Inspection on 22/11/05 for Selhurst Road 166A

This inspection was carried out on 22nd November 2005.

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

The inspector 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 15 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 13/06/06

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 Unannounced Inspection 22nd November 2005 09:30 Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 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.V265492.R01.S.doc Version 5.0 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. 3rd June 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.V265492.R01.S.doc Version 5.0 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 is currently in the process of being registered as manager with the CSCI. The inspector spoke at length to one of the two service users who was present during the inspection, and met one staff member 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 15 requirements and 3 recommendations. 10 requirements remain to be met from the previous inspection. (time-scales highlighted in bold italics on the requirements list). The inspector would like to extend his thanks to the manager for her assistance during the inspection. What the service does well: Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. 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. 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. The home is able to demonstrate that it is treating with respect the wishes of the service user regarding the eventuality of their, ageing, illness and death. Service users generally have access to safe and comfortable personal and Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 6 communal facilities. There are, however, some improvements that are in the process of being implemented, that will assist in bringing service users’ bedrooms up to a more homely standard. Service users are living in a home that is generally being well managed and run in their best interests. Generally, the home’s record keeping, policies and procedures are safeguarding service users’ rights and best interests. A checklist would, however, assist in tracking when reviews have taken place and are due. What has improved since the last inspection? Staff are undertaking training in the development of communication skills with service users who have profound communication difficulties. All staff have been placed on the waiting-list for Croydon’s multi-agency adult protection training. The home’s complaints procedure has now been revised so as to provide upto-date information regarding the referral of complaints to the CSCI and social services. Full information regarding the assessed needs of a recently admitted service user has now been obtained from the referring agency; the home must, however, complete its own second stage assessment. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 7 What they could do better: The home has yet to demonstrate that the range of needs presented by a recently admitted service user have been fully and appropriately assessed; the home needs to develop an assessment pro forma for this purpose. Each service user must be provided with a service user agreement which is specific to the service user’s placement in a care home. This must be written in a format which is appropriate to service users living at the home. While it is the home’s policy to provide a comprehensive person centred plan for each service user, detailing their health, personal and social care needs, the home has yet to put in place an appropriate service user plan for the recently admitted service user. 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 live in a safe and well-maintained, clean and pleasant environment. While some aids and adaptations have been provided, the ability of a service user, with significant disabilities, to function safely and independently requires an occupational therapist’s assessment of her needs. This is in hand. While service users are being supported by a generally capable and competent staff team, the level of staffing required to cover shifts and meet their needs should be reviewed. Generally, service users have their needs well met by an appropriately trained and qualified staff group. There is, however, a need for staff to undertake some further training relating to the specific needs presented by a new service user. 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 health, safety and welfare of service users and staff are being appropriately promoted and protected. For sufficient safeguards to be in place, however, updated risk assessments for the home must be completed. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 8 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.V265492.R01.S.doc Version 5.0 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.V265492.R01.S.doc Version 5.0 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): The home has yet to demonstrate that the range of needs presented by a recently admitted service user have been fully and appropriately assessed. 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: Standards 2 and 5 assessed. All other standards met at the last inspection. 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. Following a requirement from the previous inspection, the home has now obtained a care management assessment, risk assessment and care plan from the referring local authority; these are, however, very much out-of-date and of only limited value. While risk assessments (involving the manager and physiotherapist) have subsequently been completed for areas of risk such as mobility and eating/drinking, the home should have completed its own full assessment following the service user’s transfer from her previous placement in supported accommodation. The inspector was concerned to find no evidence of any assessment pro forma in place to assess each aspect of daily need and physical/mental functioning. Where an up-to-date care management Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 11 assessment is not available at the point of admission, a full assessment by the home is required. To this end, an appropriate assessment pro forma must be put in place and completed with the service user. A requirement applies. 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.V265492.R01.S.doc Version 5.0 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): While it is the home’s policy to provide a comprehensive person centred plan for each service user, detailing their health, personal and social care needs, the home has yet to put in place an appropriate service user plan for the recently admitted service user. Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. EVIDENCE: Standards 6 and 9 assessed. Standards 7 and 8 met at the last inspection. