 289 Waldegrave Road Twickenham Middlesex TW1 4SU Lead Inspector Sandy Patrick Unannounced Inspection 10th November 2005 10:00 Roy Kinnear House DS0000038036.V260135.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 Roy Kinnear House DS0000038036.V260135.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. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Roy Kinnear House Address 289 Waldegrave Road Twickenham Middlesex TW1 4SU 020 8892 4049 020 8891 6734 roykinnear@btconnect.com 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) The Roy Kinnear Charitable Foundation Francesca Keating Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. General The organisation must ensure that the above minimum staffing levels remain under review and that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. The number and distribution of nurses, support staff and ancillary staff must be reviewed at regular intervals. If at any time, the evidence indicates that there are insufficient staff of any category available to meet the assessed needs of service users, the CSCI will require additional staffing as appropriate. Nursing Care No more than three service users requiring nursing care at any one time. Management One full time manager 39 hours per week. One senior day nurse 39 hours per week. Staffing There must be an appropriately qualified nurse on duty at all times. Apart from limited periods of time e.g. emergencies, this person must be in addition to the registered manager. On the morning/early afternoon shift there must be, in addition to the qualified nurse, three support workers. On the afternoon/evening shift there must be, in addition to the qualified nurse, three support workers. There must be one waking night duty qualified nurse and one support worker. There must be no reduction in the establishment posts, which currently stands at 16, including the manager, without prior consultation with the Inspector Ancillary Staff One domestic worker 20 hours per week. 30th June 2005 2. 3. 4. 5. Date of last inspection Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 5 Brief Description of the Service: Roy Kinnear House provides accommodation and personal care to up to five service users. The home is registered to accommodate service users who have severe learning and physical disabilities. The home is registered to provide nursing care to up to three service users. A qualified nurse is on duty at all times. The home is situated in a residential road in Twickenham and is purpose built. All service user accommodation is situated on the ground floor. Three of the five bedrooms have patio doors leading onto an attractive and well maintained garden. The lounge also opens onto the garden. The home is situated close to local shops and amenities. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 11th November 2005, and was unannounced. The Inspection Team included a Pharmacy Inspector. The report of his findings is included within Section 4 (Standard 20) of this report. The Inspection Team met with the Manager, other staff on duty and four of the service users. They were made welcome by all. Throughout the visit, staff were observed attending to the needs of service users. They treated them with kindness and respect and service users appeared happy and comfortable. What the service does well: What has improved since the last inspection? Since the last inspection work has started to redevelop the garden and build a new office area and a sensory room in new buildings in the garden. A new service user has moved to the home and is happy and settled. A day care service is being offered to two people who are considering moving to the home when the new bedrooms are built and registered. They have their own allocated staff team and planned activities. This is useful for these Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 7 potential service users, their families and staff. However, the Foundation must make sure that any additional services such as this do not take staff, space or privacy from existing service users. The home has recently been approved to provide a work placement for up to two nurses from abroad taking adaptation courses. Two new members have joined the Board of Trustees and it is hoped that their expertise and experiences will be a positive support. 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. Roy Kinnear House DS0000038036.V260135.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 Roy Kinnear House DS0000038036.V260135.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): 1, 2, 3, 4 & 5 There are procedures to support potential service users to become familiar with the home and for staff to assess their needs. However, information on the home is limited and further work in this area is necessary. Placement contracts have been developed for all but one service user. EVIDENCE: There is a detailed Statement of Purpose for the home. This includes a copy of the home’s Aims and Objectives and the Mission Statement. There is currently no Service User Guide. The Manager reported that they are considering producing a DVD and photographic guide to the home. This would be more accessible to service users. The Foundation has produced a leaflet guide to accompany the Statement of Purpose. The Inspector recognises the difficulties of producing a full Service User Guide, which will be accessible to all service users. However, some form of Service User Guide should be created making use of written, visual and recorded information. This requirement has been made at the previous three inspections is restated. This work is particularly important giving consideration to the proposed extension of registered places, when potential service users will need as much accessible information as possible so that they can be supported to make an informed choice about whether they want to move to the home. