Inspection on 24/10/05 for Sandford Road,4

This inspection was carried out on 24th October 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandford Road,4 09/07/07

Sandford Road,4 25/05/06

Sandford Road,4 18/04/05

Sandford Road,4 30/12/04

Sandford Road,4 14/09/04

Sandford Road,4 31/01/04

Sandford Road,4 13/05/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sandford Road,4 4 Sandford Road Bromley Kent BR2 9AW Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 24th October 2005 10:30 Sandford Road,4 DS0000006910.V259756.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 Sandford Road,4 DS0000006910.V259756.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. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandford Road,4 Address 4 Sandford Road Bromley Kent BR2 9AW 020 8313 1017 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) Community Options Limited Vacant Care Home 5 Category(ies) of Past or present alcohol dependence (5), Past or registration, with number present drug dependence (5), Mental disorder, of places excluding learning disability or dementia (5) Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 April 2005. Brief Description of the Service: Sandford Road is part of the Community Options group of homes. It provides support for five residents in the category of mental disorder including past or present alcohol and drug abuse. The residents in this home are undergoing rehabilitation in order that they may live more independently in the community. The usual length of stay in this facility is two years. Residents in this home are subject to Care Programme Approach (CPA) after care systems. The staff in the home are on site throughout the 24-hour period. The staff team are supported by the manager and her deputy. Senior management is provided through Community Options and oncall systems are in place. Multidisciplinary mental health teams are provided through the Primary Care Trust. All other health care is accessed through the community. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced to monitor progress on previous requirements. The majority of standards had been addressed at the announced inspection 18 April 2005. Since the last inspection the home’s manager has applied to the CSCI process to become the registered manager. On the day of the inspection there were two staff on duty one of which was the manager. The member of support staff was covering another facility for a period during the morning and returned mid morning. The manager facilitated the inspection and provided the information as detailed in the report. At the time of the inspection there were four residents in the home, one was in hospital having suffered a relapse in his conditions. The inspector met with two residents. All residents in this home are under enhanced levels of Care Programme Approach, (CPA), which is a programme of aftercare for mental health residents. The inspector was satisfied with the findings of the day and progress made on some of the previous requirements, although three had not been sufficiently addressed and are now outstanding. What the service does well: What has improved since the last inspection? What they could do better: The care plan documentation and supporting records remain insufficiently robust or comprehensive in detail to accurately reflect residents’ needs or the interventions provided. It is particularly important with this type of resident that records are sufficiently detailed for early detection of relapse or a change in the resident’s mental health condition. Communication and contact with multi-disciplinary teams must also be fully recorded. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 6 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. Sandford Road,4 DS0000006910.V259756.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 Sandford Road,4 DS0000006910.V259756.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 The Statement of Purpose provides sufficient information relating to the facility, staff and services provided by the home in respect of rehabilitation, health and leisure. EVIDENCE: The Statement of Purpose had been revised to include details of the newly appointed manager. Also included was information on the admission criteria, aims and objectives of the facility, organisational structure complaints. Supporting information on the staff group, their training and experience were also included. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9. The care plans are still not sufficiently completed or comprehensive in detail to fully reflect the residents’ needs and associated risk assessments. EVIDENCE: The care plans and supporting risk assessments were inspected, as these had not been sufficiently detailed or comprehensive in content at the last inspection. Two care plans were randomly selected. Both care plans had documentation and risk assessments conducted under Care Programme Approach (CPA). In one care plan the assessment contained good information although this was not dated or signed. The CPA care plan was included with reviews although this was dated 4/7/2002. The manager did say that reviews had taken place, the most recent having been October 2005 and the typed information was awaited. In this mental health facility with residents on enhanced CPA, it is essential that documentation is reflective of needs to detect early onset in changes in behaviour, which may indicate the resident is relapsing. Early detection of symptoms would ensure a timely referral to appropriate professionals and treatment. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 10 There were several areas in the care plan which were not completed. This was because residents did not want to and this was often the case. There are many sections within the care plan which related to residents, and staff feel that they should not complete these. The care plans are undergoing review, however, to date these are not operational. All care plans must fully reflect needs, identify any associated risk assessments and detail all interventions. Please see repeated requirements 1 and 2. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 11 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): 11,16. It was evident that residents are supported to make choices and become as independent as possible with rehabilitation programmes specific to their needs. EVIDENCE: The inspector met with two residents individually. One resident was difficult to engage with as he felt the questions posed regarding the service and his daily life, were “too personal”. Therefore only limited information was obtained. Both stated that they had choices with their day and support provided in areas where needed. They indicated that they had flexibility in their day although structured rehabilitation programmes were in place. Rehabilitation for one resident included assistance with cooking and shopping. One resident felt she had some difficulties with certain residents; this may be because she is the only female in the home. Staff are aware of this and female staff are available to work with the resident. Visiting is open and flexibility exercised over visitors. One resident stated that she has visitors and on occasions has friends staying in her bedroom during the weekend. This was discussed with the manager. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 12 This situation may have implications for other residents, the safety of the visitor themselves and insurance implications. This should be assessed and kept under review. All local facilities, including health provision, are accessed within the local community. Voting would be residents’ choice at a local polling station. Please see recommendation 1. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 13 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): 20. The medication systems are much improved and provide better protection for staff and residents with audit trails clear to follow. EVIDENCE: The medication systems were inspected as record keeping relating to medications required tightening up at the last inspection. Since the last inspection medication systems had been reviewed. The medication charts are now clearly labelled within individual files. Photographs were in place and allergies recorded. Where hand transcriptions has been recorded two staff signatures were in place to confirm the accuracy of the information except in two cases where only one signature was present. The “as required” medications had clear instructions of when to use and the maximum dosage to be prescribed. Nonadministration of medications had reasons clearly documented. All medications received into the home and returned to the pharmacy are recorded. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 14 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. Residents have clear information advising of how to make a complaint and different avenues by which they can action it. EVIDENCE: The complaints information was on display in the hall including details of the address for the CSCI. There are supporting records including a complaints procedure and a complaints monitoring form. The CSCI has received no complaints regarding this service. The last complaint had been 15/4/05. The complaint, with the response, was available. Residents themselves gave various responses to the inspector in relation to making complaints. Their responses varied from taking their issues to head office or talking with staff or their care managers. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 15 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): 26,27 The home offers comfortable domestic style accommodation which provides communal and individual space. EVIDENCE: The lounge and dining area have both benefited from redecoration. Toilets and bathrooms are located through out the building with a shower on the top floor, and a bath on the middle floor, offering residents choice. There is one area in the home which is for those residents who smoke, the rest of the areas are non-smoking. Smoking in bedrooms is prohibited although this is difficult to enforce with some residents. Staff are aware of those who do smoke in bedrooms and extra observation and preventative measures are in place to address this. Risk assessments are in place for this issue. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Staff recruitment procedures are satisfactorily robust to protect residents. Training is encouraged and relevant to the type of residents. EVIDENCE: The home has staff on duty throughout the 24-hour period. Mornings were said to be quieter than afternoons and this is reflective of the staffing numbers, with three during the afternoon and two in the morning. There is one staff sleeping in overnight. There is a risk assessment in place for staff who are lone working. Currently there are staffing vacancies, which are covered with bank staff. On the day of the inspection, one bank staff had been asked to stop work because of issues with a male resident. The staff personnel files had been inspected at the head office of Community Options and found to be to a satisfactory standard. Staff training files were inspected. Four of the seven staff in post have completed the NVQ level 2, this included the manager. Staff training over the last year has consisted of a number of topics relevant to the type of resident in the home, as well as other more general topics including medication, food hygiene, health and safety. All staff are due to attend training on person centred approach to care planning. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 17 There was a discussion regarding manual handling as staff do not seem to have had an annual update in this. The manager confirmed that this was the case. All staff must have statutory training addressed at appropriate intervals as directed. The certificates for manual handling were located in the staff training file; these were valid for one year and had expired. One staff member confirmed that she had received a lot of training, which was paid for by Community Options and time off facilitated within the home. She felt that there was great importance put on training and equipping staff with the knowledge and skills with which to perform their work. Please see repeated requirement 3. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 18 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): 39,42. Quality assurance measures are in place to audit the service, seek residents’ views and staff opinions on the organisation. EVIDENCE: The quality assurance systems were inspected. The home operates with an open and inclusive ethos as far as this is possible within the confines of communal living. Regular house meetings are held and minutes were available The meeting offer an opportunity to discuss any matter relating to the home. Regulation 26 visits are undertaken by one of the senior managers who was the previous manager of this facility. Staff meeting are held and minutes circulated. Community Options facilitate a staff committee for staff; representatives from each of the homes attend this forum. A staff survey is conducted on an annual basis. The results of the questionnaire findings are then circulated to all staff. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 19 The employer’s liability insurance certificate was valid up to 25/11/05. One resident has money left with staff for safekeeping. The financial records were complete with two signatures and receipts, where the resident had produced these. The balance was checked against the money and found to be correct. The records for weekly fire alarm testing were in place. Maintenance of the fire system had been addressed 18/8/05 and the fire risk assessment up dated March 2005. Fire drills had been conducted March and July 2005. First names were in place and not staff signatures. All training should include the staff member’s signature. Hot water temperatures were recorded. Please see recommendation 2. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 20 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 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 3 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sandford Road,4 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000006910.V259756.R01.S.doc Version 5.0 Page 21 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 YA6 Regulation 15 Requirement Timescale for action 30/12/05 2. YA9 13 3. YA32 18 The Registered Person must ensure that care plans are comprehensive in content, kept under review and accurately reflect all of the residents. The Registered Person must ensure that contingency plans are in place to detect early onset of inappropriate behaviour and appropriate measures put in place to address this. Previous completion date 31/3/05. This is now outstanding. The Registered Person must 30/12/05 ensure that risk assessments are completed in respect of any identified risks to service users. Previous completion date 31/3/05. This is now outstanding. The Registered Person must 30/05/05 ensure that all statutory training is updated for all staff. Previous timeframe for action 30/05/05. This is now outstanding. Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 22 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 2. Refer to Standard YA15 YA42 Good Practice Recommendations The Registered Person should ensure that all residents are agreeable to visitors staying over and that this is clarified with the Insurance Company. The Registered Person should ensure all staff sign on receipt of fire training Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Sandford Road,4 DS0000006910.V259756.R01.S.doc Version 5.0 Page 24 - 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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