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 13 A requirement, for a full and detailed service user plan (in an appropriate format) to be developed and agreed with the service user, has not been met. The manager indicated that individual programme plans, detailing how aspects of care need are to be met, have been put in place. On inspection these do not constitute an integrated ‘service user plan’ and do not spell out sufficiently the areas of need and risk, the actions required to meet these, and by whom. Neither do they evidence the service user’s involvement or that of their relative or representative. The ‘service user plan’ must detail how all the aspects of personal and social support, and healthcare needs, (as detailed in standard 2.3) are to be met, and be signed and dated by the manager, service user and his/her relative/representative. The plan must be reviewed on a monthly basis. Following a requirement from the previous inspection, risk assessments have been completed for the service user admitted earlier this year. These cover areas of risk such as mobility and eating/drinking, and have been completed by appropriately experienced and competent persons. These detail the actions required to minimise risks and hazards. The other service user, who has been resident at the home for several years, has well-documented risk assessments. These include programmes for safe eating and other activities. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 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): 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. 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: Standards 13, 14 and 17 assessed. Standards 11, 12 and 15 met at the last inspection. The dining area is pleasantly laid out and provides a relaxed and congenial setting for taking meals. The inspector examined menus over a four-week period and was satisfied that a varied selection of food is offered. Breakfast, lunch and an evening meal are provided. Mealtimes are flexible and take Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 15 account of individuals’ daily routines and social arrangements. Service users are consulted as to which foods they would like purchased, and are able to have an alternative dish provided if the main menu option does not appeal. In order to ensure that the service users are receiving suitably nutritious meals a dietician regularly checks the menu. The manager advised that there is regular consultation with service users regarding their choice of meals, and full account is taken of their dietary needs and individual preferences. The inspector spoke at length with one of the two service users (who is aged over 65). She presented as settled and happy with her environment. With assistance from her key worker, she is able to exercise choice in her daily routines. There was evidence of a regular programme of social contact and activities throughout the week, which includes visits to lunchtime concerts at the Fairfield Halls, shopping trips, and visits to see friends. She also attends Church on a regular basis. The other service user, a younger adult, has both physical and learning disability, and profound communication difficulties, and attends a day centre in Peckham on two days each week, maintaining her long-term contact with day care staff and other users. She has a key worker at the home who assists her to access shops and community facilities. The manager indicated that she has settled well in the home and is able, with support, to participate in daily routines. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 16 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): While the home is able to demonstrate that it is treating with respect the wishes of the service user regarding the eventuality of their, ageing, illness and death, it needs to clarify the position should the need for nursing care arise. EVIDENCE: Standard 21 assessed. Standards 18 to 20 met at the last inspection. Following a requirement from the last inspection, the wishes of the recently admitted service user regarding the eventuality of her death have now been ascertained in a meeting held with her and her nearest family relatives. These views have been recorded on the service users file. Clarification regarding the position, should she deteriorate to the point of requiring nursing care, should, however, be provided at the next review. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has a complaints procedure in place, which is in a format suitable for the home’s service users. The procedure has now been revised so as to provide up-to-date information regarding the referral of complaints to the CSCI and social services. 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. A long-outstanding requirement from previous inspections has now been met. The complaints procedure has been updated so as to refer to the current legislation. Reference is now made to the CSCI (Commission For Social Care Inspection) and the LB Croydon, and contact details have been included. While there is an adult protection procedure in the home, this refers to the London Borough of Southwark and its POVA policy, which includes giving emergency contact numbers for that Borough. There is a long outstanding requirement for the policy to be amended so as to refer to Croydon’s POVA policy and procedures, and provide revised contact numbers. The inspector is very concerned to find that these changes have still not been made Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 18 and is giving notice that enforcement action will follow if the requirement is not met within this final extension of the time-scale. The manager advised that the home has a copy of Croydon’s adult protection policy and procedure. The home’s procedures must, therefore, be amended to be in line with this policy. The inspector recommends that the manager obtains the summarised version of Croydon’s adult protection procedures for distribution to all staff in the home. There is an outstanding requirement for the manager and all staff at the home to attend Croydon’s multi-agency adult protection training. This training is essential in providing staff with a detailed understanding of adult protection issues and with Croydon’s policy and procedures. The inspector understands that all staff have been placed on Croydon’s waiting-list, and are awaiting dates for a course to be held in January 2006. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users live in a safe and well-maintained, clean and pleasant environment. Service users generally have access to safe and comfortable personal and communal facilities. There are some improvements, which are in the process of being implemented, that will assist in bringing service users’ bedrooms up to a more homely standard. While some aids and adaptations have been provided, the ability of a service user, with significant disabilities, to function safely and independently requires an occupational therapist’s assessment of her needs. This is in hand. EVIDENCE: Standards 24, 25 and 29 assessed. All standards assessed at the last inspection, of which Standards 26, 27, 28 and 30 were met. Based on the evidence from this and the previous inspection, the two service users are living in safe and well-maintained, clean and pleasant premises. Both service users present as settled and happy with their environment. Their bedrooms reflect their individual interests and identities. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 20 However, a number of requirements remain outstanding from the previous inspection. The kitchen presents as being in need of renovation with replacement of burnt surfaces and adaptation or replacement of fitted units so as to make these more accessible for service users. The manager advised that an estimate for the work has been approved and that the necessary work is soon to be undertaken. The home must provide a system of emergency lighting so as to protect service users in the event of power cuts. The inspector understands that a decision on the work required is still pending. This is a safety concern, and must be actioned as a priority. The inspector was informed that carpeting for the new service user’s bedroom has been ordered, and that an armchair has been obtained. A replacement armchair for the second bedroom is on order. Due to problems with incontinence, carpeting of this room is no longer required. The inspector was informed that a lockable facility for the new service user’s room is due to be installed. An occupational therapist’s assessment of the new service user is still outstanding. The manager advised that following a delay, when Croydon was initially approached, the service user has now been placed on a waiting-list for an O.T. assessment by the LB Southwark, having been classified as being at ‘moderate risk’. While aids and adaptations already in place are assisting in meeting the service user’s needs, further assessment and provision is required. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 21 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): Generally, service users have their needs well met by an appropriately trained and qualified staff group. There is, however, a need for staff to undertake further training relating to the specific needs presented by a new service user. While service users are being supported by a generally capable and competent staff team, the level of staffing required to cover shifts and meet their needs should be reviewed. EVIDENCE: Standards 32, 33 and 36 assessed. Standards 32 and 35 were met at the last inspection. Following the admission to the home of a service user with ‘Rett’s Syndrome’, a recommendation was made at the last inspection for staff to be provided with some relevant training to develop their understanding of this condition and to acquire relevant skills. The manager has not so far been able to access any specific training in this area, but has obtained some useful information concerning this condition from the British Epilepsy Association. It was agreed that she would contact the association again to see if any training is available. She also advised that the service user’s key worker and other staff are to attend a two-day training course scheduled in December/January. The course is called ‘Communication without words’, and is designed to assist the development of communication skills with people who are unable to Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 22 communicate verbally. The course, which is run by a speech and language therapist, is organised by Croydon Social Services. No new members of staff have been appointed since the last inspection. 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 confirmed that Person Centred Planning training is planned for staff early in the New Year. 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 however the manager only receives one ‘office day’ per week. For the remainder of her shifts she is included on the rota and will work a variety of shifts, including night shifts. Comment has previously been made regarding this matter. Consideration should be given by the service provider to removing the manager from night shifts, and to increasing the managers ‘office days’ given the increasing workload involved in managing a care home. The staffing level should be increased so as to allow this to happen. A recommendation applies. Two requirements relating to Standard 34, and one relating to Standard 36, have been met. Staff records, including those relating to supervision and training are now being held in lockable cabinets within the home. The manager confirmed that staff are receiving regular supervision, at four to six-weekly intervals. Supervision is recorded in a structured format which details practice issues, training needs, and goals. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 23 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): Service users are living in a home that is generally being well managed and run in their best interests. 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. A checklist would, however, assist in tracking when reviews have taken place and are due. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. For sufficient safeguards to be in place, however, updated risk assessments for the home must be completed. EVIDENCE: Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 24 Standards 37 to 40 and 42 assessed. Standard 43 met at the last inspection. The manager, Pauline Parchment, who has been acting-up since 1 March 2005, confirmed that her appointment has recently been made permanent, and that her registration is currently being applied for with the CSCI. She holds NVQ Level 3 and was registered to commence study for NVQ Level 4 and the RMA (Registered Managers Award) in September 2005. She has had relevant experience within another Choice Support home prior to transferring to 166a Selhurst Road. The manager is receiving support and supervision from a service manager. The atmosphere in this small home is a positive and happy one. Discussion with one of the two service users, and views which have previously been expressed by staff, indicate that the home is being competently managed and that staff feel they are being appropriately supported. Service users present as settled and reassured by the supportive approach of the manager and staff, and no concerns have been expressed. Concerns from the previous inspection which indicated that there had previously been a lack of vigilance in following admission and staffing procedures, have now been addressed and the inspector felt assured that the manager has been receiving appropriate support from her line manager. 