Inspection on 09/07/07 for Sandford Road,4

This inspection was carried out on 9th July 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandford Road,4 25/05/06

Sandford Road,4 24/10/05

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 9th July 2007 09:30 Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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.V339818.R01.S.doc Version 5.2 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.V339818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandford Road,4 Address 4 Sandford Road Bromley Kent BR2 9AW 020 8313 1017 020 8313 9703 gina.benjamin@community-options.org.uk 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 Mrs Regina Ann Benjamin 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.V339818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 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 Manager and her deputy support the staff team. Senior management is provided through Community Options and on call systems are in place. Multidisciplinary mental health teams are provided through the Primary Care Trust. All other health care is accessed through the community. The weekly fee for this service is £303.28 per week. The inspection report is available in the home. Staff will, if needed, assist residents to read and understand its content. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a one day period by one inspector. The site visit was unannounced. At the time of the inspection the Manager was on duty with two support staff. The home does not employ ancillary staff as residents are expected to address daily task as this as part of rehabilitation. The Manager had completed the AQAA prior to the site visit and provided information except contact details for residents. Questionnaires were sent out to next of kin, multidisciplinary team members and residents. At the time of writing this report there had been no comment cards received. During the site visit the inspector had an opportunity to meet with those residents who were on site and interview staff. A selection of records were inspected including those relating to heath and safety and quality assurance. The care plans risk assessments and other supporting documentation of those residents that were part the case tracking were inspected. Key workers who were on duty, met with the inspector, and provided further information regarding that individual resident. Staff training files are retained at the Head Office therefore these could not be inspected at the site visit. Staff training records were provided on site and confirmed a lot of training had taken place. What the service does well: The service manages those residents who suffer from mental disorder and are endeavouring to live in the community. Sandford Road is a home, which prepares residents to move on to more independent living by preparing them with the skills that they will need. The home has been successful in facilitating move on to more independent accommodation with several residents. Community Options is a supportive organisation who provide good training for staff on going support and work in collaboration with staff. Staff confirmed that in their opinion the were well supported. The company has structures in place both within the individual service and at Head Office level to encourage and support resident involvement in company developments. One recent development has been the involvement of residents in staff recruitment for which the residents have received training. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home is maintained in a domestic style with residents having their individual bedrooms and communal areas on the ground floor. The home itself is compact and allows little in the way of staff space. The ground floor office is cramped with the medication cabinet, computer, phone, storage of records and documentation, as well as the sleeping in bed. It is very difficult to work in, which was proved during the site visit .The ringing telephone also makes concentration difficult. This space should be reviewed. The hall way in the home is unwelcoming, which is in sharp contrast to the other communal areas. The hall is also used for storing the Hoover. The rear garden whist tidy, could be further developed with assistance form residents. Staff in this home support residents with meal preparation and encourage healthy living, which can be challenging with such residents. It is recommended that staff have training on specific areas such as diet and nutrition to enhance their existing knowledge. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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 Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information prior to placement and involved in a series of introductory visits, which afford ample opportunity to sample the service prior to admission. The assessment process allows staff to establish the level of need residents have and devise care plans to meet those identified needs. Reports received through CPA and the multi disciplinary team furnishes staff with further information to address residents’ needs. EVIDENCE: The inspector viewed the care plans of those residents who were recently admitted and the documentation in preparation for a proposed admission. All prospective residents are asked to a complete an application form in respect of their placement. In the first care plan there was assessment documentation relating to 28 March 2006, conducted by John Cribbens, the second and third assessments had been conducted by Gina Benjamin the Home Manager. The information outlined in this assessment identified the resident’s presenting problems including those relating to physical and mental health issues. It detailed the risks posed by those health issues, which is particularly important when dealing with residents who have fluctuating mental health problems. In addition to the three assessment visits, the resident had also visited the home Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 10 twice a week up to the date of admission, and during that time formed relationships with staff and other residents in the home. This resident had been issued with an information pack, which included the Statement