Inspection on 12/12/05 for Russell Hill

This inspection was carried out on 12th December 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

Russell Hill 05/07/07

Russell Hill 16/05/06

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 Russell Hill 33 Russell Hill Purley Surrey CR8 2JB Lead Inspector Mohammad Peerbux and David Halliwell Unannounced Inspection 12th and 13th December 2005 9:30 Russell Hill DS0000064951.V273527.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 Russell Hill DS0000064951.V273527.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. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Russell Hill Address 33 Russell Hill Purley Surrey CR8 2JB 020 8763 2611 020 8288 3614 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) Independence Homes Limited *** Post Vacant *** Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not Applicable Brief Description of the Service: Russell Hill is owned, managed and staffed by Independence Homes Ltd. The property is registered with the Commission for Social Care Inspection (CSCI) to provide residential care for up to seven adults with learning disabilities. The home particularly provides residential care for younger adults aged between 18 and 65 with epilepsy and severe learning disabilities. Russell Hill is a detached property in a quiet road in Purley. It has seven single bedrooms. Communal areas include lounge, dining room, kitchen, bathrooms on ground and first floor, a multi use therapy room, a multi sensory room and a secure private garden. There is a lift between the ground and first floor. The home supports and encourages each service user to maximize their independence. The aim is to promote individual skills and helping service users to reach their full potential. The home treats each service user as a person in his or her own right and value them for their own individuality. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2005/06. It took place over two days .The first day of the inspection was unannounced. Some time was spent looking at the policies and procedures, talking to the deputy development manager and deputy manager. Some of the service users were spoken to however due to their cognitive ability it was difficult to seek their views. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The home should have sufficient information for prospective service users to be clear on whether the home will be able to meet their needs and all service users need to have a costed contract/statement of terms and conditions in place. Although service user’s care plans are comprehensive and include detailed information about their needs and personal goals, these care plans would have far greater authority if service users were involved where possible in their development. A “missing person” profile must be in place for all service users Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 6 who are at risk of absconding. The system for administration of medications also needs to be improved. The home’s complaints procedure must be given and/or explained to each service user in an appropriate language and format for them to understand. It must also include information on how to refer a complaint to the Commission for Social Care Inspection at any stage should the complainant wish to do so. The home needs to report any significant accident or incident to all appropriate bodies. The home must have a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. Staff need to be supervised on a regular basis. With regards to the management of the home, the registered person must forward an action plan to the Commission on how they are going to maintain consistency of management. The registered person needs to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected. 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. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4 and 5 There was not sufficient information available to ensure that prospective service users have a understanding as to whether the home will be able to meet their needs. Service users in the home are not always aware of the services they are being offered as no signed contracts were in place. EVIDENCE: There was no evidence that the home has a Statement of Purpose or Service User’s Guide on the day of the inspection. The registered person is required to produce an up-to-date Statement of Purpose setting out the aims, objectives and philosophy of the home, its services and facilities, and terms and conditions. The Statement of Purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service user’s guide. Both documents should be made available in the home at all times and should be kept under review (by the registered person) and revised should any changes to the service occur. If such a revision were required the provider would not need to gain permission from the Commission for Social Care Inspection (CSCI) to make the changes, but CSCI should be notified of the changes within 28 days. The registered person must also provide each prospective service user with a service user guide to the home. It is recommended that the service users’ guide be made available in Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 9 formats suitable for the service users for whom the home is intended (e.g. appropriate languages, pictures, video, audio or explanation). There was evidence that service users have a full care needs assessment in place and these form the basis for the care plans. Prior to admission the registered person visits and assesses potential service users. The care needs assessments are very comprehensive. It was clear that service users’ needs are being met given that needs assessments and care plans are in place, however this would be improved with staff training and supervision and also with the involvement of service users and carers. Records revealed that service users are in regular contact with other health and social care professionals who regularly visit the home to check that assessed needs are being met. The home has many therapists providing the opportunity for individual weekly sessions to each service user. Therapists currently include an Art Therapist, Complimentary Therapist, Drama Therapist, Music Therapist and Nutritional Therapist. The deputy development manager confirmed that all prospective service users are encouraged to visit the home as often as practical, to