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. While the home seeks the views of service user’s and monitors the home on a regular basis, 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, and ensure that the home is meeting its aims, objectives and statement of purpose. The results of these surveys can then be made available to service users, their representatives and other interested parties including the CSCI and form the basis of an annual development plan. A requirement is made for the home to develop ‘feedback’ questionnaires for relatives and friends, and for visiting professionals and other parties, regarding their views about the home and the services provided. A questionnaire, in an appropriate format, for the two service users, must also be developed, and completed with them by a relative, friend or independent advocate. The manager advised that all policies and procedures are reviewed annually by the Service Manager, each year. Staff has access to regularly updated versions of the homes policies and procedures that they must sign and date as proof that they have read and understand new or revised policies and procedures. The inspector examined the Policies and Procedures manual which included a comprehensive selection of policies and procedures, but review dates are not included on the home’s copies. The inspector is making it a requirement for the Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 25 home to evidence a front sheet checklist detailing the full list of policies and procedures in place and the date when each entry was last reviewed. The home had a health and safety inspection on 25/10/05, as a result of which a new bath chair hoist has been ordered. The inspection also identified the need for revised health and safety risk assessments to be put in place, to include those for COSHH (Control of Substances Hazardous to Health), Fire Safety, Manual Handling and General Risks. A requirement applies, for all recommendations identified in the report of the Health and Safety Inspection of the Home on 25/10/05, to be implemented as a priority. Fire equipment was tested on 27/10/05. Records of fire drills was evidenced, the most recent fire drill having been held on 17/11/05. Fire drills are undertaken on a two monthly basis, and fire safety training has been undertaken in recent months by the manager and staff. Fire safety training is due to be held on 16/12/05 for two staff who have not yet completed this. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Selhurst Road 166A Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 X 2 X DS0000028564.V265492.R01.S.doc Version 5.0 Page 27 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 Timescale for action 31/12/05 2 YA5 5(1)(c) 3 YA6 13(4)(b) & (c) Where a comprehensive and upto-date care management assessment is not available, the home must fully assess the service user’s needs at the point of admission. An appropriate assessment pro forma must be put in place, and an assessment completed with the recently admitted service user. An agreement which details all 31/03/06 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 which is appropriate to the communication needs of service users living at the home. The responsible person must 31/12/05 ensure that a service user plan is developed and agreed with the recently admitted service user, and involving family, friends and/or advocate as appropriate. This must indicate the ways in which assessed needs and goals will be met, and detail the DS0000028564.V265492.R01.S.doc Version 5.0 Page 28 Selhurst Road 166A 4 YA23 13 5 YA23 13(6), 18(1)(a) 13(4)(a) & (c) 16(2)g & h 6 7 YA24 YA24 8 YA29 13(4)a & c 9 YA25 16(2)c 10 YA25 16(2)c 11 YA25 16(2)c support and services provided by the home. The POVA procedure must be updated as outlined in the 2003/4 annual inspection reports. This requirement has not been met within previously set timescales and enforcement action will follow if this requirement is not met. The acting manager and all staff at the home must attend Croydon’s multi-agency Vulnerable Adult training. The home must provide emergency lighting. The kitchen requires renovation with replacement of burnt surfaces, and adaptation or replacement of fitted units so as to make these more accessible for service users. An O.T. (Occupational Therapy) assessment of the new service user must be carried out, and a report obtained. Any recommendations made must be implemented. If not covered in the O.Ts report, written advice and clarification should be sought from the occupational therapist regarding the need for the installation of grab rails adjacent to the shower and toilet. The new service users room must have some carpeting laid. The wardrobe requires repair or replacement. The new service users room must include a lockable facility for securely storing any personal valuables or possessions. The second bedroom, used by the other service user, requires the replacement of a rather worn armchair with a new, DS0000028564.V265492.R01.S.doc 31/03/06 31/01/05 31/03/06 31/03/06 31/12/05 31/12/06 31/12/06 31/12/06 Selhurst Road 166A Version 5.0 Page 29 comfortable one. 12 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. 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. The home must provide a checklist at the front of the policies and procedures manual detailing the date when each entry was last reviewed. All recommendations identified in the report of the Health and Safety Inspection of the Home on 25/10/05, must be implemented as a priority. 31/03/06 13 YA39 24(2) 30/04/06 14 YA40 12(1)(a) 31/03/06 15 YA42 13(4)(a), (b) & (c) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations The inspector recommends that the manager obtains a summarised version of Croydon’s adult protection procedures for distribution to all staff in the home. Consideration should be given by the service provider to DS0000028564.V265492.R01.S.doc Version 5.0 Page 30 2 YA33 Selhurst Road 166A removing the manager from night shifts, and to increasing the managers ‘office days’, given the increasing workload involved in managing a care home. The staffing level at the home should be increased to allow this to take place. 3 YA32 Staff should be provided with some specialist training input relating to Rett’s Syndrome and the care and health needs which this condition presents. Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Selhurst Road 166A DS0000028564.V265492.R01.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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