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 10 All service users are assessed by their placing authority and by managers at the home before they move to the home. The assessment includes visits to the home and over night stays. Information from health care professionals and representatives of the service user are included within the assessment. The Inspector examined assessment information for the newest service user. This information was thorough and the service user plan reflected assessed needs. The Foundation hopes to create three new bedrooms which they plan to register with the Commission for Social Care Inspection. They must make an application to do this. Over the last few months, two service users who hope to have places within the new bedrooms once these are registered, have started to spend time at the home during the day. They have participated in activities with other service users. This is important as part of the assessment process and helps them to become used to the home and staff. The Manager reported that they have their own allocated staff. It is also important for the Foundation to consider the impact that offering a day care service to these potential service users has on those who live at the home. Their communal space and privacy is being jeopardised by offering a service to others and a day care service must not be run from the home to any service users unless this is part of a plan for them to move into the home. Contracts, including terms and conditions of residency, are in place for all but one of the service users. However, the Manager reported that the placing authority for one service user were refusing to issue a contract. The Registered Provider must ensure that contractual arrangements including terms and conditions of residency are in place for all service users. The requirement made at the last three inspections is restated. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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, 7 & 9 Service users’ needs are recorded within individual plans of care. Assessments of risk are not in place for individual service users where there is a perceived risk or where restrictions are in place. Therefore there is no evidence of the decision making process for judgements made within service user plans and restrictions. EVIDENCE: Individual service user plans are in place for all service users, including the two people who receive a day care service. These clearly outline needs and how these should be met. There is evidence that families and health care professionals have been involved in the development of plans. All plans have been regularly reviewed. Daily care notes are made by staff. Service users at the home have various communication needs and some have difficulties expressing choices and preferences. Service user plans indicated that known choices and preferences were recorded and that the staff had consulted with representatives of service users to gain information in relation to this. Where service users are able to indicate choice, this was recorded and staff are expected to use guidance to offer choices. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 12 Risk assessments for individual service users are not in place. Some service users are able to move around the home, open doors and get out of bed on their own. Assessments of risk must be developed, recorded, and agreed by representatives wherever there is a potential risk for a service user and also where restraining devices, such as adjustable bedsides and wheelchair belts, are in place. The requirement made at the last inspection is restated. Service users at the home have different communication needs. The Inspector saw examples of staff using various communication techniques and touch with service users. The Manager told the Inspector that the Music Therapist videoed some of his work with service users to help staff and families understand the progress they had made. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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, 14, 15, 16 & 17 Service users are offered individual support to meet their needs. They are supported to access the community and participate in a wide range of educational and social activities. Service users are supported to maintain contact with their families and friends. Staff demonstrated that they treated service users with respect. There is a balanced and varied menu, which has been approved by a Dietician who visits the home regularly. EVIDENCE: Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 14 Service users are supported to participate in a range of activities, on an individual basis and in groups. Each service user is allocated one member of staff throughout the day to support them. Service users attend local places of worship and have links with colleges and social groups. Service users access local colleges, have therapeutic input and make use of leisure facilities. Throughout the home, there is a range of sensory equipment. Individual activities are organised for service users, according to needs and known preferences. These include attending college, use of hydrotherapy pools and sensory rooms, reflexology and music therapy. Staff on duty reported that service users accessed the local community, making use of leisure facilities, shops and other local resources. There is a variety of television, video and music equipment in communal and