encourage a familiarisation process with the premises, its location and the other service users and staff. The home has a transitional package in place. The deputy development manager informed that the home does not cater for emergency admission. None of the service users have a costed contract/statement of terms and conditions between the home and the service user. The registered person is required to develop and agree with each service user a written and costed contract/statement of terms and conditions between the home and the service user. The contract should ideally be in a format/language appropriate to each service user’s need, and/or reasonable efforts have been made to explain the contract to the service user. When drawing up the contract, service users must be supported by family, friends and/or advocate, as appropriate. The service user must have a copy of the contract, which has been signed by the service user or their relatives and the registered provider. Russell Hill DS0000064951.V273527.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): 6,7,8,9 and 10 Service user’s care plans are comprehensive and include detailed information about their needs and personal goals. However these care plans will have far greater authority if service users were involved where possible in their development. The home operates a risk management strategy thus enabling the service users to participate in activities in the home and in the community with appropriate support. EVIDENCE: Three service users’ care plans were sampled, it was noted that they were all up to date and well maintained. Overall, the plans demonstrated a thorough needs assessment, which clearly set out how current and anticipated needs would be met. The plans checked established individualised procedures for service users likely to challenge the service, focusing on positive management strategies. However it was noted that none of the care plans were drawn up with the involvement of the service user together with their family, friends and/or advocate as appropriate, and relevant other agencies/specialists. The registered person must ensure that service users care plans are drawn up after consultation with the service user, family, friends and an advocate where Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 11 appropriate. The care plan must also be made available in a language and format that the service user can understand and is held by the service user unless there are clear and recorded reasons not to do so. It was positively noted that some of the care plans have been reviewed in October 2005 and that the service users have recently been allocated key workers. Staff provide service users with the information, assistance and communication support they need to make decisions about their own lives. However there has not been any service user’s meeting since the home opened in September 2005. The registered person must ensure that service user’s meeting are taken place on a regular basis so as to ascertain and take into account their wishes and feelings. The deputy development manager stated that none of the service users manage their own finances. The records of all incoming and outgoing payments were audited and there were some expenses made on behalf of the service user’s with no description next to the amount that have been spent. The registered person is required to keep an up to date records and receipts of all the expenses made by the service users or on their behalf by staff. There have been several occasions where service users have been out for lunch and the home has used the service user’s money to pay for the lunch. This was discussed with the deputy development manager who agreed that these expenses should have been paid by petty cash and not by service users money. Risk assessments for service users were examined. Potential risks are identified covering all aspects of their daily living both inside and outside the home. The risk assessments give details to what action is required to minimise identified risks and hazards. Two of the service users are at risk of absconding however none of them have a completed missing profile in place. The registered person is required to have a completed missing profile in place for all service users are at risk of absconding. The deputy development manager informed that the risk assessments of all the service users have recently been updated and the old risk assessments have been shredded. The deputy development manager was advised that old records should be kept so that they can be referred to in the future. The regulation states that, “records…shall be retained for not less than three years from the date of the last entry”. The home has a confidentiality policy in respect of personal information held in relation to service users. The home believes that it has a duty of confidentiality to its service users. The home regards this as being of the utmost importance and a key part in building a trusting, caring environment where service users can live safe in the knowledge that their confidences will be kept and where information about them will be protected safely. Each staff is given a copy of the confidentiality policy to ensure that they are aware of their responsibility as far as confidentiality is concerned. Russell Hill DS0000064951.V273527.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): 14, 15,16 and 17 Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. Dietary needs are well catered for and a well balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The home is supporting service users to access appropriate activities through the activity programme. The service users access local leisure facilities and shops. The staff team are available to support service users while accessing community resources. Activities arranged by the home are run by trained staff with appropriate professional support and advice. Service users are actively encouraged to maintain links with their families and friends. The deputy development manager stated that the home has an ‘open’ visitor’s policy and simply recommends that visitor’s telephone to say they are coming to ensure there loved one will be available. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 13 Service users, who were at home at the time of this inspection, appeared to enjoy some level of independence. Routines can be very flexible and are well observed to take into account all the service users individual needs. The home has a policy on privacy and the deputy development manager advised that service users have locks on their bedroom door, which can be locked from inside and outside. Some of the service users were spoken to however due to their cognitive ability it was difficult to seek their views regarding the care and support they receive. The home has a planned menu. Two of the service users are on special diet. The deputy development manager informed that a nutritionist visit the home twice weekly to give advice as appropriate regarding service users’ dietary needs. Russell Hill DS0000064951.V273527.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): 18,20 and 21 Service users’ personal, physical and emotional health needs would be better met with the involvement of service users and their carers and family in the care planning process. This would ensure service users individual needs are met holistically. The system for administration of medications is poor and potentially place service users at risk. EVIDENCE: The findings indicated that service users are able to exercise some level of independence in their personal care needs with appropriate support from staff where needed. The overall impression gained from observing how service users live at the home, indicated a good culture of semi-independent living, with most users have reasonable control over their lives and support from staff where needed. The deputy development manager informed that personal support is provided in private, and intimate care by a person of the same gender where possible and if the service user wishes. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 15 is not given as prescribed, staff must ensure that they record the reason for this. The registered person must ensure that medication administration records are accurately completed at all times. While checking the medications, it was noted that there was a section of a one blister pack of medication left in the cupboard with no instruction or service user’s name on it. The deputy development manager was not able to confirm on whose medication it was. The registered person must ensure that Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971. Currently there are no service users who self medicate. The home has a policy on ageing and death however none of the service users have their last wishes documented on their personal files. The registered person must ensure that the wishes of service users regarding death and dying are recorded, with the involvement of other stakeholders including friends, family members and advocates as appropriate. Russell Hill DS0000064951.V273527.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 and 23 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. Although the home has policies and procedures in place to protect service users from abuse, the lack of training and insight of staff, compromises service user’s safety. EVIDENCE: The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint however it is only available in written format. The registered person must ensure that the home’s complaints procedure has been given and/or explained to each service user in an appropriate language/format, including information for referring a complaint to the Commission for Social Care Inspection at any stage should the complainant wish to do so. The deputy development manager stated that there have been two complaints and one compliment since the home opened. The home has its own protection of vulnerable adults policy in place. The home should also have a copy of the Croydon adult protection policy, guidelines and procedures. Since the home opened there have been a number of significant accidents and incidents that have not been reported to the Commission or the Care Management Team. At present there is an investigation being carried out by the Croydon Adult Protection Team regarding an incident, which happened in October of this year .The home did not report the incident to either the Care Management Team or the Commission. This incident came to light at the service user’s review meeting and was reported to the Commission by the Care Manager. The registered person is required to ensure that service users are Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 17 safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The registered person is also required to ensure that every person within the home who witnesses abuse, or hears of it, or learns of a potentially abusive situation in relation to a vulnerable person must report it to his/her superior or directly to the appropriate Care Management Team. The Commission must also be informed. It is never someone else’s responsibility. The deputy development manager stated that not all staff have had training on abuse. The registered person must make suitable arrangements by training staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. Russell Hill DS0000064951.V273527.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): 24,29 and 30 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: Overall the home was decorated to a reasonably good standard throughout and appeared to be very comfortable, bright and warm. The home is situated on a quiet road near the centre of Purley. It is within easy walking distance of local shops and amenities, including public transport links. The home has made provision regarding environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. The home has a passenger lift in place. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Generally staff are recruited appropriately and employed in sufficient numbers to meet the health and social needs of their service users. Care staff are not receiving supervision on a regular basis, which could have an impact on the standards of care being provided to service users. EVIDENCE: At the times of inspection, only one staff had a job description on file. The deputy development manager was not able to evidence that all the other staff have a job description in place. The registered person must ensure that all staff working in the home have a job description in place so that they are aware of their roles and responsibilities. The staff need to be aware of their own knowledge and skill limitations and know when it is appropriate to involve someone else with more specific expertise. Independence Homes has a good overall training programme for staff in order to build on their competences. However there are no staff at present that hold an NVQ2. 