Inspection on 28/06/07 for Selhurst Road 166A

This inspection was carried out on 28th June 2007.

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

Other inspections for this house

Selhurst Road 166A 13/06/06

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 28th June 2007 9:30am Selhurst Road 166A DS0000028564.V343945.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.V343945.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.V343945.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 T/F 020 8653 8891 NO EMAIL www.choicesupport.org.uk Choice Support 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) Miss Paulette Angela Parchment Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Selhurst Road 166A DS0000028564.V343945.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. 13th June 2006 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.V343945.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 adults 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 spoke with one resident. The inspector examined staff and service user records and other documentation relating to the management and running of the home. These included residents’ health action plans, care plans and risk assessments. Staff records examined included staff rotas, supervision, appraisal and training records. The inspector completed an inspection of the premises and looked at documentation relating to the day-to-day running and management of the home. This included policies and procedures and records relating to the logging of accidents, incidents and complaints (one having been recorded). Documentation relating to health and safety was also examined; this included the home’s risk assessments, servicing and maintenance certification. The inspector also referred to the pre-inspection Annual Quality Assurance Audit (AQAA), which has been completed by the home’s manager. In line with an agreement made between the Chief Executive of Choice Support and the CSCI Provider Relationship Manager, all staff recruitment records are now located within the Human Resources section of Choice Support’s regional office at Westminster Bridge Road in London, The inspector visited this office on 11/7/07 and inspected the relevant staff records. The inspector would like to extend his thanks to the registered manager, Pauline Parchment, for her assistance in helping to facilitate this inspection. As a result of this inspection, there are 7 requirements, of which 5 are unmet from the previous inspection. Though relatively low in number, this represents a significantly high proportion of unmet requirements. These need to be addressed as a priority. Generally, the home is evidenced to be providing a good service to the two residents, with good monitoring of their health, welfare 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. There is evidence from Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 6 feedback at reviews that residents’ rights are being respected, and that the home is providing an enabling and inclusive home environment. There are, however, some issues which need to be addressed. To enable each resident to have an understanding of the terms and conditions of their placement, a service user agreement, written in an appropriate and user-friendly format, must be provided. Person centred care plans need to be put in place, to reflect individual needs, wishes and preferences. Quality assurance questionnaires and processes must be developed so as to evidence that the home is achieving key outcomes for service users and that it is meeting its stated aims and objectives. What the service does well: Prospective residents are being provided with the information they require, and the opportunity to visit, to enable an informed choice as to whether the home is likely to be suitable in meeting their needs. Residents admitted to the home have been fully assessed and know that their individual needs will be met. Residents are being encouraged and supported to participate fully in the dayto-day life and routines of the home, and to develop an independent and community orientated lifestyle. Residents are being consulted regarding decisions that affect them, and are having their rights and responsibilities recognised in their daily lives. Residents are being assessed regarding potential risks to their health and safety, and enabled to take responsible risks wherever possible. Residents are being enabled to participate fully, and to exercise choice and control, in their daily routines and activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents’ rights and responsibilities are being respected and recognised in their day-to-day lives. Residents are being offered a healthy diet, in pleasant surroundings, and are able to exercise choice and flexibility with meal arrangements. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 7 The health and personal care needs of residents are being met, and their privacy respected. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. The home has an appropriate complaints procedure in place, which is in a format suitable for the home’s service users. Residents live in a safe, hygienic and well-maintained environment with access to pleasant and appropriate communal facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, being well suited to their individual needs. Residents have sufficient aids and adaptations with which to maximise their independence. The home presents as being clean, pleasant and hygienic. Residents are having their needs well met by an effective, appropriately trained and qualified staff group. Residents are living in a home that is generally being well managed and being run in their best interests. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. However, the home’s bath hoist must be serviced on a six-monthly basis. What has improved since the last inspection? What they could do better: Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 8 Residents must have person-centred care plans which reflect their views and preferences as to how their daily needs and aspirations are to be met. To enable each resident to have an understanding of the terms and conditions of their placement, a service user agreement, written in an appropriate and user-friendly format, must be provided. While, generally, staff are being supported, supervision is not taking place on a sufficiently regular basis. Policies and procedures must be reviewed and kept up-to-date. 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 residents and meeting its aims and objectives. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Selhurst Road 166A DS0000028564.V343945.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.V343945.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are being provided with the information they require, and the opportunity to visit, to enable an informed choice as to whether the home is likely to be suitable in meeting their needs. Residents admitted to the home have been fully assessed and know that their individual needs will be met. To enable each resident to have an understanding of the terms and conditions of their placement, a service user agreement, written in an appropriate and user-friendly format, must be provided. EVIDENCE: This small home has two residents, each with their own bedroom, bathroom and toilet. There have been no new admissions to the home within the last 12 months. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 11 The home has 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). Time is spent going through the service user guide to ensure that the resident understands its’ contents. Both the statement of purpose and the service user’s guide have been reviewed and updated. To assist in overcoming the communication difficulties presented by residents, and potential residents, these documents have been produced in a more accessible format, using pictures and symbols. There have been no new admissions to the home within the last 12 months. 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. Should the admission proceed, there is a two to three month trial period, prior to an initial review meeting, to decide whether the placement is meeting the person’s needs and is to become permanent. A requirement from the previous inspection, for the home to put in place an appropriate assessment format, has been met. The assessment format assesses each aspect of daily need and physical/mental functioning, and includes risk assessments. The manager understands that an up-to-date care management assessment and care plan must be obtained for any referral from health or social services. Prospective residents are able to visit the home, to meet residents and staff, and to experience the feel of the home before a decision on admission is reached. The inspector is satisfied that the home is able meet residents’ needs and aspirations. There is evidence of a high level of commitment by staff in responding to residents’ needs and in helping to facilitate their participation in daily activities. Staff are appropriately qualified, with NVQ qualifications, and are offered a wide range of training opportunities with which to develop their existing knowledge and skills and to competently carry out their duties. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 12 The inspector spoke with one long-term resident who was present, an older person. She presented as settled and content and as being happy and content in her environment. There had, however, been some earlier concerns relating to the conduct of a particular ex-staff member, and the effect that this had on the resident at the time. These concerns were, however, addressed by the manager and the staff member has since left. The other resident, a younger adult with severe communication difficulties, who has lived in the home for about 2-3 years, was not present during the inspection. However, feedback from the manager, and in notes of reviews, indicates that the placement has been successful in meeting her needs, and that she is being well supported in her environment. A requirement for each resident to have an agreement, which clearly states the terms and conditions of their placement, is in the process of being met. The current agreement, called an ‘assured tenancy agreement’ is not appropriate for the resident’s placement in residential care, being a technical rather than a user-friendly document. The manager showed the inspector an existing agreement form. This has been produced in an appropriate format for people who have communication difficulties, by Hyde Housing, and which is to be adapted to meet the home’s specific terms and conditions. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 to 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents must have person-centred care plans which reflect their views and preferences as to how their daily needs and aspirations are to be met. Residents are being encouraged and supported to participate fully in the dayto-day life and routines of the home, and to develop an independent and community orientated lifestyle. Residents are being consulted regarding decisions that affect them, and are having their rights and responsibilities recognised in their daily lives. Residents are being assessed regarding potential risks to their health and safety, and enabled to take responsible risks wherever possible. EVIDENCE: Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 14 A requirement from the previous inspection, for person-centred care plans to be developed, remains to be met. Residents’ care plans are descriptive and limited in scope, and do not provide a sufficiently comprehensive picture of the residents’ 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. Through the introduction of person-centred support, the home is aiming to involve residents more fully in the day-to-day running of the home. The manager advised that there has been person-centred planning training for staff, and that person-centred care plans are currently being developed. These should fully involve the individual and should detail both those aspects of care and daily living tasks where assistance is required and those tasks where the resident can manage or be enabled to do so independently. 