private areas. There is also a computer in the main lounge. Staff on duty reported that some service users enjoying using this. There is a wide range of sensory and leisure equipment. Service users are offered music therapy, reflexology and aromatherapy on a regular basis. There is a flexible visitors procedure. The Manager reported that staff work closely with visitors. There was evidence of good communication between staff and families, including communication books and photographic records. Staff were observed to interact appropriately with service users and use appropriate forms of address. The atmosphere at the home was relaxed and peaceful. Staff were observed to treat service users with respect. The home caters for a variety of dietary needs. The Manager reported that staff work closely with a local dietician, who offers advice and support with menu planning and monitoring of needs. Records of food eaten by service users is appropriately recorded and monitored. Menus at the home indicated choice and variety. The kitchen was well stocked with fresh food on the day of the inspection. Shortly before the inspection there was a Halloween party at the home. The Manager reported that other special events were being organised over the Christmas period. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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 the following standard(s): 18, 19, 20 & 21 Personal and health care needs are appropriately recorded and monitored within service user plans. The home liaises with health care professionals and their guidance is included within service user plans. The home has adequate arrangements for the ordering, storage, recording, administration and monitoring of medication and has access to a pharmacist for advice. Omissions and errors in recording, administration were found that might have had an affect on the health and welfare of residents. There is no procedure to be followed in event of death of a service user and therefore staff may not have accessible information on what they need to do if this should occur. EVIDENCE: Personal care needs are appropriately recorded. Bathing and support with personal care are recognised as important, and staff spoke about ways in which they make these activities a positive and enjoyable experience for service users. The service users at the home have a range of complex health needs. The home works closely with health care professionals, and this is evidenced in service user plans. All service users are registered with local GPs. The home Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 16 is registered to provide nursing care to three service users. A registered nurse is on duty throughout the day and night. Health care needs are appropriately recorded in service user plans and include information from health care professionals. There is a record of all accidents and incidents. The written medication policies and procedures were found to be adequate on a previous inspection and were not reviewed on this visit. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. The Manager and nurse in charge were interviewed and all medications not supplied in the monitored dosage system counted and compared to the records of receipt and administration. From these discussion and observations the receipt of administration was not recorded for one resident on admission to the home and the quantity of medication carried over from one month to the next was not recorded on the current administration record. This made it difficult to assess if the correct medication had been given. The dose of one medication had changed from one month to the next. No records were seen that the dose change had been checked and the records were not clear as to the correct dose to be given. The doctor was contacted at the time of the visit and the correct dose confirmed. In one instance the Dosett box had been used out of sequence despite being labelled sequentially. This resulted in the resident receiving one medication on consecutive days instead of alternate days on one occasion. From discussion with staff the error had no impact on the health of the resident and the correct dose was currently being administered. Medication for one resident was overstocked and had not been used in correct rotation. The nurse had detected this and had asked that no further supply be sent until requested. One item in a residents’ room had expired. The item was not currently being used and was removed on the day of the visit. There were no appropriate warning signs for the storage of oxygen cylinders. All medication was stored securely and records indicated that all other medication had been administered appropriately. There are records in place of visits by the pharmacist. Issues identified on the last visit had been addressed. There is an appropriate procedure for care of ill and dying service users. There is no procedure to be followed in event of death of a service user. A procedure for staff to follow must be put in place. There must be recorded information on a specific individual wishes or preferences in this area. The requirement made at the last inspection is restated. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 There is an appropriate complaints procedure. Procedures are in place to protect service users. However, staff have not been appropriately trained as to what constitutes abuse and how to report suspect abuse. Therefore service users are at risk and are not adequately protected. Criminal record checks and written references were not in place for staff and volunteers who work with service users. Therefore the Registered Person cannot guarantee the suitability of these people and service users may be at risk of harm or abuse. EVIDENCE: There is an appropriate complaints procedure, including time scales and contact details for the Commission for Social Care Inspection. There have been no complaints since the last inspection of the service. The home has adopted the London Borough of Richmond Protection of Vulnerable Adults Procedure and has its own procedures on abuse and whistle blowing. The home has information on Child Protection Procedures from the London Borough of Richmond. The Manager must ensure that any updates on policy and procedure are available at the home. The majority of staff have not received training on protection of vulnerable adults or children. This training is essential for staff to understand what constitutes as abuse and the procedures to be followed in the case of suspected abuse. Minutes of a staff meeting held since the last inspection, indicated that some unacceptable practices had been observed by managers. This highlights a particular need for staff training in this area. The service Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 18 users at Roy Kinnear House are vulnerable and have communication needs, therefore it staff must have a clear understanding of these issues and how they can protect service users from harm or abuse. This training has been outstanding and has been the subject of requirements made at the last three inspections. The Registered Person must recognise the importance of this training for staff and arrange for all staff to undertake relevant training. The requirement made at the last three inspections is restated. Criminal record checks are not in place for all staff and volunteers. One staff members criminal record check had been made by a previous employer in 2003. It is essential that thorough checks, including criminal record checks are made by the Roy Kinnear Foundation on all staff and volunteers before they undertake work with the vulnerable service users who live at the home. The requirement made at previous inspections is restated. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 19 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, 25, 26, 27, 28, 29 & 30 The environment is spacious, clean and well maintained. The home is attractively decorated throughout and staff are commended for their work to personalise rooms. The environment meets the needs of the current service user group. EVIDENCE: Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 20 The accommodation is purpose built and is suitable to meet the needs of service users. All accommodation accessed by service users is on the ground floor. There is a large, mature and attractive garden to the rear. The home is attractively decorated throughout, with many areas, including bedrooms and communal areas, redecorated over the past year. Since the last inspection work has started to improve the garden area. A new office area and a sensory room have been built, although these rooms were not completed at the time of the inspection. Much of the garden has been cleared and new sensory equipment and a path have been built. The work was not complete, but the Inspector was able to see the plans for completion. The garden and sensory room will be a positive addition to the home. There are plans to redevelop areas of the building creating three new bedrooms and a new kitchen area. This work is due to commence in early 2006. The Registered Persons need to make an application to register the additional bedrooms. All bedrooms and communal space meet or exceed the size requirements of the National Minimum Standards. Bedrooms are highly personalised and reflect individual tastes and personalities. Three bedrooms have patio doors leading to the garden. The lounge/diner is large and patio doors lead to the garden. There are two bathrooms available for service users, one with a specialist bath, the other with a shower facility. The home is well equipped with sensory equipment throughout and this gives opportunities for stimulation and relaxation for service users. The Manager reported that the new bathroom will be a sensory environment, with sound and lighting to enhance relaxation. Suitable adaptations have been made to the environment and individual equipment is provided for service users as required. The Manager reported that the physiotherapist and occupational therapist have regular input into the home. The home is spacious and the environment well maintained. It is important that the home continues to meet National Minimum Standards size requirements for communal space following the refurbishment, so that service users have enough room to meet their needs. Storage at the home can be problematic and service users have large and numerous pieces of equipment necessary to meet their needs. The Manager reported that additional storage facilities were planned. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 21 The home was clean and well maintained throughout. Appropriate procedures are in place for the laundering of clothes, infection control and control of substances hazardous to health (COSHH). Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 35 & 36 There are sufficient numbers of staff on duty and the staffing structure is appropriately organised. The staffing levels must be reviewed when new service users are admitted. There is information for staff on their roles and responsibilities. The home has not made thorough checks on all staff and volunteers and service users are placed at risk. Staff have not undertaken essential training and therefore may lack the necessary skills and knowledge to ensure the health and wellbeing of service users. Staff have not received regular support through individual or team meetings. EVIDENCE: Individual job descriptions are in place for all roles within the home. There are systems for appropriate communication and additional guidelines and information for staff on their roles and responsibilities. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 23 The Manager reported that the home has just been accepted to run adaptation courses for nurses from abroad to work towards a British nursing qualification. The Manager will mentor up to two nurses in their work placement. These staff will not be included within the staff compliment and will work in addition to approved staffing levels. The Manager reported that the home was fully staffed and that there was a number of familiar temporary staff who covered vacancies and leave. The Manager reported that all potential staff have a formal interview at the home and also spend time with service users and staff as part of the recruitment process. A number of students from a local college are due to undertake some work at the home offering drama therapy. The Manager reported that criminal record checks were being made on these students. The Manager reported that they have experienced some difficulties in obtaining criminal record checks for staff and volunteers but this problem now seems to be resolved. However, checks on one volunteer and a number of staff who already work at the home remain outstanding. The criminal record check for one member of staff was made by a previous employer in 2003. The recruitment process must include thorough checks made by the Roy Kinnear Foundation prior to employment. Staff files examined indicated that insufficient reference checks had been made on some staff. Two files did not have written references. Staff at the home have undergone some training since the last inspection, this includes administration of rectal diazepam, and further training in infection control has been arranged. However some important training remains outstanding, this includes protection of vulnerable adults and children. New staff have not undertaken training in basic first aid or food hygiene. Individual training profiles are not in place and must be developed. Training needs must be identified within these and plans recorded for each individual to meet their training needs. The requirement made at the previous two inspections is restated. The Manager reported that work to support staff to achieve NVQs is due to commence in January 2006. No staff were undertaking NVQs at the time of the inspection. There has been no formal individual supervision sessions with staff since the last inspection. The Manager reported that she and her Deputy Manager offer informal support and supervision. This is valuable, however, formal supervision meetings must also take place and must be recorded. The requirement made at previous inspections is restated. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 24 There has been one recorded staff meeting since the last inspection. Daily handover meetings are held for staff on duty. This is important. However, additional staff meetings for sharing information, training, policy and procedure discussion and consistency are essential and must take place on a regular basis. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 25 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, 40, 41, 42 & 43 The Manager is appropriately experienced. The CSCI has not been notified of significant events. Appropriate checks are made on health and safety. EVIDENCE: The Manager is a qualified nurse. She reported that she plans to undertake an NVQ Level 4, and must make plans to do this. She has additional qualifications in theology. The Manager has been in post since July 2003 and was registered with the CSCI in 2005. Over recent years the Manager’s role has become more strategic within the organisation. A number of key managerial tasks within the home have not been met. This includes the supervision, training and support of staff and the development of risk assessments for service users. This work is essential to make sure service users are safe and well cared for. As Registered Manager the primary role is for the day-to-day running of the home. The Inspector Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 26 recognises the importance of the strategic successes achieved by the Manager; and is aware that this part of her role is important both to her personally and to the organisation. However, the Foundation must make sure that the Manager has sufficient time to fulfil her role as Registered Manager of the residential service. The Registered Persons reported that the Board of Trustees has undergone some changes over the past year. Two new Trustees have joined the board. One of these is a medical professional who knows the service users at the home and the other works for a social care organisation. The Chair of the Trustees reported that changes to the way the Trustees work and support the Manager are going to be introduced and it is hoped that these will benefit the service. The Manager reports to the Board of Trustees however does not have regular professional supervision. This support is essential in order for her to fulfil her role. Consideration should be given to the employment of a suitable qualified person to offer professional support and supervision to the Manager. Since the last inspection one service user was admitted to hospital. The CSCI had not been notified of this event. The Registered Person must make sure that the CSCI is notified of all events which affect the well being of service users, including hospitalisation and accidents. The Registered Person is required to organise for unannounced monthly visits of the service to monitor the quality of service delivery. Reports from these visits must be forwarded to the Commission for Social Care Inspection. Since the last inspection only one reported visit has taken place. These visits and reports must be made monthly. The requirement is restated. Checks on health and safety, fire safety, water temperatures, first aid, electrical and gas safety were seen. The Manager reported that she has worked alongside the board of trustees to undertake a full financial audit of the service and to develop a business plan. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Roy Kinnear House Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 3 3 DS0000038036.V260135.R01.S.doc Version 5.0 Page 28 YES 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 YA1 Regulation 5 Requirement Timescale for action The Registered Person must 31/03/06 compile information to produce a Service User Guide, which is made available to service users. Previous timescale 31/10/05. requirements 31/03/05 and 2 YA3 4 12 16 23 The Registered Person must 31/12/05 make sure any additional services offered from the home do not have a negative impact or detract from the service offered to existing service users. The Registered Person must 31/01/06 make sure that contracts of care are in place for all service users and that copies are held at the home, available for inspection. Previous timescale 31/10/05 requirements 31/03/05 and 3 YA5 5 Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 29 4 YA9 13(4), (6) & (7) The Registered Person must 31/12/05 make sure that individual risk assessments are in place for all service users who are at risk and where any restrictions are in place. Previous requirement - timescale 28/02/05 and 31/08/05 This must be prioritised and be completed by the timescale for action. Evidence must be forwarded to the Commission for Social Care Inspection Failure to comply may lead to enforcement action being taken. 5 YA20 13(2) The Registered Person must make sure that: 1. The receipt of all medication is recorded appropriately. 1st December 2005. 2. The Dosett boxes are used in correct rotation. 1st December 2005. 3. There are arrangements for checking and confirming any unauthorised dose changes. 1st December 2005. 4. Arrangements are in place to audit the use of medication not supplied in the compliance aids. 1sr December 2005. 5. Appropriate warning signs are in place for the use of oxygen. 1st December 01/12/05 Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 30 2005. 6. All items that have expired are removed from use. 1st December 2005 6 YA21 12(1) NMS The Registered Person must: 31/01/06 1. Develop a procedure to be followed in event of death of a service user. 2. Ensure that individual wishes and preferences are recorded. Previous requirement - timescale 31/03/05 and 30/09/05 7 YA23 13(6) 19(1)(a) The Registered Person must 31/01/06 make sure that all staff receive training in recognising and reporting abuse (protection of vulnerable adults and children). Previous requirement - timescale 31/07/05 and 31/10/05 This must be prioritised and training must be organised to take place by the timescale for action. Evidence must be forwarded to the Commission for Social Care Inspection Failure to comply may lead to enforcement action being taken. 8 YA23YA34 13 19(1)(a) Sch2 The Registered Person must 31/01/05 make sure that thorough checks are made on all staff and volunteers. These must include two written references and criminal record checks recieved prior to the commencement of employment. DS0000038036.V260135.R01.S.doc Version 5.0 Page 31 Roy Kinnear House This must be prioritised and staff information must be complete by the timescale for action. Evidence must be forwarded to the Commission for Social Care Inspection Failure to comply may lead to enforcement action being taken Staff files must be complete and missing information for existing staff and volunteers must be requested. Previous requirement timescale 30/09/05 9 YA32 18(1) 19(1)(a) – The Registered Person must 31/03/06 proactively support staff to undertake NVQs. Previous requirement timescale 31/12/05 – 10 YA35 18(1) The Registered Person must 31/03/06 make sure that individual training profiles are developed for all staff. These must identify all training needs. Training needs must be met. Training profiles must be in place by 31/01/06 Previous requirement –timescale 31/03/05 & 31/10/05 11 YA36 12(5) 18(2) The Registered make sure that: Person must 31/12/05 1. All staff receive regular individual supervision with their line manager. 2. Regular team meetings are held. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 32 Previous requirement timescale 31/08/05 – 12 YA39 26 The Registered Organisation 31/12/05 must make sure that a representative conducts unannounced inspections of the service each month. They must produce a report of their findings and forward a copy of this to the Commission for Social Care Inspection. Previous requirement timescale 31/08/05 – 13 YA37 37 The Registered Person must 31/12/05 make sure that the CSCI is notified of any event affecting the well being of service users. 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 YA38 Good Practice Recommendations Consider the employment of a suitably qualified person to offer professional supervision and support to the Manager. Roy Kinnear House DS0000038036.V260135.R01.S.doc Version 5.0 Page 33 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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