Inspection on 03/06/05 for Selhurst Road 166A

This inspection was carried out on 3rd June 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 no outstanding requirements from the previous inspection report, but made 19 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 22/11/05

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 Announced Inspection 3 June 2005 9:30am 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 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 Stationary 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) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Selhurst Road (166a) Address 166a Selhurst Road, South Norwood, London, SE25 6LS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8653 8891 Choice Support Care Home 2 Category(ies) of Learning Disability (2) registration, with number of places Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 24 March 2005 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). Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 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. There has been one recent admission of a young adult. Both service users have their own bedroom and there are spacious communal facilities. This announced inspection was conducted over one day and involved consultation with the acting manager, who has been managing the home since 1.3.05, following the departure of the registered manager. The inspector spoke to staff on duty and service users during the inspection. As a result of this inspection, there are 19 requirements, 3 of which are unmet from the last inspection. The inspector would like to thank the service users, acting manager and staff for their assistance throughout the inspection. What the service does well: Service users indicated that they feel settled in this home and that they are satisfied with the care and support they receive from staff. Overall the inspector found Selhurst Road to be a comfortable, relaxed and pleasant environment, providing a good level of support for residents. Comprehensive information is being provided by the home to assist prospective service users to decide whether the home is likely to be a suitable environment in which to live and have their needs met. Prospective service users are given the opportunity to visit and stay at the home prior to deciding whether they wish to move in. Service users are enabled to make choices in their day-to-day lives and are consulted regarding decisions that affect them. Staff on duty at the time of the inspection were observed to be interacting with the service users in a caring, respectful and professional manner. Service users are assisted to participate in daily routines and to develop independent daily living skills. There are opportunities for participating in appropriate day care activities and for accessing shops, and recreational facilities in the local community. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 6 The home actively encourages service users to maintain family links and friendships. Service users are supported in visiting and receiving visits from friends or relatives. Personal support and social care needs are generally being met in accord with service users’ preferences. Arrangements are in place to ensure that the health care needs of service users are being met. Generally, service users have their needs well met by an appropriately trained and qualified staff group. All staff have appropriate induction, supervision and appraisal arrangements, and there is a comprehensive training programme in place. Staff are being appropriately supported, and supervised, and an appraisal process has been developed. The inspector was satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. Safety checks and certification are in place. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 7 What has improved since the last inspection? What they could do better: The home has an admission procedure which specifies the need for a full assessment of an individual’s personal, social and health needs to be carried out prior to an admission. This procedure was not, however, followed in the case of a recent admission of a new service user, the only assessment on file dating from May 2001. 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, it is concerning that none has yet been put in place for the recently admitted service user. Without an up to date assessment and care plan the service user’s needs cannot be fully assessed and addressed. This is placing the service user at potential risk. The home is being required to complete these forthwith and to ensure that assessments and care plans are completed prior to any future admission. While well-documented risk assessments are in place for one service user, it was concerning to find that none have yet been put in place for the recently admitted service user. Given the service user’s significantly high level of needs, the failure to have put risk assessments in place is potentially compromising the user’s safety and security. The home is being required to put these in place forthwith, and to ensure that risk assessments are completed prior to any future admission. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 8 Each service user should have a tenancy agreement stating the terms and conditions of their placement. For the recent admission there was no evidence of any such agreement having been drawn up with the service user. While the home’s policies and procedures, regarding the eventuality of the service user’s ageing, illness and death, are in place, the wishes of the recently admitted service user have not yet been recorded. While the home has a complaints policy and procedure in place, the procedure includes some inaccurate and incomplete information, and must be revised in line with a previous requirement. While the home has adult protection policies and procedures in place, which evidence that service users are being protected from abuse, the procedure includes some inaccurate and incomplete information, and must be revised in line with a previous requirement. The awareness of staff to adult protection issues needs to be raised through appropriate adult protection training. To this end there is a requirement for all staff at the home to attend the one-day Adult Protection course which is facilitated by Croydon social services. Service users generally have access to safe