1 member is currently undertaking an NVQ level 2, and another NVQ level 4 and all staff are receiving LDAF training, which will contribute to their NVQ’s at a later stage. The registered person is required to ensure that the staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 20 The deputy manager stated that 7 staff are employed at 33, Russell Hill and there are 2 waking night staff. Only 1 agency is used and there is an agency induction checklist, which is used with each new agency member of staff. The home has a staff team, with sufficient numbers and complementary skills to support service users’ assessed needs at all times. However the Commission has some concerns about the management of the home. A meeting will be set up in the near future with the Registered Provider to discuss this issue. At the time of the Inspection recruitment procedures seemed appropriate. Four staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. However according to the Regulation 26 visit carried out on the 29th of November it was noted that some of the staff do not have a copy of the terms and conditions. The registered person must ensure that staff files contain all the information required by the Care Homes Regulations 2001. All new staff are required to attend an induction-training day at Head Office before they start at 33, Russell Hill. The probationary process lasts for 12 months. Service Users had not been and are not involved in the process of recruitment, however it would be beneficial if they were. The training and development programme set up by Independence Homes is comprehensive and staff potentially should receive appropriate support from this and the supervision process to carry out their roles and functions effectively for service users. From a meeting with the Head of Training for Independence Homes, there is not a limit on the amount of training an individual staff member may receive. The importance for the organisation is that staff receive the training they need to do their job. The areas covered by training seem to be comprehensive in their coverage of the National Minimum Standards. Full implementation of the organisational policies and programmes at 33, Russell Hill has not yet been achieved. E.g. Individual staff training programmes have not yet been developed. The registered person must ensure that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The registered person must also ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. The deputy development manager stated that staff supervision has yet to start. The registered person must ensure that staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice, and that these sessions are recorded and signed by both the supervisor and supervisee. The registered person must also ensure that the staff have an annual appraisal with their line Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 21 manager to review performance against job description and agree career development plan. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 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 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): 37,38,40,41,42 and 43 The frequent changes of manager compromise the consistency of service users’ care and well-being. The health, safety and welfare of service users and staff are not being protected, as fire safety is not being adhered to. EVIDENCE: Since the home opened in September 2005,there have been two managers that were in post and both have since left. The deputy manager is presently managing the home with the support of the deputy development manager. The Commission is very concerned about the management of the home. The registered person is required to forward an action plan to the Commission on how they are going to maintain consistency of management. The overall impression when visiting the home is that there was little to suggest that staff is appropriately supported or supervised. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 23 There has been only one staff meeting since the home opened. The registered person is required to ensure that regular staff meetings are taking place so that the staff can express their views. The home has in place a comprehensive selection of policies and procedures covering most of the topics set out in Appendix 3 of the National Minimum Standards for Younger Adults. The deputy development manager stated that staff have access to the home’s policies and procedures and that they must sign and date as proof that they have read and understand new or revised policies and procedures. The home needs to improve on its records keeping. During the inspection, it was noted that some of the documentations were not being completed fully. The registered person is required to ensure that individual records and home records are completed fully and are kept up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. It was noted from the Regulation 26 visit carried out on 29th 0f November 2005 that the fridge and freezer temperatures were not being taken on a daily basis. The registered person is required to ensure that fridge and freezer temperatures are monitored on a daily basis to ensure the safety of service users as well as staff. It was also noted that the water temperatures have not been checked as the home was waiting for the arrival of the thermometer. This is very concerning as the service users are being put at risk. The registered person is required to check the water temperatures on a regular basis so that service users are not at risk of being scalded. With regards to fire safety, the Fire Authority carried out an inspection in September 2005 and the home’s fire safety arrangements were found to be of a satisfactory standard. During the inspection it was noted that the laundry room door was wedged open. The registered person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. Hazardous substances are appropriately stored. PAT testing, gas, legionella, electric and fire checks have all been undertaken appropriately. No business and financial plan was available at the time of inspection. The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection. The home has a current employers liability insurance in place and has insurance cover for service users’ belongings/valuables. Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 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 1 3 3 3 2 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 2 2 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Russell Hill Score 3 X 2 2 Standard No 37 38 39 40 41 42 43 Score 1 2 X 3 2 2 2 DS0000064951.V273527.R01.S.doc Version 5.0 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 Requirement The registered person is required to produce an up-to-date Statement of Purpose setting out the aims, objectives and philosophy of the home, its services and facilities, and terms and conditions. The registered person must provide each prospective service user with a service user guide to the home. A copy of the Statement of Purpose and Service User’s Guide should be made available in the home at all times. The registered person is required to develop and agree with each service user a written and costed contract/statement of terms and conditions between the home and the service user. The registered person must ensure that service users care plans are drawn up after consultation with the service user, family, friends and an DS0000064951.V273527.R01.S.doc Timescale for action 28/02/06 2 1 5 28/02/06 3 1 17(2) 28/02/06 4 5 5 (c) 28/02/06 5 6 15(1) 28/02/06 Russell Hill Version 5.0 Page 26 advocate where appropriate. 6 6 15(2) Service user’s care plans must also be made available in a language and format that the service user can understand and is held by the service user unless there are clear and recorded reasons not to do so. The registered person must ensure that service user’s meeting are taken place on a regular basis so as to ascertain and take into account their wishes and feelings. The registered person is required to keep an up to date records and receipts of all the expenses made by the service users or on their behalf by staff. The registered person is required to have a completed missing profile in place for all service users are at risk of absconding. The registered person must ensure that medication administration records are accurately completed at all times. The registered person must ensure that Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971. The registered person must ensure that the wishes of service users regarding death and dying are recorded, with the DS0000064951.V273527.R01.S.doc 31/03/06 7 7 12(2) 31/01/06 8 7 17(2) 31/01/06 9 9 Schedule 4 (16) 13/12/05 10 20 13(2) 13/12/05 11 20 13(2) 13/12/05 12 21 12 31/03/06 Russell Hill Version 5.0 Page 27 involvement of other stakeholders including friends and family members as appropriate. 13 22 22(2) The registered person must ensure that the home’s complaints procedure has been given and/or explained to each service user in an appropriate language/format, including information for referring a complaint to the Commission for Social Care Inspection at any stage should the complainant wish to do so. The registered person is required to ensure that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The registered person must is required to ensure that every person within the home who witnesses abuse, or hears of it, or learns of a potentially abusive situation in relation to a vulnerable person must report it to his/her superior or directly to the appropriate Care Management Team. The registered person must make suitable arrangements by training staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. 28/02/06 14 23 13(6) 13/12/05 15 23 13(6) 13/12/05 16 23 13(6) 31/03/06 Russell Hill DS0000064951.V273527.R01.S.doc Version 5.0 Page 28 17 31 18(1)(a) The registered person must ensure that all staff working in 31/03/06 the home have a job description in place so that they are aware of their roles and responsibilities. The registered person is required to ensure that the staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. The registered person must ensure that staff files contain all the information required by the Care Homes Regulations 2001. The registered person must ensure that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The registered person must also ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. 31/03/06 18 32 18(1)(a) 19 34 18(4) 28/02/06 20 35 18(1)(C) 31/03/06 21 35 18(1)(C) 31/03/06 22 36 18(2) The registered person must ensure that staff have regular, 28/02/06 recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice, and that these sessions are recorded and signed by both DS0000064951.V273527.R01.S.doc Version 5.0 Page 29 Russell Hill the supervisor and supervisee. 23 36 18(2) The registered person must ensure that the staff have an 31/03/06 annual appraisal with their line manager to review performance against job description and agree career development plan. The registered person is required to forward an action plan to the Commission on how they are going to maintain consistency of management. The registered person is required to ensure that regular staff meetings are taken place so that the staff can express their views. 31/01/06 24 37 8 and 9 25 38 12(5) 31/01/06 26 41 17 The registered person is required to ensure that individual records 13/12/05 and home records are completed fully and are kept up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. The registered person is required to ensure that fridge and freezer 13/12/05 temperatures are monitored on a daily basis to ensure the safety of service users as well as staff. The registered person is required to check the water temperatures on a regular basis so that service users are not at risk of being scalded. The registered person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning DS0000064951.V273527.R01.S.doc 27 42 13(4) 28 42 13(4) 13/12/05 29 43 13(4) 13/12/05 Russell Hill Version 5.0 Page 30 system. 30 43 25 The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection. 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations It is recommended that the service users’ guide be made available in formats suitable for the service users for whom the home is intended (e.g. appropriate languages, pictures, video, audio or explanation). Russell Hill DS0000064951.V273527.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 Russell Hill DS0000064951.V273527.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. 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