Inspection on 13/06/06 for Selhurst Road 166A

This inspection was carried out on 13th June 2006.

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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Selhurst Road 166A 28/06/07

Selhurst Road 166A 22/11/05

Selhurst Road 166A 03/06/05

Selhurst Road 166A 24/03/05

Selhurst Road 166A 03/11/04

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 Selhurst Road 166A 166a Selhurst Road South Norwood London SE25 6LS Lead Inspector Peter Stanley Key Unannounced Inspection 13th June 2006 1:00pm Selhurst Road 166A DS0000028564.V299286.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 Selhurst Road 166A DS0000028564.V299286.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. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selhurst Road 166A Address 166a Selhurst Road South Norwood London SE25 6LS 020 8653 8891 020 8653 8891 NO EMAIL 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) Choice Support Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user over the age of 65 to be accommodated for as long as the home can continue to meet all of their assessed needs. 22nd November 2005 Date of last inspection Brief Description of the Service: Selhurst Road is situated off the main thoroughfare, in a residential area of South Norwood. The property consists of a large, wheelchair accessible bungalow, which provides a single bedroom for each of the residents. It is well placed for access to local facilities such as shops, the post office, cafes, pubs and the library, and within reasonably easy access to the centre of Croydon. The home is a few minutes walk from a bus route and close to a mainline rail station. Selhurst Road is registered to provide a home for two adults, in the younger adult age group, with a learning disability (although a variation has been granted with regard to the age of one resident who is over the age of 65). Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 166a Selhurst Road is a small purpose-built home, run by Choice Support, the providing organisation. The home is registered for two adults with learning disabilities. There is one long-term resident over the age of 65 for whom a variation has been granted. Both service users have their own bedroom and there are spacious communal facilities. This is a very small care home and provides a homely environment with one-to-one key worker support. This announced inspection was conducted over one day and involved consultation with Pauline Parchment, who has been managing the home since 1.3.05, and who has been registered as manager with the CSCI. The inspector met both service users and two staff members on duty. The inspector examined service user records and other documentation relating to the management and running of the home. As a result of this inspection, there are 12 requirements, 6 of which are unmet from the previous inspection. The inspector was particularly concerned to find that the Vulnerable Adults protection procedure has not, as yet, been updated so as to be consistent with Croydon’s procedures. The manager was advised that this requirement is long overdue and will become an enforcement issue if this is not addressed. The inspector understands that all staff are booked to attend Croydon’s statutory vulnerable adult training on 12/7/06. Other requirements, which remain to be met include the need for an appropriate assessment, and person centred care plans, to be developed, an appropriate service user agreement to be drawn up, and the implementation of quality assurance questionnaires and processes. Generally, the home is evidenced to be providing a good service to its’ two service users with good monitoring of health, social and support needs, and good development of individual abilities and community activity. The home provides a pleasant environment in which to live and the manager and staff present as caring and enabling in their approach. What the service does well: Comprehensive information is being provided by the home to assist prospective service users decide whether the home is likely to be a suitable environment in which to live and have their needs met. Service users are assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. Service users are being assessed regarding potential risks to their health and safety, and are being enabled to take responsible risks wherever possible. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 6 Service users are assisted to participate in daily routines and to develop personal daily living skills. There are opportunities for participating in appropriate day care activities and for accessing shops, and recreational facilities in the local community. The home actively encourages and enables service users to maintain family links and friendships. Service users rights are being respected and their responsibilities recognised in their daily lives. There is choice and flexibility with meal arrangements. The quality of food is wholesome, nutritious and varied, with service users’ dietary needs being fully taken into account. Meals are taken in a pleasant and congenial setting. Service users’ physical and emotional health needs are being met. The home has an appropriate complaints procedure in place, which is in a format suitable for the home’s service users. Service users are living in a generally safe and well-maintained environment. Service users have access to safe and comfortable personal and communal facilities, with improvements having been made so as to bring service users’ bedrooms up to standard. Generally, service users have the specialist equipment they require to maximise their independence. The individual needs of service users, relating to their safe use of the toilet and bathroom, have been assessed and aids and adaptations are due to be installed. The home presents as clean, pleasant and hygienic. Service users benefit from clarity of staff roles and responsibilities. Generally, service users are having their needs well met by an appropriately trained and qualified staff group. The acting manager has not, however, been enabled to undertake training leading to an NVQ Level 4. Service users are benefiting from a qualified, competent and well-supported staff team. Service users are being supported by the home’s recruitment policy and practices. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The home must ensure that prospective service users are appropriately and fully assessed and that full information regarding their care and support needs is obtained. Each service user must be provided with a service user agreement. This must be written in a format which is appropriate to service users living at the home. For there to be a comprehensive record of service users assessed and changing needs, person centred care plans need to be developed and reviewed on a regular, monthly basis. Personal support and social care needs are generally being met in accordance with service users’ preferences. However, this needs to be fully demonstrated in service users care plans. Generally, service users are being protected by the home’s medication policy and procedures. However, there is a potential risk to service users that arises Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 8 from the failure of the home to securely store controlled drugs separately from other medication. Service users cannot be confident that they are fully protected from abuse until the home’s adult protection policy and procedures have been bought into line with local statutory procedures, and staff have attended Croydon’s adult protection training. Service users are living in a home that is generally being well managed and run in their best interests. The acting manager must, however, be provided with the organisational support with which to demonstrate her competence by completing studies for the necessary management qualifications. The home needs to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is supporting service users and meeting its aims and objectives. Generally, the home’s record keeping, policies and procedures are safeguarding service users’ rights and best interests. However, all policies and procedures must be annually reviewed. 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. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 9 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 Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 10 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 to 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Comprehensive information is being provided by the home to assist prospective service users decide whether the home is likely to be a suitable environment in which to live and have their needs met. The home must ensure that prospective service users are appropriately and fully assessed and that full information regarding their care and support needs is obtained. Each service user must be provided with a service user agreement. This must be written in a format which is appropriate to service users living at the home. EVIDENCE: The home had compiled a detailed statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. The Statement of Purpose includes all the information detailed in Schedule 1 of the Care Homes Regulations (2001). The home has developed a service user’s guide that is written in a format/language suitable for the service users and contains all the elements of regulation 5(1) (2) (3). There have been no new admissions to the home within the last 12 months. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 11 The inspector understands that the home’s admission procedure is for a full assessment of an individual’s personal, social and health needs to be carried out prior to any admission, this being undertaken by the registered manager with additional reports being provided from other professionals. A requirement from the previous inspection, for the home to put in place an appropriate assessment format, for assessing any new potential service users, remains to be met. The assessment needs to assess each aspect of daily need and physical/mental functioning, and include risk assessments. An up-to-date care management assessment and care plan must be obtained for any referral from health or social services. The home has an experienced staff team two of whom hold an NVQ Level 3 and one an NVQ Level 2, with one staff member currently studying for an NVQ Level 2. The inspector met both service users, one of whom, a younger adult, transferred to the home about 18 months ago. Whilst difficult to engage, due to communication difficulties, the inspector was able to ascertain that the service user continues to feel settled and well supported in her environment. She has the support of a key worker who was transferred to the home from her previous placement. The inspector also spoke to the key worker who demonstrated a knowledge and understanding of the service user’s needs and was observed to interact in an enabling and caring way. Inspection of the service user’s review notes indicated that the placement has been meeting her needs, and is providing opportunities for personal self-expression and development. This is assisted by two days a week attendance at a day care centre in Southwark where a range of activities are provided. The inspector also spoke to the other service user, an older person, and was able to ascertain that she is feeling content and well supported by staff. A review is due to be held, but previous review notes indicate that the placement is meeting her needs, and that there are varied opportunities for social contact and community activities. The inspector observed a high level of commitment by staff in responding to service users’ needs and in helping to facilitate their participation in daily activities. Staff are offered a wide range of training opportunities with which to develop their existing knowledge and skills and to competently carry out their duties. A requirement for each service user to have an agreement, which clearly states the terms and conditions of their placement, has yet to be met. The current agreement, called an ‘assured tenancy agreement’ is not appropriate for the service user’s placement in residential care, and an agreement must be drawn up which details all the terms and conditions for their placement, as detailed under the relevant care standard 5.2; a requirement applies. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 12 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 to 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. For there to be a comprehensive record of service users assessed and changing needs, person centred care plans need to be developed and reviewed on a regular, monthly basis. Service users are assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. Service users are being assessed regarding potential risks to their health and safety, and are being enabled to take responsible risks wherever possible. EVIDENCE: Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 13 The inspector examined service users care plans. These are descriptive and limited in scope, and do not provide a sufficiently comprehensive picture of the service user’s needs and capabilities, and how these are being addressed. Whilst there is additional information included in personal profiles detailing personal information relating to preferences and capabilities, this needs to be included in the care plans. Person-centred care plans, in both writing and pictures, need to be developed. These should fully involve the service user and should detail both those aspects of care and daily living tasks where assistance is required and those where the service user can manage or be enabled to do so independently. Service users’ care plans must also be signed and dated, to indicate when the plan has been initiated or reviewed, and must be reviewed on a regular, monthly basis. Requirements apply. The inspector evidenced the completion of risk assessments on service users’ files. These cover areas of risk such as mobility, eating/drinking, medication and risks associated with daily living and other activities. From his discussion with the manager and with staff members, the inspector was satisfied that appropriate strategies are in place for managing risk. The Service User Guide makes clear that service users are assisted to make choices in their day-to-day routines and activities and are consulted regarding decisions that affect them. Service users are consulted on a one-to-one basis through regular contact with staff, and comments and views are noted in service users’ daily diaries. Staff members on duty were observed to work with service users in an enabling and client-centred way. The acting manager has advised that key workers meet on a monthly basis with service users and that information is noted in the person centred planning book. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 14 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 to 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assisted to participate in daily routines and to develop personal daily living skills. There are opportunities for participating in appropriate day care activities and for accessing shops, and recreational facilities in the local community. The home actively encourages and enables service users to maintain family links and friendships. Service users rights are being respected and their responsibilities recognised in their daily lives. There is choice and flexibility with meal arrangements. The quality of food is wholesome, nutritious and varied, with service users’ dietary needs being fully taken into account. Meals are taken in a pleasant and congenial setting. EVIDENCE: Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 15 Both service users are encouraged by the staff team to participate in regular activities of daily living, such as meal preparation, household chores, the laundry and setting and clearing the dining table. Service users are encouraged to participate in activities such as tidying their rooms, planning menus, and shopping for food. Service users are able to watch television or videos, and there is a pleasant garden in which they can sit out in nice weather. One service user attends a lunch club, and goes to a lunchtime concert at the Fairfield Halls once a week. She also attends a local church on a regular basis. The other service user, a younger adult, attends a day centre in Peckham, two days a week, where she maintains contact with her friends and peer group. The centre provides a hydro pool and trampolining, with an exercise programme being in place. Both service users go out into the community and access shops and community facilities. The inspector was advised that the home has purchased a motability vehicle which both service users share. This enables them to visit friends and visit shops, parks and other places in the community. The home has access to its own transport, which has disabled access, and which is used for outings and day trips. Both service users are on the electoral roll and are encouraged to exercise their right to vote. The evidence from review notes and service user files indicate that service users are being consulted regarding their rights and responsibilities in their daily lives. The home actively encourages service users to maintain family links and friendships. With the support of their key workers, both service users are encouraged and enabled to visit friends and relatives. Service users’ records and the visitors book evidence that there are regular visitors to the home. Service users are able to see visitors in the privacy of their rooms if they wish. Each service user has a day set aside for visiting or receiving family/friends. There are no restrictions on visitors other than they arrange to visit at reasonable times. Breakfast, lunch and an evening meal are provided. The dining area is pleasantly laid out and provides a relaxed and congenial setting for taking meals. Mealtimes are flexible and take account of individuals’ daily routines and social arrangements. The inspector observed a vegetarian pasta dish being prepared, which presented as being tasty, nutritious and wholesome. Both service users presented as happy with the food being served. The manager has advised that there is regular consultation with service users regarding their Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 16 choice of meals, with service users being consulted as to which foods they would like purchased. A dietician regularly visits the home to check the menu with full account being taken of the service users’ dietary needs and individual preferences. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 17 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 to 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Personal support and social care needs are generally being met in accordance with service users’ preferences. However, this needs to be fully demonstrated in service users care plans. Service users’ physical and emotional health needs are being met. Generally, service users are being protected by the home’s medication policy and procedures. However, there is a potential risk to service users that arises from the failure of the home to securely store controlled drugs separately from other medication. EVIDENCE: Both service users are receiving personal care and support according to their assessed needs. However, as detailed under standard 6, this needs to be fully demonstrated in service users’ care plans. One service user has a relatively high level of support due to her impaired mobility and communication difficulties. Service users are encouraged to Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 18 choose which clothes to wear and to express their preferences regarding how their care is provided. In accordance with policy guidelines, staff aim to ensure that privacy and dignity are maintained when assisting service users with their personal care needs. A wheelchair accessible shower and bath seat are provided to assist in meeting users’ needs. An individual health plan is in place for each resident. These are reviewed and updated on a regular basis. The inspector examined service users’ health care records. Service users receive regular health checks, while generally there is evidence of any health concerns being followed up through referral to the appropriate health professional, with health checks and treatment being arranged as required. Both service users are registered with a GP who is based at the local health centre. Other community based health care professionals have regular or occasional contact, and include specialist district nurses, dentists, opticians, audiologists, and chiropodists. Service Managers regularly visit the home to check that assessed needs are being met. Generally, service users are being protected by the home’s medication policy and procedures. All staff employed at the home are able to administer medication, all having undertaken accredited training. There is also internal training provided for staff by Choice Support. The supplying pharmacist visits the home at 3-monthly weekly intervals, and offers advice and support to staff regarding medication. The last inspection took place on 10/5/06, no issues having been identified. The inspector examined medication records, these being appropriately maintained. Each service user has a written statement detailing their medication needs, and the manager undertakes a medication audit on a weekly basis. The inspector identified one area of concern, the storage of a controlled drug in the same cupboard as other medication. To comply with relevant legislation, any controlled drug must be stored separately in a fixed locked metal cupboard, with a double lock mechanism; a requirement applies. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an appropriate complaints procedure in place, which is in a format suitable for the home’s service users. Service users cannot be confident that they are fully protected from abuse until the home’s adult protection policy and procedures have been bought into line with local statutory procedures, and staff have attended Croydon’s adult protection training. EVIDENCE: There have not been any complaints recorded since the last inspection, and none recorded since August 2001. There is information for residents (in both writing and pictures) regarding how to make a complaint. The complaints procedure has been updated so as to refer to the current legislation. The inspector is very concerned that a requirement for the amendment of the home’s adult protection procedure still remains outstanding. The manager advised that the home has a copy of Croydon’s adult protection policy and procedure. However, the home’s procedure still refers to the London Borough of Southwark and its POVA policy, and has not, as required, been amended so as to be in line with the Croydon POVA policy and procedures, and stating the relevant Croydon contact numbers for referrals. The home has been previously warned that enforcement action will follow if this requirement is not met. The inspector was advised that all staff have been booked in for Croydon’s multi-agency Vulnerable Adult training for the 12 July 2006. Selhurst Road 166A DS0000028564.V299286.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 to 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are living in a generally safe and well-maintained environment. Service users have access to safe and comfortable personal and communal facilities, with improvements having been made so as to bring service users’ bedrooms up to standard. Generally, service users have the specialist equipment they require to maximise their independence. The individual needs of service users, relating to their safe use of the toilet and bathroom, have been assessed and aids and adaptations are due to be installed. The home presents as clean, pleasant and hygienic. EVIDENCE: Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 21 The bungalow is spacious, and well suited to wheelchair users. This is set back off the main road, behind larger buildings. Access is via a narrow alleyway, which is just accessible by car. The home presents as clean, bright and comfortable, with good access to local amenities. The fabric and décor of the premises appeared to be in good condition. The bungalow is spacious, with adequate communal space for both residents. This has a large, well-furnished lounge, with a dining area at one end. There is a spacious hallway, which can easily accommodate a wheelchair. Visitors are greeted by the chirping of two budgerigars, which belong to one of the residents. There is a large garden to the side of the house, which provides a pleasant area in the summer months. Following a previous requirement, the home has now installed an emergency lighting system so as to safeguard service users in the event of power cuts. A number of other requirements have been addressed. Some new carpeting for one new service user’s bedroom has been laid, and an armchair obtained. The wardrobe has been repaired, and a lockable drawer, for safeguarding personal valuables, has been provided. A replacement armchair for the second bedroom has also been obtained, though it is the service user’s preference to use this in the lounge. The kitchen has been refitted with new units, these now being more accessible for the two service users. The bathroom and toilet is shared by the two service users. The inspector evidenced a report from an occupational therapist who has now visited the home and assessed the needs of the wheelchair-bound service user. Recommendations are being implemented. Grab rails are due to be installed to assist use of the shower and toilet, and a new bed and shower chair have been ordered. The home presents as being clean, pleasant and hygienic. The washing machine is situated in a large cupboard in the hallway, while the dryer is in the kitchen. There is a locked COSHH cupboard. Relevant training in food hygiene and infection control is in place for staff. Selhurst Road 166A DS0000028564.V299286.