or Purpose and Resident’s Guide as well as other literature relating to services locally. There was a dual diagnosis contract issued and to the resident. This contract was very specific particularly around drugs and alcohol issues. In addition terms and conditions were issued which the resident and a representative from Community Options had signed. There was written confirmation of the placement sent to the care Manager, and the resident the inspector was advised. The home had received information from the previous placement, Banbury House, prior to admission. This information included detailed risk assessments dated 13/3/07 and 1/8/06. Both of these documents detailed presenting risks and the management strategies to be put in place. These were being used to inform the current risk assessment used within Sanford Road. Within the risk assessment information violence and aggression were identified. There was also discharge information obtained from Oxleas NHS Trust, that included notes of a pre discharge meeting held 22/5/07.The core assessment conducted under CPA procedures was also included in the assessment information. A second resident’s file was inspected it too contained assessment information similar to that included in the first file. Documentary evidence of trail visits, discharge meetings and the CPA care plan were available. The resident’s contract, terms and conditions and placement offer were evidenced. This resident had had an occupational therapy assessment; the report from this was included. The home was in the process of assessing a prospective resident for admission. Included within his information were records relating to trial visits. Prior to admission there is named key worker identified for the resident. The Statement of Purpose should be reviewed to reflect the correct Chief Executive and organisational structure. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s care plans were reflective of identified needs and provided staff with information on how to address these. Risk assessments were used as enabling tools to promote independence for residents, whilst minimising risks. EVIDENCE: In those files inspected, the care plan information was well organised and the information easy to access. The resident who had been admitted 4/7/07 had a hand written care plan sheet outlining potential issues. Within this information, some areas had only the issue stated with no further information. Issues such as those relating to violence and aggression were in a risk assessment format. The Manager explained this was because there had not been insufficient time to discuss problem areas and possible interventions with the resident; hence this was a brief outline of presenting problems. Initial care plans should be in place within 48 hours of admission for new residents. Any potential problems, which may affect the health, safety or welfare of any person, must be carefully detailed Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 12 and have supporting risk assessments and contingency plans in place relevant to the place that they reside. There was in place a CPA (Care Programme Approach), care plan that had been generated February 2007. This care plan was the one, which staff were using to guide support required for this resident. Outlined in this care plan were issues including those relating to physical, mental, social and family support as well as substance misuse. There was neither the resident’s signature nor that of the care co coordinator. There was also the previous CPA care plan on file. The second care plan that was inspected was dated April 2007 it included physical and mental health issues. Within this information some broad terms had been used such as the diagnosis. Within the interventions section the information included the actual presentation of the problem not the actions to be taken to address the issue. Risk assessments covered those, which were specific to the individual resident’s problems, and those that were related to living in a community setting. Residents are encouraged to identify possible risks and strategies, which may assist in managing these to enable more independence. Risk assessments contained the Manager’s signature and that of the key worker. The fire risk assessment also included the resident’s signature. Risk assessment information was also outlined on the multidisciplinary assessment. Individual missing person’s risk assessments are in operation in this home. There was a weekly planner outlining rehabilitation activities including recreation and leisure. The records included a document headed “WRAP “, which is a wellness recovery action plan. Key worker sessions were recorded and from these document it was evident that they took place monthly although more frequently when the resident was first admitted. Information is retained in the staff office and this is where staff handovers take place. Please see requirement 1. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled and encouraged to maximise daily living skills with staff support whilst ongoing monitoring tracks progress made in these areas. EVIDENCE: Residents in this home are supported to become as independent as possible and promote the skills to live more independently. Residents are individually assessed to establish what skills they already have and action plans are drawn up to address those areas where support is required. Each resident has a weekly planner, which identifies those activities for the week. These activities include house tasks, meal preparation, shopping, budgeting cooking and leisure activities. During the course of the site visit many residents were out of the home and others came back for short periods then went out again. All residents can leave the home unaccompanied as the assessments have satisfied that criteria. Residents have freedom passes that allow free public transport. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 14 One resident was seen during the inspection to be addressing his household tasks, something, which he knows, he has to be able to do before possible future placement is considered. Another resident has started gardening and in the garden has tomatoes growing. The house holds community meeting which are monthly with refreshments provided. The meetings are minted and circulated. This provides a good forum for residents to raise any issue related to living in the home. Residents are invited to a weekly relaxation group held in the premises. The home has communal meals, which the residents themselves organise. Residents, as part of their rehabilitation shop, budget and prepare their own meals. Each resident has allocated space in cupboards for storing their purchases. Staff promote healthy eating although it is the residents choice what food they buy. Literature on healthy eating was seen to be available in the home. Some residents stated that they bought ready meals for convenience and cost. Residents can suffer from increased appetite with some medications and they can become obese. It is recommended that staff are provided with more training on nutrition especially conditions such as diabetes and obesity. The home is located close to many facilities, which is beneficial for residents. One resident was going swimming after lunch – there is a leisure centre located in the town centre. Visiting is open, and contact with friends and family is encouraged. Residents can go on day and weekend leave, staff would ensure that medication, transport and contact details were organised. There is a payphone in the hall. The home has a number of leisure items in the home including a TV, radio, a selection of DVD’s, and daily newspapers delivered. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care provision is accessed through the local provision, which for this type of resident is appropriate and promotes integration in to the community. Mental heath care is provided through the multi disciplinary team, under CPA aftercare, which provides good on going monitoring and early detection of possible relapse. EVIDENCE: The residents in this home all access health care provision within the local community. All residents have a GP identified as soon as they move in to Sandford Road and access dentists, chiropodists etc in the community. All residents at Sandford Road are under the care of either the ACT team ( Assertive Community Treatment Team) or the RST ( Rehabilitative Support Team). The teams offer structured and intensive programmes of support to meet the needs of the more complex client group.Those residents who are under Care Programme Approach ( CPA) aftecare sytems, are subject to regurlar reviews by the multidisciplinary team. Residents are requested to attend and a representative form Sandford Road would input into the meeting, Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 16 updating the team on progress made and other relevant information. Of the two residents case tracked, only one had information relating to health care as the other resident had been in a short period of time. The records evidenced that health care was accessed through the local services. Health care records included information on GP appointments, visits to the dentist and a weight record. Information relating to these visits was recorded in the record master and the appointment notifications with follow up letters were retained on file. It is recommenced that an aid memoir is developed to reference all health care appointments, for easy access to such information, and as a staff prompt for appointments. Mental heath follow up is through out patient attendance, visits by the CPN, in house monitoring and collaborative working with the multidisciplinary team. Residents are supported to attend these meetings and to compile agenda for these meetings. The home has very few accidents. Any incidents are reported to the CSCI through Regulation 37 notifications, although there have been few of these recently. The medication charts were inspected. No administration of drugs was observed, as this did not take place at the site visit. Medication administration charts were completed with photographs of resident attached. The medications to be administered “ as required “ had the full instructions for use included. Those medications, which are administered as required, are recorded on a separate sheet for monitoring purposes. The home has Temezepam and Lorazepam in use currently. These are checked by two staff and signatures confirm administration of such. There was documentation in relation to those medications received into the home and those returned to pharmacy. The pharmacist stamp was proof of receipt of returned medications. Homely remedies are recorded as administered and the stock balance documented. The homely remedies list had been agreed by the GP, this was dated July 2005 and may require reviewing as residents have changed since then. There are two residents who self medicate. All residents are provided with lockable space to safely store medications. The residents who self medicate are issued with dosette boxes. Staff routinely spot check and monitor resident’s compliance wit medications. Staff were aware of the possible signs that resident were not taking their prescribed medications. The home had in place guidance for self-medication, which had been issued through the CSCI Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 17 inspector in conjunction with the inspecting pharmacist. The home has it’s own policies and procedures including assessments for those residents who are self medicating A list of staff signatures were in place of al those staff who administer medications. The medication policy was dated 2003 and this should be reviewed particularly in light of recent guidance. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints policies and procedures afford residents and staff safety ensuring all concerns will be taken seriously. Staff were aware of what to do in the event of suspected abuse and knowledgeable about external avenues for referral. EVIDENCE: The information relating to complaints was available on display in the hall. It included information on who to contact internally as well as external avenues such as the CSCI and the Ombudsman. Timescales for initial and final responses were included in this procedure. In addition Community Options have a comprehensive complaint policy, which is available in the policy manual. All residents are advised of the procedure at the point of admission, and have information provided on compliants in their information files,which are issued to all residents. Residents in this home have several avenues by which they can raise concerns either internally or exrenally through the multi disciplinary team.House meetings and individual one to one sessions provide forums for discussions. There is a suggestion box located in the dining room which residents are encouraged to use. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 19 The company have a standard complaints monitoring form, which includes a section to detail if the complainant was satisfied with the outcome of the investigation. The last complaint recorded was dated 23/03/06.The documentation relating to these included notes of the investigation and the final outcome letter. The inspector has found that Community Options have an open and transparent ethos and this is the approach used when complaints are received. Staff with whom the inspector met were aware of how to action a complaint and stated that all complaints would be taken seriously. The inspector met with staff and asked questions in relation to adult protection and whistle blowing . They demonstrated a good working knowledge of these and how they should be actioned and reported. They were clear that external bodies should be used and were aware of how to contact them Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment in which to live. It is centrally located which offers residents easy access to all local services. EVIDENCE: A tour was undertaken with one of the support workers . The only areas, which the inspector was only able to view, were the communal areas as residents were not in to give permission, and those who were in the home did not want their rooms inspected. All of the communal areas were clean, tidy and maintained in a domestic manner. The fish tank and plants are looked after by a resident who is particularly fond of doing this .One resident was observed tidying the lounge as part of his weekly activities. The kitchen area was clean as was all of the equipment in it. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 21 Residents are involved in redecoration of the house and all proposed replacement furniture and furnishings are discussed with them .Photographs on the wall again were representative of the current house residents. Residents are consulted and involved in the personalising and decorating of their individual rooms to reflect thier taste. All resiednsts are supported on a individual basis to maintain their rooms and living space, as part of their rehabilitation programme. On the first floor landing one window was fixed closed the other was without a restrictor. This window had two bars across it, although should someone be determined to get out they would be able to do so. In light of potential selfharm and suicide this window needs to be made safe. The garden was tidy laid with lawn and garden seating available. One resident was actively growing tomatoes, which were doing well. This is one of his hobbies and provides him with a good sense of achievement. The home has benefited from recarpeting of the ground floor hallway, office and stairs. In addition there has been new flooring laid in the upstairs bathroom. The inspector was advised that redecoration of bedroom 3 had been addressed. There was evidence of garden furniture including a table and chairs which had recently been purchased. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents needs. They are equipped with regular training appropriate to the work they do, and senior staff provide on going management support. EVIDENCE: At the time of the inspection there were three staff on duty two support workers and the Manager. The home operates on the following staffing levels: 2/3 morning, 2/3 afternoon and one night staff sleeping in. There is one staff member working 9- 5 pm in addition to these numbers. Staffing levels need to be kept under review and increased as resident’s need dictate. Particular attention should be paid to the night period, as one staff member on duty can leave the home very vulnerable with this type of resident. Currently there are seven staff employed including the Manager. There are no ancillary staff employed as all of these tasks are included as part of resident’s rehabilitation. A copy of the staff rota is made available to residents for any comment, which they may wish to make . Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 23 Community Options have a lone working risk assessment in operation for times when this may occur, as on night duty. The Manager is due to go on maternity leave December 2007 for a period of five months, and the deputy manager will provide management cover during this time. The CSCI will need to be notified in writing of this arrangement within four weeks of receiving this report. The inspector met with those staff on duty. The first support worker to meet with the inspector had been on duty at pervious inspections and had also been interviewed as past of these. She had been in post for one year and three months. She confirmed that in he opinion staff were well supported and that there was enough staff to address the work in hand. She stated that supervision was conducted every four to six weeks, and discussion included personal development, roles and responsibilities as well as performance issues. She demonstrated a good knowledge on adult protection; whistle blowing, dealing with violence and aggression. She confirmed that there was a lot of training provided including mandatory topics and those relating to residents conditions. She was currently doing NVQ level 3, and her assessor attended Sandford Road for regular sessions. Her training file included certificates for training and an individual training plan for further training. She advised the inspector that after every course there was an evaluation of the training. One suggestion is that staff spend time shadowing or working in other Community Options homes to broaden their field of experience . One of the support workers on duty was also leaving and had submitted her notice. She had been in post two and a half years. This staff member was interviewed and she too demonstrated a good knowledge on topics she was asked about although was anxious about speaking to the inspector. She confirmed a lot of training and had just completed her NVQ level 3. The Manger advised the inspector that there is a new staff performance monitoring tool due to be introduced in the near future by Community Options. The staff files are located at Community Options head office. This had been agreed with the NCSC some time previous as the homes have limited storage space, which is particularly true in Sandford Road. All of the staff files for Community Options will be inspected later this year. On previous inspections of the staff files these have been to a good standard. The Manager confirmed that all staff have been up dated in the statutory topics except one member of staff because of course availability. Staff meetings are held monthly where any issue can be raised. Minutes of these meetings were available on site. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 24 The home has had ongoing problems with sickness, this was raised by the Manager and staff on duty. Due to staff sickness and annual leave, the home are using approximately two shifts a week covered by bank staff. The home rarely uses agency as they are found not be satisfactory in terms of consistency or their ability to function effectively. The bank staff that have been used are long term and one staff has been employed with Community Option previously. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by Gina Benjamin, and supported by senior staff at Head Office, who are experienced in this field of work. Health and safety issues are addressed through regular servicing and maintenance, which provide a safe establishment for staff to work in and residents to live. Quality assurance measures provide information on ways to improve and develop the service. EVIDENCE: The Manager has been in post for seven years. She has competed the CSCI process to become the Registered Manager. She has NVQ level 4 and holds the RMA. In addition she has updated her training in all of the mandatory subjects. Other qualifications and training include a diploma in dual diagnosis and a oneday course on personality disorder. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 26 The Manager provides a level of consistency and continuity, which is essential with type of resident. She is experienced in this area of work and provides staff with ongoing support and problem solving advice. She is supported in her role by senior staff at Head Office of which some are qualified nurses in the field of psychiatry. The home has in place a number of health and safety measures for resident’s protection. The home’s individual health and safety statement had been signed by the Chief Executive Chris Mansie. The home has one person who has complete the four day first aid course, all other staff have completed the one day course. The Environmental Health Officer had visited in April 07 and had been satisfied with the conditions he found. The hot water temperatures are checked monthly. This home is without a dishwasher and washing up is done by hand. The home should clarify with the EHO, what the acceptable temperature at outlet is, for washing up at the kitchen sink. Service certificates included recent gas inspection and electrical portable appliance testing. The five year electrical certificate was due. The certificates for legionella testing and chlorination were followed up by the Manager after the inspection. The fire installation had been inspected June 07 and two recommendations were made which the Manager was aware of and was dealing with. There was information in relation to emergency fire procedures. In addition the fire risk assessments had been updated when the latest admission had arrived. There was evidence of weekly fire alarm testing and tests on the emergency lighting, the last one dated 6/7/07. Fire drills had been conducted twice in 2007 with residents and staff initials, in place as confirmation of attendance. In relation to quality assurance measures some of these have been included under previous sections, such as residents meetings. Staff meetings are also held monthly and minutes circulated. Community Options facilitates an annual resident satisfaction survey. This is addressed by an independent agency that seek the views, collate the information and report back to Community Options. The company also conduct an annual staff survey. Again the results are collated and the information published by way of graph representations of findings. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 27 Hyde Housing, the company who own and maintain the Community Options buildings, conducts an annual audit, this was due to take place 11 July 2007. The results of this are forwarded to the head office and the Manager. Residents are invited to be active at board level and are invited to attend. Regulation 26 visits had been conducted - although a gap of some six months was evident due to staff sickness. These visits must be conducted monthly unannounced and a report on the findings left. Please see requirement 2. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 28 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 29 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. 1. YA6 15 The Registered Manager must 30/08/07 ensure that care plans are in place with 48 hours of admission. The care plans must detail any areas, which affect the health safety and welfare of residents, or any other person. The Registered Person must inform the CSCI in writing of their arrangements for management cover, whilst the Registered Manager is on maternity leave. 30/11/07 2 YA38 9 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 YA40 Good Practice Recommendations The Registered Person should ensure that all policies are reviewed on a regular preferably annual basis or when good practice or legislation changes. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 30 2. YA18 The Registered Manager should ensure that there is a female staff member on duty to address the individual resident’s need. Sandford Road,4 DS0000006910.V339818.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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