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. The inspector evidenced the completion of risk assessments on residents’ files. These cover areas of risk such as mobility, eating/drinking, medication and risks associated with daily living and other activities. Appropriate strategies are in place for managing risk. A statutory 12 monthly care management review is arranged with each resident, at which the suitability of the placement, in meeting the individual’s needs, is reviewed. This is attended by the individual’s key worker, care manager and nearest relative(s). The inspector noted that one resident’s review was held in March 2007, while the other resident is scheduled to have their review on 26 July 2007. The Service User Guide makes it clear that residents are assisted to make choices in their day-to-day routines and activities and are consulted regarding decisions that affect them. Residents are being consulted on a one-to-one basis through regular contact with staff, and comments and views are noted in residents’ daily diaries. There are clear programmes in place, which specify how residents wish to have their support delivered, and a detailed support plan which outlines their individual requirements in regard to their health, personal care and day-to-day routines. Staff members have been observed to work with residents in an enabling and client-centred way. The manager has advised that each resident meets on a monthly basis with his or her key worker, and that information is noted in the person centred planning book. Information about residents is being held securely in lockable filing cabinets, and there is a policy on the need to maintain confidentiality. Issues of confidentiality are reinforced through staff induction, training and supervision. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being enabled to participate fully, and to exercise choice and control, in their daily routines and activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents’ rights and responsibilities are being respected and recognised in their day-to-day lives. Residents are being offered a healthy diet, in pleasant surroundings, and are able to exercise choice and flexibility with meal arrangements. EVIDENCE: Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 16 The philosophy of the home, as indicated in the home’s Statement of Purpose, is to promote independence and enable residents to develop a wide range of social and independent living skills. Both residents 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. Residents are also encouraged to participate in activities such as tidying their rooms, planning menus, and shopping for food. Both residents have activity programmes that reflect their individual interests and wishes. One resident, an older person, goes to occasional concerts at the Fairfield Halls, attends her local church every Sunday, and goes to a lunch club once a month. She also maintains contact with a friend, visiting each other’s home and going out together on occasion. The other resident, 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 residents maintain contact with another resident with whom they lived with for about six weeks, in another home, whilst redecoration and building work was taking place. The home provides a pleasant place in which to spend time and relax. There is television, with a video and a dvd player, and there is a pleasant, small garden in which both residents can sit out in nice weather. Both residents are encouraged to go out into the community and access shops and community facilities. The home has a motability vehicle which both residents 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. The home actively encourages residents to maintain their family links and friendships. With the support of their key workers, both residents 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. Residents are able to see visitors in the privacy of their rooms if they wish. Each resident 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. Both residents 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 residents are being consulted regarding their rights and responsibilities in their daily lives. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 17 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. There is regular consultation with residents regarding their choice of meals, with residents 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 dietary needs and individual preferences. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 to 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are being met, and their privacy respected. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. EVIDENCE: Both residents are receiving personal care and support according to their assessed needs. However, person centred care plans need to be developed so as to provide a sufficiently comprehensive picture of the residents’ needs and capabilities, and how these are being addressed. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 19 The inspector spoke individually with one resident, an older adult. Whilst unable to engage her in discussion, she presented as content and well cared for. Information recorded on service user files indicated that residents’ personal and social care needs are being well monitored and met. One resident has a relatively high level of support due to her impaired mobility and communication difficulties. Residents are encouraged to 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 with personal care needs. A wheelchair accessible shower and bath seat are provided. Residents receive regular health reviews and there is an individual health plan in place for each resident. These are reviewed and updated on a regular basis. The home is developing person-centred Health Action Plans (My Health), which are compiled in an accessible format, using pictures and symbols. This details comprehensive information regarding each resident’s health history and health care needs, and involves each resident in the process of identifying these and how they are to be met. Each resident receives regular health checks, with any health concerns being followed up through referral to the appropriate health professional. Health checks and treatment are arranged as required. One resident has had recent contact with a dietician, and is being referred to an audiologist for a hearing test, while the other resident has had recent contact with a psychiatrist, and has six-weekly appointments with a diabetic nurse. Both residents 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 and chiropodists. Service Managers from Choice Support regularly visit the home to check that assessed needs are being met. Residents are being protected by the home’s medication policy and procedures. Neither resident administers any of their own medication, and there are six monthly medication reviews. 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. Staff receive 12 monthly medication training refreshers, and have their competence to administer medication tested annually. The supplying pharmacist visits the home at 3monthly weekly intervals, and offers advice and support to staff regarding medication. The last inspection took place on 7/2/07, no issues having been identified. There has also been a pharmacists inspection from the local health trust (on 15/2/07) which provided a good report on medication practice in the home. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 20 Medication records are being appropriately maintained. Residents have a written statement detailing their medication needs, and the manager undertakes a medication audit on a weekly basis. One area of concern from the last inspection has been addressed. There is now a separate locked container for the storage of any controlled drugs. This is located within the locked metal medication cupboard. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 to 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a 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. EVIDENCE: The complaints procedures and information given to residents and their relatives is up to date, and comprehensive, providing details as to how, and to whom they should complain. Residents are assisted to understand the complaints procedure, with access to their care manager being arranged should grounds for making a complaint against the home arise. Independent advocacy, and/or support with communication, can be arranged if this is required. 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. There has been one complaint recorded since the last inspection. This was formalised following the raising of concerns by a resident regarding the actions of a staff member. This involved acts of verbally aggressive behaviour by a Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 22 staff member towards one of the residents, an older adult, behaviour that had caused the resident to become anxious and unsettled, and to exhibit some behavioural problems. On coming to the attention of the manager, this situation was addressed internally and the staff member was transferred to another home. A risk management meeting was held with the care manager and advice was sought from a psychiatrist regarding the disruptive effects of the abuse upon the resident. A strategy was subsequently put in place to address the resulting behavioural difficulties this had caused, the strategy having apparently proved successful in addressing these. The inspector was, however, concerned that the incidents involving verbal abuse had not been referred to the local adult protection agency (Croydon Social Services) and that the staff member concerned had not been suspended but transferred to another home. The manager advised that the staff member concerned had subsequently been dismissed following another incident at the home to which she was transferred. The home’s Safeguarding Adults policy has been developed in line with the Government’s ‘No Secrets’ legislation and the adult protection policy of the local authority (LB Croydon). While the home’s policy has been updated so as to be in line with Croydon’s POVA policy, the relevant procedures were not acted upon in this case. The registered providers and manager are reminded that any incident of abusive behaviour must, in future, be immediately referred to the appropriate local adult protection agency (in Croydon) for a full investigation, and the CSCI notified. Failure to do so is potentially putting vulnerable adult service users at risk. A requirement, for statutory training has now been met. The inspector was advised that the manager and staff have now completed statutory adult protection training, and that a new staff member has been placed on the waiting list. The home has procedures in place for ensuring that residents’ finances are safeguarded. There are weekly finance checks, and finances are monitored monthly on registered person visits. The service manager for Choice Support also audits finances every three months. Properties lists and securities books are maintained for both residents. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 to 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, hygienic and well-maintained environment with access to pleasant and appropriate communal facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, being well suited to their individual needs. Residents have sufficient aids and adaptations with which to maximise their independence. The home presents as being clean, pleasant and hygienic. EVIDENCE: Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 24 The home 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 appears to be in good condition. The home is spacious, with adequate communal space for both residents. It has wheelchair access. There is a large, through lounge, with a dining area at one end, and provides a pleasant area in which to sit and relax. The home is comfortably furnished throughout, and has a very homely feel. There is a spacious hallway, which can easily accommodate a wheelchair. The communal lounge opens onto a small garden and patio, with newly purchased patio furniture. This provides a pleasant place to spend time and receive visitors. The two bedrooms are individually furnished and are decorated to reflect the wishes of the two residents. Since the last inspection, there has been a major programme of redecoration and refurbishment at the home. Both residents’ rooms have been redecorated, and the lounge, hall and one bedroom have been re-carpeted. There has been a major conversion with one bedroom now having its own self-contained bathroom and toilet, and the other having its own shower and toilet. The kitchen, which had been previously renovated to include accessible fitted units, has also been redecorated, together with the sleepover room for the overnight care worker. The boiler has now been rehoused in a separate closet within the reception area. The home has installed an emergency lighting system so as to safeguard residents in the event of power cuts. The home is well maintained and is kept to a good standard. The home was last assessed by an occupational therapist in 2006, and has sufficient aids and adaptations in place. This includes raised toilet seats and grab rails for use of the shower and toilet, a shower chair and a bath hoist. The home also has a motability vehicle which both residents share, and which enables them to access the local community. 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.V343945.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are having their needs well met by an effective, appropriately trained and qualified staff group. Residents are being safeguarded by the home’s recruitment policy and procedures. While, generally, staff are being supported, supervision is not taking place on a sufficiently regular basis. EVIDENCE: The home has a close-knit staff team who are trained in the specific needs of the home’s two residents. There is clarity of staff roles and responsibilities, with job descriptions outlining the respective duties and responsibilities of staff. There are six-weekly staff team meetings when issues relating to staff roles and responsibilities are discussed. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 26 The home has a structured induction as part of the probationary period of employment, which is signed and dated on completion. A recently recruited staff member has been completing their induction, working through a TOPPS induction programme. The staff member is scheduled to undertake further training including medication and adult protection. The home has an ongoing training and development programme, with each staff member having their own training and development plan; The manager maintains a record of training undertaken by all staff. The training programme includes training in Adult Protection, Medication, Manual Handling, Health & Safety, First Aid, Food Hygiene and Fire Safety. Staff have also received training in communication skills. This has assisted in developing relevant knowledge in this area. A speech and language therapist also visits the home and works with both the resident and staff so as to develop object recognition abilities and the use of body language as a means of communication. Staff are encouraged to obtain relevant National Vocational Qualifications. Two staff members have achieved an NVQ Level 3, and another is working towards an NVQ Level 2. Another staff member is due to commence her NVQ Level 2, once her probationary period has been completed. The inspector examined staff supervision notes. This indicated that staff supervision has not been sufficiently regular for some staff. One staff file indicated a four-month gap between two supervision sessions on 30/1/07 and 4/6/07. Staff must have supervision on at least a two-monthly basis. A requirement applies. Supervision is being recorded in a structured format which details practice issues, training needs, and goals. The home has appropriate recruitment policy and practices in place, which, in general, are providing the required level of protection for residents. One new staff member has been appointed since the last inspection. Recruitment records were not available at the home at the time of inspection. In line with an agreement made between the Chief Executive of Choice Support and the CSCI Provider Relationship Manager, all staff recruitment records are now located within the Human Resources section of Choice Support’s regional office at Westminster Bridge Road in London, The inspector visited this office on 11/7/07 and inspected the relevant staff records. These were found to be in order, all the necessary pre-employment checks having been satisfactorily completed. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 to 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is generally being well managed and being 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 residents and meeting its aims and objectives. Residents’ rights and best interests are being safeguarded by the home’s record keeping. However, not all policies and procedures are being reviewed and kept up-to-date. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. However, the home’s bath hoist must be serviced on a six-monthly basis. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 28 EVIDENCE: The registered manager, Paulette Parchment, has been managing the home since 1 March 2005, and has 17 years experience of working with people who have learning difficulties. She has had relevant experience within another Choice Support home prior to transferring to 166a Selhurst Road. The manager holds an NVQ Level 3 and is due to commence studies for the NVQ Level 4 and Registered Managers Award. The atmosphere in this small home is a positive and happy one. The inspector met with one resident, an older adult, who presented as settled and happy with the home. Feedback from reviews indicates that both residents are feeling well supported by the manager and staff. Views previously expressed by staff 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 residents and their relatives where possible. The manager carries out weekly checks, which includes seeking residents’ views. Periodically, the manager is expected to write a quality monitoring report. There are two requirements relating to quality assurance that remain to be met. These have been outstanding from the previous two key inspections and must be given a high priority for implementation. The manager advised the inspector that the providers (Choice Support) are currently developing their quality assurance processes. A policy and procedure has been put in place, and a questionnaire has been drawn up for ascertaining the views of residents. These have not, as yet, been completed with the two residents at 166a Selhurst Road. The inspector was advised that these are scheduled to be completed in October 2007, and that it is the provider’s intention for these to be completed with the residents at Selhurst by a manager from another service within Choice Support. Questionnaires have not, as yet, been developed for relatives and friends, or for professionals, care managers and other parties. These must be prioritised. There is also an outstanding requirement for a Development Plan to be put in place. This is detailed in Standard 39.2 and should evidence whether the home is meeting its aims and objectives. The Plan should summarise the findings from surveys and other feedback, and should reflect aims and outcomes for service users. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 29 The inspector was concerned to find that a requirement relating to the annual review of policies and procedures has not been met. The manager advised that this is the responsibility of the Service Manager for Choice Support, Sarah McGuire. Inspection of the Policies and Procedures checklist indicated that policies for adult protection and medication have been updated in 2006 (as highlighted in the previous report), but that the majority have not been reviewed within the last three years. As detailed in Standard 40.3 staff must be given access to up-to-date copies of policies and procedures. There is a weekly audit of all health and safety checks by the manager, which is documented. The home has completed all the necessary up-to-date maintenance and safety checks, covering electrical installation (11/06), electrical appliances (4/07) and gas (8/06), 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, was last serviced on 10/11/06. Fire safety equipment and alarms were last inspected in November 2006, and fire drills undertaken on a three monthly basis, the last being held on 25/6/07. Fire safety training was last held on 28/2/06,and needs to be updated; a requirement applies. Health and safety, and Fire Risk assessments for the home have been updated in February/March 2007, and the COSSH assessment updated in April 2007. Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 30 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 3 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 2 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 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 3 3 2 3 1 2 3 3 x Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5(1)(c) Requirement Service user agreement 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 residents living at the home. Partly met. A draft format is in place. 2 YA6 15(1) Person-centred care plans. Person-centred care plans (produced in both written and pictorial forms) must be developed for both service users. These should fully involve the service user (and his/her representative) and should detail all aspects of daily Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 32 Timescale for action 31/10/07 31/10/07 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. Care plans must be reviewed on a regular, monthly basis. Not met from previous inspection. Time-scale extended. 3 YA36 18(2) Staff supervision. All staff must receive supervision on at least a two-monthly basis. Failure to do so potentially impairs the quality of support provided to residents. 4 YA37 9(2)(b)(i) Management qualifications. The manager must register and undertake study leading to an NVQ4 qualification in management and care. Partly met. Registered and on waiting list to commence studies. 5 YA39 24(1) & (3) Quality assurance. The home must develop ‘feedback’ questionnaires for service users, relatives and friends, and for visiting Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 33 31/07/07 31/03/08 31/10/07 professionals, regarding their views about the home and the services provided. A questionnaire, in an appropriate format, for the two residents, must be developed and completed with them by a relative, friend or independent advocate. Not met from previous inspection. Time-scale extended. 6 YA39 24(2) Quality assurance. 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. Not met from previous inspection. Time-scale extended. 7 YA40 12(1)(a) Review of policies and procedures. All policies and procedures must be kept under review and, where necessary, updated. The date of review must be evidenced on the home’s policies and procedures checklist. 31/12/07 31/03/08 Selhurst Road 166A DS0000028564.V343945.R01.S.doc Version 5.2 Page 34 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.V343945.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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