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from clarity of staff roles and responsibilities. Generally, service users are having their needs well met by an appropriately trained and qualified staff group. The acting manager has not, however, been enabled to undertake training leading to an NVQ Level 4. Service users are benefiting from a qualified, competent and well-supported staff team. Service users are being supported by the home’s recruitment policy and practices. EVIDENCE: There is clarity of staff roles and responsibilities in the home, with both the manager and two staff members on duty demonstrating to the inspector a clear understanding of their roles and responsibilities. Job descriptions, outlining their respective duties and responsibilities are in place. Generally, service users have their needs well met by an appropriately trained and qualified staff group. The inspector examined relevant induction, Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 23 supervision and training records. All staff are receiving appropriate induction, supervision and appraisal arrangements, and there is a comprehensive training programme in place. There is a structured induction as part of the probationary period of employment, which is signed and dated on completion, followed by an ongoing programme of training for staff which includes training in food hygiene, medication, health and safety, fire safety, and moving and handling. The manager maintains a record of training undertaken by all staff. Staff are encouraged to obtain relevant National Vocational Qualifications. Two staff members possess an NVQ Level 3, and one, an NVQ Level 2. Another staff member is studying for her NVQ Level 2. The inspector is, however, concerned to find that the acting manager has not been able to undertake training leading to an NVQ Level 4 (see next section). The home has previously admitted a service user with Retts Syndrome, but has had difficulty in accessing specialist training in this area. The manager has, however, obtained an information pack from the Retts Syndrome Society. The pack provides comprehensive information regarding this condition. Staff have received training in communication skills (on 6/3/06) which has assisted in developing relevant knowledge in this area. A speech and language therapist also visits the home and is working with both the service user and staff so as to develop object recognition abilities and the use of body language as a means of communication. During the day the expectation is that there will be two staff on duty, while at night one member of staff will ‘sleep-in’. A check of the rota showed that these levels were being maintained. The inspector examined staff supervision notes and evidenced that staff are receiving regular supervision, at six-weekly intervals. Supervision is recorded in a structured format which details practice issues, training needs, and goals. Annual staff appraisals are being carried out. The home has appropriate recruitment policy and practices in place, which, in general, are providing the required level of protection for service users. There have, however, been previous concerns regarding recruitment records not being kept at the home. No new members of staff have been appointed since the last inspection. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 24 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 to 43 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are living in a home that is generally being well managed and run in their best interests. The acting manager must, however, be provided with the organisational support with which to demonstrate her competence by completing studies for the necessary management qualifications. The home needs to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is supporting service users and meeting its aims and objectives. Generally, the home’s record keeping, policies and procedures are safeguarding service users’ rights and best interests. However, all policies and procedures must be annually reviewed. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. Updated risk assessments for the home have been completed. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager, Paulette Parchment, has been managing the home since 1 March 2005, and has applied to become the home’s registered manager with the CSCI. She has had relevant experience within another Choice Support home prior to transferring to 166a Selhurst Road. She holds NVQ Level 3 and was registered to commence study for NVQ Level 4 and the RMA (Registered Managers Award) in September 2005. This is required as part of the registration process. The inspector is, therefore, very concerned to learn that the manager has not, so far, been enabled by her employer, Choice Support, to demonstrate her competence by undertaking the necessary studies leading to these qualifications; a requirement applies. The atmosphere in this small home is a positive and happy one. The inspector met both two service users, which indicated that both service users feel settled and happy with the home, and well supported by the manager and staff. Views expressed by two staff members, who were present during the inspection, indicate that the home is being competently managed and that staff feel they are being appropriately supported. No concerns have been expressed. Service managers from the managing organisation carry out unannounced quality checks on a monthly basis. These visits include discussion with service users and their relatives where possible. The manager carries out weekly checks, which include seeking service user’s views. Periodically, the manager is expected to write a quality monitoring report. There are two requirements which remain to be met relating to the need for the home to develop robust quality assurance processes. The home needs to develop its quality assurance processes and develop questionnaires