and comfortable personal and communal facilities. Service users require some adaptations to the bathroom and kitchen to ensure safety and help facilitate their independence. There are also some improvements which need to be made to bring service users’ bedrooms up to standard. While the home has appropriate recruitment policy and practices in place, it was not possible to complete recruitment checks for a recently transferred staff member, as her staff file has not been received. Failure to have appropriate staff records in the home represents a potential risk to service users. The home is presently being managed by the acting manager in an open and generally competent way. Staff and service user feedback indicates that the atmosphere in the home is a happy and positive one. There are, however, concerns arising from this inspection which indicate that there has been a lack of vigilance in following procedures, for which line management support for the acting manager would appear to have been lacking. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 9 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) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 10 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 Standards Statutory Requirements Identified During the Inspection Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 11 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 standard(s) 1, 2, 3, 4, and 5 Comprehensive information is being provided by the home to assist prospective service users decide whether the home is likely to be a suitable environment in which to live and have their needs met. In order that service users can be assured their needs can be fully met a full assessment of an individual’s personal, social and health needs has to be carried out prior to an admission. Prospective service users are given the opportunity to visit and stay at the home prior to deciding whether they wish to move in. Each service user should have a tenancy agreement stating the terms and conditions of their placement otherwise this prevents the service user, his relatives and agents from knowing what services will be contractually provided and whether all his needs will be met. EVIDENCE: The home had compiled a detailed statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. The home has developed a service user’s guide which is written in a format/language suitable for the service users. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 12 Following the death of one of the two service users, there has been a new admission to the home. The inspector examined the service user’s file and was concerned to discover that no recent care management or internal assessment has been completed prior to her admission. The last full (care managed) assessment on file was dated 31.5.01. Neither was there any evidence of any recent risk assessments having been completed, those on file being several years out of date. The acting manager advised the inspector that risk assessments were in the process of being carried out. There was evidence of a recent physiotherapy assessment, and the inspector was advised that there had been an occupational therapy assessment visit, though there was nothing on the service user’s file to evidence this. The inspector understands that the home’s admission procedure is for a full assessment of an individual’s personal, social and health needs to be carried out prior to any admission, with this being undertaken by the registered manager with additional reports being provided from other professionals. All the relevant documentation, policies and procedures outlining the assessment processes are in place, but these were not evidenced to have been followed with this admission. The home has an experienced staff team two of whom hold an NVQ Level II or above in care, and another who is currently being registered. The inspector was advised that the new service user was transferred to the home with the key worker from her previous placement. The inspector spoke to the new service user and ascertained that she had settled in, and likes the home. The inspector also spoke to the key worker who demonstrated a knowledge and understanding of the service user’s needs and was observed to interact in an enabling and caring way. The inspector observed a high level of commitment by staff in responding to service users’ needs and in helping to facilitate their participation in daily activities. Staff are offered a wide range of training opportunities with which to develop their existing knowledge and skills and to competently carry out their duties. Prospective residents are invited to visit the home, and meet with the staff team and other residents, and have a meal with them. Further visits may then be arranged, such as being invited to spend a whole day at the home, then a weekend stay. Following this they would be admitted, with a trial period agreed between the home and the placing authority. The home caters for longterm placements and does not take emergency admissions. The acting manager advised that the new service user visited the home with her family, and then stayed for a weekend before deciding to move in. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 13 Each service user should be provided with a tenancy agreement. This must indicate which room is to be occupied. The inspector was concerned to learn from the acting manager that the new service user has yet to receive a tenancy agreement. This must be drawn up with the service user, in a format which is appropriate to the service user’s needs, supported, as appropriate, by family, friends and/or an advocate. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 14 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 standard(s) 6, 7, 8 and 9 Service users cannot be confident that the home will identify and meet their assessed health ,personal and social care needs when they first move into the home. Service users are assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. While well-documented risk assessments are in place for one service user, it was concerning to find that none have yet been put in place for the recently admitted service user. Given the service user’s significantly high level of needs, the failure to have put risk assessments in place is potentially compromising the user’s safety and security. EVIDENCE: Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 15 The inspector examined the file of a recently admitted service user and could find no evidence of a proper service user plan having been drawn up. The inspector was advised by the acting manager that following the service user’s admission on 2.5.05 a six-weekly care management review has been scheduled, following which a plan is to be drawn up. The inspector is concerned that no interim service user plan has been developed and is making it a requirement for a full and detailed service user plan (in an appropriate format) to be developed and agreed with the service user. This should involve family/ friends and/or an advocate as appropriate. This must indicate the ways in which the service user’s assessed needs and goals will be met, and detail the support and services provided by the home. The other service user at the home has a comprehensive ‘person centred plan’ which explains, in both writing and pictures, the various aspects of the care plan, including personal care, medication and health. There is also has an ‘individual personal profile’ which is reviewed on a six-monthly basis. Accompanying these are goal records sheets. Target dates are set for goals to be achieved and are reviewed as and when necessary. Staff members on duty were observed to work with service users in an enabling and client-centred way. The Service User Guide makes clear that service users are assisted to make choices in their day-to-day routines and activities and are consulted regarding decisions that affect them. Service users are consulted on a one-to-one basis through regular contact with staff, and comments and views are noted in service users’ daily diaries. The acting manager advised that key workers meet on a monthly basis with service users and information noted in the person centred planning book. There has not been any previous wish for service user meetings, but with the recent admission, the inspector recommends that this is explored again with the present service users. For the service user who has been recently admitted there was no evidence of any recent risk assessments having been completed, those on file being several years out of date. The acting manager advised the inspector that risk assessments were in the process of being completed. The inspector is requiring that risk assessments and strategies for the recently admitted service user are put in place and evidenced, and that no further admission to the home takes place without risk assessments having been first completed. 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) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 16 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 standard(s) 11, 12, 13, 14 and 15 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 and recreational facilities which improves their opportunities to be involved in the local community. The home actively encourages and enables service users to maintain family links and friendships. EVIDENCE: Both service users are encouraged by the staff team to participate in regular activities of daily living, such as meal preparation, household chores, the laundry and setting and clearing the dining table. Service users are encouraged to participate in activities such as tidying their rooms, planning menus, and shopping for food. Service users are able to watch television or videos, and there is a pleasant garden in which they can sit out in nice weather. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 17 One service user attends a lunch club, and goes to a lunchtime concert at the Fairfield Halls once a week. She also attends a local church on a regular basis. The recently admitted service user is continuing to attend a day centre in Peckham, two days a week, until a day centre place becomes available in Croydon. The service user indicated that she enjoys going there. The acting manager advised that the centre provides a hydropool and trampolining, with an exercise programme being in place. Both service users go out into the community and access shops and community facilities. The home is hoping to replace a motability vehicle, for the use of both service users. The home has access to its own transport, which has disabled access, and which is used for outings and day trips. Both service user’s are on the electoral role. The home actively encourages service users to maintain family links and friendships. Service users can see visitors in private their rooms if they wish. Each service user has a day set aside for visiting or receiving family/friends. There are no restrictions on visitors other than they arrange to visit at reasonable times. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 Personal support and social care needs are generally being met in accord with service users’ preferences, and arrangements are in place to ensure that health care needs are being addressed. An individual plan of care, detailing how all aspects of care are to be met, is not, however, in place for the recently admitted service user. The home has a clear policy and procedures in place for the receipt, recording, storage, handling, administration and disposal of medicines which ensures that the service users are adequately protected. While there are appropriate policies and procedures in place, the wishes of the recently admitted service user regarding the eventuality of her ageing, illness and death have not yet been recorded EVIDENCE: Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 19 Both service users receive personal care and support according to their needs. An individual health plan is in place for each resident. These are reviewed and updated on a regular basis. Service users are encouraged to choose which clothes to wear and to express their preferences regarding how their care is provided. The recently admitted service user, who has Retts Syndrome, requires a relatively high level of support due to her impaired mobility and communication difficulties. Staff aim to ensure that privacy and dignity is maintained when assisting service users with their personal care needs. A wheelchair accessible shower and bath seat are provided to assist in meeting users’ needs. The inspector looked at health care records. Both service users are registered with a GP who is based at the local health centre. Other community based health care professionals have regular or occasional contact, and