so as to obtain the views of service users, family, friends, health and care professionals and other interested parties. so as to ensure that the home and statement of purpose. The inspector was advised that a service user questionnaire is presently being piloted by Choice Support, with this scheduled to be introduced for use at 166 Selhurst Road. The home must also evidence that it is meeting its aims and objectives and put in place an annual development plan. This should include the results of surveys and other feedback, and copies made available to service users, their representatives, and other interested parties including the CSCI. Generally, the home was found to be maintaining appropriate staffing and service user records. On the last inspection, the inspector was advised that the Service Manager reviews all policies and procedures annually, and that staff have access to regularly updated versions of the homes policies and procedures. The evidence from this inspection is that this is not happening. The inspector previously examined the home’s Policies and Procedures manual, Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 26 which included a comprehensive selection of policies and procedures, but did not include dates when these were last reviewed. Following a requirement from the previous inspection, a front sheet checklist detailing the full list of policies and procedures has now been put in place, with the date when each entry was last reviewed being entered. The inspector was very concerned to find that several policies and procedures, including Adult Protection and Medication (entered as last reviewed in 2003), have not, it seems, been reviewed for some years, two of which (Data Protection and Personal Care) date back to 1998. As required in the regulations, all policies and procedures must be reviewed at least annually; a requirement therefore applies. The home has completed all the necessary up-to-date maintenance and safety checks, covering electrical installation (23/2/05), electrical appliances (4/06) and gas (26/10/05), with those for the smoke alarm, water temperature, fire safety and COSHH (Control of Substances Hazardous to Health) being completed on a weekly basis. A bath hoist which has been installed requires evidence of six-monthly servicing; a requirement applies. Fire safety equipment and alarms were last inspected on 6/4/06, and fire drills undertaken on a three monthly basis, the last being held on 15/5/06. Fire safety training, last held on 28/2/06, is next scheduled to take place on 20/6/06. The home has a rolling programme of training in manual handling, food hygiene, first aid and medication. Health and safety risk assessments for the home have been updated in 2006, and the Fire Risk assessment last completed in March 2006. Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 1 2 3 2 3 Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14(1) & (2) Requirement An appropriate assessment pro forma must be put in place, and be completed with any potential service user. The assessment needs to assess each aspect of daily need, support and physical/mental functioning, and include risk assessments. 2 YA5 5(1)(c) An agreement which details all the terms and conditions for their placement, as detailed under the relevant care standard 5.2, must be drawn up with each service user. This must be written in a format that is appropriate to the communication needs of service users living at the home. Previous time-scale not met. 3 YA6 15(1) Person-centred care plans 30/09/06 (produced in both written and pictorial forms) must be developed for both service users. These should fully involve the service user (and his/her DS0000028564.V299286.R01.S.doc Version 5.2 Page 29 Timescale for action 31/07/06 31/07/06 Selhurst Road 166A representative) and should detail all aspects of daily living and care, and how these will be met. This must include those aspects that the service user is able to manage independently, or can be enabled to do so with encouragement, or with practical support or resources. 4 YA6 13(4)(b) & (c) Service users’ care plans must be signed and dated, to indicate when the plan has been initiated or reviewed, and must be reviewed on a regular, monthly basis. 30/06/06 5 YA20 13(2) 13(4)(a) & (c) The responsible person must (in 31/07/06 accordance with the relevant RPS legislation) ensure that any controlled drugs, which are being administered to service users, are securely stored in a fixed metal cupboard, with a double lock mechanism, separately from other medication. The POVA procedure must be updated as outlined in the 2003/4 annual inspection reports (so as to be in line with the Croydon POVA policy and procedure). This requirement has not been met within previously set timescales. 31/07/06 6 YA23 13 7 YA23 13(6), 18(1)(a) The acting manager and all staff at the home must attend Croydon’s multi-agency Vulnerable Adult training. Training has been booked for 12/7/06. 31/07/06 8 YA37 9(2)(b)(i) The manager must register and undertake study leading to an DS0000028564.V299286.R01.S.doc 31/10/06 Selhurst Road 166A Version 5.2 Page 30 NVQ4 qualification in management and care. 9 YA39 24(1) & (3) The home must develop ‘feedback’ questionnaires for service users, relatives and friends, and for visiting professionals, regarding their views about the home and the services provided. A questionnaire, in an appropriate format, for the two service users, must be developed and completed with them by a relative, friend or independent advocate. Previous time-scale not met. 10 YA39 24(2) The results of surveys and other feedback must form the basis of an annual development plan, and be made available to service users, their representatives and other interested parties including the CSCI. Previous time-scale not met. 11 YA40 12(1)(a) All policies and procedures must have been reviewed and, where necessary, updated within the last 12 months. The date of review must be evidenced on the home’s policies and procedures checklist. The home’s bath hoist must evidence six-monthly servicing. 31/10/06 31/12/06 31/10/06 12 YA42 13(4) 30/09/06 Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 32 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 Selhurst Road 166A DS0000028564.V299286.R01.S.doc Version 5.2 Page 33 - 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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