include specialist district nurses, dentists, opticians, audiologists, and chiropodists. Service users receive regular health checks and potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. Service Managers regularly visit the home to check that assessed needs are being met. The acting manager advised that all five 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. A pharmacist visits the home at eight weekly intervals, and offers advice and support to staff regarding medication. Medication records are appropriately maintained and each service has a written statement detailing their medication needs. Medication is audited by the manager on a weekly basis. There are policies/procedures in place with regard to dealing with the death of a resident. Since the last inspection on 3/11/04 one of the two service users, who had been resident at the home for several years, passed away. The two service users had been close and would often go out together. The inspector understands that support was provided for the other service user and that family and friends of the deceased were kept informed. A garden bench is to be donated by the family in memory of the service user. The inspector ascertained that the wishes of the recently admitted service user regarding the eventuality of her ageing, illness and death have not yet been recorded. This must be done in consultation with the service user and her immediate family. The wishes of the other service user has been recorded. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 20 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 standard(s) 22 and 23 The home has a complaints procedure in place, with a format which is accessible for the home’s service users. However, in order that the service users can feel assured that their views and concerns will listened to and acted on appropriately some changes need to be made to the procedure. Service users cannot be confident that they are fully protected from abuse until changes are made in the adult protection policy and staff are appropriately trained. 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 requirement regarding the need for the complaints procedure to be revised has not yet been met. This has been outstanding from previous inspections. The procedure must be updated so as to refer to the current legislation. Reference must be made to the CSCI (Commission For Social Care Inspection) and the LB Croydon (and not to previous Inspection units and the London Borough of Southwark). Contact details must be included. The procedure must be updated so as to include all elements of this standard. While there is an adult protection procedure in the home, it, like the complaints procedure, refers to the London Borough of Southwark and its POVA policy, including giving emergency contact numbers for that Borough. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 21 The acting manager advised that the home now has a copy of Croydon’s adult protection policy and procedure. The home’s procedure must be amended to be in-line with this policy. The inspector was concerned to learn that, as yet, no staff at the home have attended Croydon’s multi-agency Vulnerable Adult training. This training is essential in providing staff with a detailed understanding of adult protection issues and Croydon’s policy and procedures. The inspector is making it a requirement for the acting manager and all staff at the home to attend this training. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 22 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 Apart from one aspect service users live in a safe and well-maintained, clean and pleasant environment. While service users generally have access to safe and comfortable personal and communal facilities, there are some improvements that need to be made to bring service users’ bedrooms up to a more homely standard and communal areas more accessible, EVIDENCE: Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 23 The bungalow is spacious, and well suited to wheelchair users. This is set back off the main road, behind larger buildings. Access is via a narrow alleyway which is just accessible by car. The home presents as clean, bright and comfortable, with good access to local amenities. The fabric and décor of the premises appeared to be in good condition. The inspector was advised that the home does not provide any emergency lighting in the event of power cuts. This is a safety concern for service users and a requirement applies. The inspector completed an audit of furnishings and fittings and noted a number of matters which require attention, and for which requirements are made. The new service user’s room presents as being a little bare and short of home comforts. The room would benefit from the laying of some carpeting and the provision of a comfortable armchair. The wardrobe will not easily open and requires repair or replacement. A lockable facility for securely storing any valuables or personal possessions must also be provided. The second bedroom, used by the other service user, also requires carpeting and the replacement of a rather worn armchair with a new, comfortable one. 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 inspector noted that one cupboard was only able to partially open due to the installation of a spin dryer directly adjacent to it. The bathroom and toilet is shared by the two service users. Given the mobility problems experienced by the newly admitted service user it would appear advisable to install a grab rail adjacent to the shower and another grab rail adjacent to the toilet. The inspector understands that the occupational therapist has visited the home to assess the new service user’s needs, though no report was available to view. A report of the O.T assessment must be obtained, and any recommendations implemented. Written clarification should be sought from the occupational therapist regarding the need for these adaptations if these are not covered in the report. The bungalow is spacious, with adequate communal space for both residents. This has a large, well-furnished lounge, with a dining area at one end. There is a spacious hallway which can easily accommodate a wheelchair. Visitors are greeted by the chirping of two budgerigars, which belong to one of the residents. There is a large garden to the side of the house, which provides a pleasant area in the summer months. The home’s two service users presented as settled in their environment and indicated that they liked the home. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 24 The home presents as 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) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36 Generally, service users have their needs well met by an appropriately trained and qualified staff group. However in order that this continues there is, however, a need for staff to undertake training relating to the specific needs presented by a new service user and also to review the adequacy of staffing levels. With the exception of one important area the home has appropriate recruitment policies and practices in place. If this shortfall is not rectified it represents a potential risk to service users. Apart from one new member of staff, service users can be confident that staff are being appropriately supported and supervised and supervision is being fully recorded. EVIDENCE: Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 26 The home has five staff, of whom two have NVQ Level 3, one has NVQ Level 2 and one is working towards NVQ Level 2. The acting manager advised that the other staff member is being registered to work towards NVQ Level 2. The home has a full programme of induction and foundation training which meets TOPPS requirements. All new members of staff employed on a permanent basis receive a structured induction as part of their probationary period of employment, which is signed and dated on completion. There is an ongoing programme of training for staff which includes training in food hygiene, medication, health and safety, fire safety, and moving and handling. Staff are scheduled to do Person Centred Planning training later this year. The acting manager advised that the training needs of staff are monitored and training requests sent to the provider’s head office. Training courses are provided at the provider’s own training centre in Central London. The inspector observed that staff worked in an enabling and respectful way with service users, He spoke to staff members and found them to be committed and caring in their approach. The inspector also tried to engage the new service user and was able to ascertain from her responses that she felt happy in the home and comfortable with her key worker. The inspector understands that the key worker transferred across with the service user from her previous placement, and that the worker has been assisting other staff to recognise and manage her needs. Given the communication difficulties involved in working with this service user, the inspector identified a need for staff to be provided with training in the development of communication skills, training which, he understands has not, as yet, been provided. Staff would also benefit from some specialist training input relating to Rett’s Syndrome. During the day the expectation is that there will be two staff on duty, while at night one member of staff will ‘sleep-in’. The rota showed that the between 7pm and 11pm one rather than two staff are on duty. Given the high level of support needs of the recently admitted service user the inspector would expect to see two staff on duty at all times during the day and evening. The inspector understands that there is a 0.5 staff vacancy which could be used to help provide this cover. A requirement applies. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 27 The acting manager is included on the rota and works a variety of shifts, including night shifts. Consideration should be given by the service provider to increasing the managers ‘office days’ given the administrative tasks of managing a care home. Staff files include the full name of the member of staff, address, date of birth, two written references from previous employers, and the date when employment commenced. The inspector was concerned to find that there was no file for the new staff member who has transferred to the home, with the new service user, from a supported living unit. The acting manager advised the inspector that the file has not yet been forwarded to her from the previous placement. The inspector understands that employment checks would have been carried out prior to her employment with Choice Support and that an upto-date CRB certificate is in place. The inspector was, therefore, unable to inspect the staff file or to evidence the CRB check. A requirement therefore applies. A requirement made at the 2003/04 announced inspection stated that all documentation relating to staff must be kept in the home. This must be complied with. The acting manager advised that all staff receive supervision every four to six weeks. Supervision is recorded in a structured format which details practice issues, training needs, and goals. The inspector was concerned that records relating to supervision and training, for the new staff member were not available for inspection. The acting manager advised that these have not yet been transferred across from the staff member’s previous unit. A requirement applies. There is a process for completing annual appraisals of staff performance and career development plans, which was put in place in 2004. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 28 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 42 and 43 The home, has an acting manager, who is presently managing in an open and generally competent way. However the service users cannot be fully assured that their rights and best interests are being safeguarded whilst the home does not follow its own procedures. The health, safety and welfare of service users and staff are being appropriately promoted and protected. EVIDENCE: The acting manager holds NVQ Level 3 and is 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 inspector understands that she has to formally apply for the Registered Manager’s post, which is likely to be within the next two or three months. The acting manager is receiving support and supervision from a service manager. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 29 The atmosphere in the home seemed to be a positive and happy one. It is early days for the acting manager, who started to manage the home on 1 March, but staff views expressed indicate that the home is being competently managed and that they are being appropriately supported. Service users presented as settled and reassured by the supportive approach of the acting manager and staff, and no concerns have been expressed. There are, however, concerns arising from this inspection which indicate that there has been a lack of vigilance in following admission and staffing procedures, for which support from above would appear to have been lacking. The home has not been used to having any house meetings as there has not apparently been any expressed wish for this from the service users. With the recent new admission the acting manager is intending to look again at the possibility of a house meeting involving both service users and staff. The home has completed all the necessary up-to-date maintenance and safety checks, covering electricity, gas etc, with those for the smoke alarm, water temperature, fire safety and COSHH (Control of Substances Hazardous to Health) being completed on a weekly basis. Fire drills are undertaken on a two monthly basis, and fire safety training has been undertaken by the acting manager (on 3/5/05) and arranged for all staff in June and July 2005. The home has a rolling programme of training in manual handling, food hygiene, first aid and medication. The annual accounts and business plan of the company are not held at the home but at Head Office. The inspector was not made aware of any concerns. The responsible person is reminded of the requirement to notify the Commission if financial viability is in doubt at any stage. Copies of the homes accounts and business plan must be supplied to the Commission as and when required. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 1 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 3 3 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 2 2 2 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Selhurst Road (166a) Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 3 G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 31 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) Requirement Timescale for action 1.07.05 2. YA6 15(1) 3. YA9 13(4)(b) & (c) For the service user who has been recently admitted a full reassessment must be completed. A copy of this must be forwarded to the CSCI. The responsible person must ensure that any new service user is admitted only on the basis of a full assessment of their personal, social and health needs. The responsible person must 1.07.05 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 support and services provided by the home. For the service user who has 1.07.05 been recently admitted, risk assessments must be completed, and risk strategies put in place and recorded in the service user plan. A copy of these documents must be forwarded to the CSCI. The responsible person must ensure that risk assessments are completed prior to any further Version 1.30 Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Page 32 4. YA5 5(1)c 5. YA25 16(2)c 6. YA25 16(2)c 7. YA25 16(2)c 8. YA24 16(2)g & h 9. YA29 13(4)a & c 10. YA21 12(1)a, 15(1) admission of a new service user. These should be completed in consultation with the service user and involve relevant social and health care professionals. A tenancy agreement must be drawn up with the service user, in a format which is appropriate to the service user’s needs. The service user must be supported, as appropriate, by family, friends and/or an advocate. The new service users room must have some carpeting laid and a comfortable armchair provided. 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 carpeting and the replacement of a rather worn armchair with a new, comfortable one. 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. A report of the O.T assessment, relating to the needs of the new service user, must be obtained, and a copy forwarded to the CSCI. 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 wishes of the recently admitted service user regarding the eventuality of her ageing, 1.07.05 1.08.05 1.08.05 1.08.05 1.10.05 1.09.05 1.08.05 Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 33 illness and death must be ascertained in consultation with the service user and her immediate family. These wishes must be recorded on the service users file. 11. YA22 22 The complaints procedure must be updated as outlined in the 2003/4 annual inspection reports. This requirement has not been met within previously set timescales. 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. The acting manager and all staff at the home must attend Croydon’s multi-agency Vulnerable Adult training. The home must provide emergency lighting. Staff must be provided with training in the development of communication skills in working with service users who have profound communication difficulties. The manager must ensure that there are two staff on duty at all times during the day and evening. The responsible person must ensure that all documentation relating to staff records is held in the home and is available for inspection. The CRB certificate for the staff member who has recently started work at the home must be evidenced, and a copy forwarded to the CSCI. The responsible person must ensure that records relating to the supervision and training of Extended to 1.10.05 12. YA23 13 Extended to 1.10.05 13. YA23 13(6), 18(1)(a) & (c) 13(4)(a) & (c) 18(1)a & c 1.11.05 14. 15. YA24 YA32 1.10.05 1.10.05 16. YA33 18(1)a 1.08.05 17. YA34 18. YA34 19(1)(b), 17(2) and (3), Sch.4, No 6 19(1)b Sch 2, No 7 17(2) and (3), Sch.4, No 1.08.05 1.08.05 19. YA36 1.08.05 Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 34 6f all staff are held in the home and are available for inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA8 YA32 YA33 Good Practice Recommendations The inspector recommends that the option of service user meetings is explored again with the present service users. Staff should be provided with some specialist training input relating to Rett’s Syndrome and the care and health needs which this condition presents. Consideration should be given by the service provider to increasing the managers ‘office days’ given the administrative tasks of managing a care home. Selhurst Road (166a) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 35 Commission for Social Care Inspection 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) G53 S28564 selhurstroad166A V204150 030605 stage4.doc Version 1.30 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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