Inspection on 16/04/07 for Shirley Gardens, 43

This inspection was carried out on 16th April 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirley Gardens, 43 24/04/06

Shirley Gardens, 43 24/11/05

Shirley Gardens, 43 21/10/04

Shirley Gardens, 43 29/07/04

Shirley Gardens, 43 09/10/03

Shirley Gardens, 43 29/07/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Shirley Gardens, 43 Ealing London W7 3PT Lead Inspector Sarah Middleton Key Unannounced Inspection 16th, 17th April 2007 09:30 Shirley Gardens, 43 DS0000027714.V334277.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 Shirley Gardens, 43 DS0000027714.V334277.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. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirley Gardens, 43 Address Ealing London W7 3PT 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) 0208 810 0431 0208 567 1704 hm43shirley@ealing.org.uk Ealing Consortium Limited Manager post vacant Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 Brief Description of the Service: 43 Shirley Gardens is a facility for seven people with mental health needs, both under and over 65 years of age. The home is also registered for people with physical disabilities but it is not wheelchair accessible and there is no lift or special equipment. Ealing Consortium Ltd manages the home. It is owned by Ealing Family Housing Association, who is responsible for repairs and maintenance. The home is a three-storey house, located in a cul-de-sac in a residential area of Hanwell, close to the Uxbridge Road. Adjoining the home is a block of flats for eleven tenants for whom an outreach service is provided by the residential homes staff team. Some of the flats can be accessed from the homes office. The home has seven single bedrooms, located over the three floors, one of which is on the ground floor. The ground floor also has two small lounges, a dining room, kitchen, laundry, sleeping-in room and office. The first and second floor each have three bedrooms. There are three bathrooms with toilets, one on each floor, and two additional separate toilets. There is a staff shower in the sleeping-in room. The large car park is accessed from Shirley Gardens and there is a small garden area to the front, with access to the Uxbridge Road. The staff team consists of the Registered Manager, two senior support workers and support workers. There is one domestic worker. There is a minimum of two staff on each shift and one member of staff sleeps in at night. There is no waking night cover. Fees range from £963.74-£991.94 per person per week, this includes contributions from Social Services and the resident living in the home. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The Inspector spent ten hours on this inspection process, not including the planning and report writing. The Inspector viewed various documentation, such as care plans, risk assessments, staff files, health and safety records. Three residents were spoken with and two members of staff. The residents had completed four surveys and one survey was completed by a social worker. Overall feedback was positive and contributions and comments, where relevant, have been included into this inspection report. The Manager who is in charge of the home will be referred to as the Manager Designate; they have been in post approximately seven weeks and have recently become a permanent member of staff with the Registered Provider. The aim is for him to apply to the CSCI to become the Registered Manager. The Manager Designate and one of the senior members of staff assisted with the inspection process. There had been one previous requirement made at the last inspection and this had not been met. In addition eleven new requirements and two recommendations were made at this inspection. All of the Key Standards were inspected during the two-day inspection. Please note that the term resident, used throughout this report, replaces the previously used term, “service user” and refers to the people living in the home. The Inspector was satisfied that the home was aware of residents individual needs and preferences and considered equality and diversity issues as part of supporting the residents. What the service does well: The home has a staff team who have worked well together in the absence of a Manager. Staff feedback was positive regarding how they work as a team in the interests of the residents. In addition, residents commented positively on the staff team. There is an understanding amongst the staff team, including the new Manager Designate, regarding the needs of the residents who live in the home. This awareness aims to recognise and promote the individual abilities and issues faced by those living in the home. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home had not met the last requirement made at the last inspection. Pre-admission assessments must be completed and made available for inspection, so that it can be established that new residents moving into the home have been thoroughly assessed and the home can evidence how they have confirmed they can admit the resident and meet their needs. Risk assessments must be completed on all identified needs, including those new people who have moved into the home. It is vital that information is recorded so that all members of staff know how to support the resident and what the potential identified risks are to the resident and/or towards others. The medication systems need to be simple, practical but robust to ensure checks can be carried out and errors identified quickly and dealt with accordingly. The sofas need re-covering, as they are full of cigarette holes, thus making the furniture look shabby and dirty. The odour on the second floor must be addressed, as this had been an ongoing problem. Staff employment files must have a recent photograph of all members of staff. The staff training records must be up to date and training must be up to date for all members of staff. In addition, staff must receive ongoing specialist additional training relating to the different aspects of supporting residents who have mental health needs. The quality assurance systems currently in place do not include a short report or summary that is available for residents or for inspection. This short report should aim to indicate the work the home has been doing to improve the quality of care offered in the home. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 7 Staffing levels at night must be reviewed and where necessary increased to ensure the home can evidence that the staffing levels are sufficient in number to support the people living in the home. In addition, in the event of a fire, the staffing numbers must be sufficient to safely and quickly evacuate all residents, both those living in the registered home and those living in the adjoining eleven flats. This is important to consider, as at least two of the residents in the registered home do not respond to the fire alarm being set off. Furthermore another two residents, also living in the registered home have mobility issues and cannot move quickly or independently. A detailed environmental risk assessment must be carried out, looking at all aspects of the home and identifying any problem areas that could pose a risk to residents and others. 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. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments were not available and so it was not clear how the resident’s needs were assessed. Prospective residents are able to visit the home and meet with others before making a decision to move into the home. EVIDENCE: The Inspector was informed that a new resident had moved into the home earlier in the year. The previous Service Manager, who has subsequently left their position, had assessed this resident. However there were no available reports or assessments available to view and confirm that this had occurred. The Manager Designate stated they would look into identifying where this assessment was. An assessment was viewed from Social Services, but this was almost a year old. The Inspector was shown a blank pre-admission assessment that would be used in the future. This covered areas such as mental health needs, behaviour and ability to perform certain tasks. The Inspector stressed the importance of assessing prospective residents to fully establish their needs and to identify any potential risks that could be difficult to manage. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 10 Furthermore, where relevant, the home should obtain as much up to date information from the Local Authority to gain an insight into their professional opinion regarding the resident’s needs. A requirement was made for preadmission assessments to be completed and made available. The Inspector spoke with a newly admitted resident who confirmed they had visited the home and spent time meeting the other residents and staff before deciding to move into the home. When asked, the new resident stated they could have refused to move into the home and that their personal views would have been listened to, however upon visiting the home, they decided to agree to move in. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are completed with resident’s involvement and are individual and reviewed to meet their needs. Residents are supported to make decisions about their lives. Risk assessments had not been completed on all potential risks. These need to be completed in order to ensure the resident and others are safeguarded. EVIDENCE: The Inspector viewed a new resident’s file. On the first day of the inspection a care plan was not available and this shortfall was discussed with the Manager Designate, who informed the Inspector that the keyworker was in the process of completing a care plan. The completed care plan was then viewed on the second day of the inspection. The Inspector stressed the importance of developing an initial care plan as soon as a resident moves into the home. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 12 Care plans are live working documents and should be updated and altered as new information becomes available or when residents needs change. Staff commented on how the documents used such as, personal care assessments and the general care plan/review used are not easy to use with the residents who have mental health needs. The Manager Designate is looking to introduce a more appropriate document that meets the needs of the residents. Care plans are reviewed every six months and resident’s views are included into the reviews. Currently care plans viewed cover a range of areas such as personal care needs, and personal aims and objectives for the resident. Samples of daily records were also viewed and these outline what any relevant information such as activities, mood and personal care. Currently the home has several files on each individual resident and throughout the inspection it was difficult to locate the information needed to confirm particular standards were met. This was discussed with the Manager Designate and the senior member of staff, who agreed that files needed to be reduced, preferably holding all relevant information regarding a resident in one file. The systems are being looked at and the Manager Designate was aware that the current system was confusing and in places repetitive and would be working to introduce new simpler systems in the future. Staff and residents confirmed the home encourage residents to make decisions for themselves. One response from a resident via a completed survey stated that they have the freedom to make decisions. Where they are able to, residents go to the bank to withdraw their own monies and visit local shops to purchase personal items. No residents have advocates. The Inspector viewed a sample of risk assessments. These were difficult to locate as many were in various files. Risk assessments had been completed on those residents who often refuse to receive health/medical treatment. Moving and handling risk assessments were out of date and the newly admitted resident did not have any risk assessments completed on them, even though the social services report clearly indicated that there had been risks to others. In addition, there are some residents who do not respond to the fire alarm going off. The Inspector advised that all potential risks must be considered, such as the fire issue and going out alone without staff. The Inspector discussed these shortfalls with the Manager Designate and a re-stated requirement was made for risk assessments to be completed on all identified and potential risks. Discussions took place regarding ensuring that all staff know how to complete risk assessments. As with care plans, risk assessments must be live working documents that staff are aware of and the information must be updated as and when residents needs change. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to engage in activities both appropriate to their abilities and needs and in the home and community. Residents are encouraged to maintain social relationships with family and friends to ensure they have contact with those they wish to see. Resident’s rights and responsibilities are respected and promoted in the home. Meal provision aims to offer residents a combination of choice and provide a healthy balanced diet. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home continues to have ongoing difficulties in motivating and encouraging residents to take part in activities. The interests and abilities of each resident is varied, therefore the home needs to ensure they can cater for each individual need. Many of the residents are able to go out in the community independently and do so throughout the day, whilst others choose to spend time in the home. The Inspector was informed that some residents enjoy going on an annual holiday and have one to one or two to one support from staff. The home also offers occasional day trips, but often residents decline to go at the last minute. The home must continue to evidence all the activities that take place with each resident, including those that occur within the home, such as cleaning their rooms, doing the laundry or cooking. Those residents spoken with said they liked to come and go and would often they visit various places, such as the local parks or cafes. The standards relating to activities are only just met and this was discussed with the Manager Designate, who needs to be mindful that residents need regular support and encouragement to engage in any meaningful task. As mentioned above, community resources are accessed, such as pubs, cafes and shops. For the most part, residents access these independently, although some residents lack the interest or confidence and need staff to be with them to fully access local places. Few residents have family or friends; those that do are encouraged to maintain contact. A social worker that completed a survey indicated they were happy with the home and arranged regular visits with the resident to ensure they were kept informed of any changes. As indicated in this report, some residents are able to come and go, as they want to, see Standard 42 relating to this current arrangement. Staff were seen to be respectful of residents privacy by knocking on residents bedroom doors. Residents receive their mail and usually open this in front of staff, so that appointments or anything important can be dealt with. Residents also have keys to their bedrooms and to the front door. A member of staff stated that residents are informed about voting but they rarely use their vote. Some residents were seen to spend time in their rooms whilst others interacted with each other in the main living room. Meal provision varies as most residents make their own breakfast and some go out for lunch in the community. Staff make every attempt to know what meals have been eaten and will ask residents what they have had for those meals not taken in the home. There is a menu for the main evening meal and each resident contributes his or her preference for that week. Staff monitor the meals to ensure they are varied and incorporate fresh produce. Resident’s feedback was positive regarding the meals. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 15 The Inspector did not see any meals during the time they were at the home. The kitchen was clean and tidy and opened food was dated and wrapped. Fridge/freezer temperatures had been taken and were within an appropriate range. Kitchen knives are counted and locked away. Some residents used to assist with the shopping but now this rarely occurs. Both residents and staff confirmed that residents rarely assist with the preparation of meals. Staff discussed with the Inspector the problems the home faces with some residents going into kitchen late at night and preparing food. This poses not only a potential hazard to the home, in particular as there is only one member of staff working at night, but also that it is not health to eat late in the evening or at night. Currently the kitchen is unlocked at all times, but the home is considering locking it at a certain time at night. The Inspector advised that this should be discussed with all those concerned and that the reason for doing this should be clearly recorded to evidence why this room is to be locked at a certain time. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal care support in their preferred way that respects their privacy and dignity. Overall health needs are met and the home aims to support residents to receive the health care they need. Shortfalls in the medication systems were identified, thus jeopardising the welfare and safety of residents. EVIDENCE: There is one female resident living in the home and she receive same gender care with regards to their personal care needs. Staff described how they prompt and encourage residents depending on their individual capabilities. One staff member informed the Inspector on how they are aware of the residents preferred routines and the areas they need support in, such as shaving. Bedtimes are flexible and residents choose the clothes they wear. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 17 The Manager Designate is currently carrying out an audit of the health services residents currently access and those residents who do not wish to access particular health services, such as the Dentist. The Inspector viewed the health records to see the type of services accessed. After each appointment, or where a resident refuses to attend an appointment, staff record the visit and any treatment of action to be taken. As stated earlier risk assessments had been completed on those residents who refuse treatment. The Inspector advised the staff that they must ensure they know how to respond if a resident is in pain. The staff team were aware of their duty of care. All residents have a GP and see other professionals such as Optician, Psychiatrist and Occupational Therapist. Physical health needs are considered on care plans, although some of the information was not written in sufficient detail and this was brought to the attention of the Manager Designate. Residents weight is checked on a regular basis to monitor any major changes. The Inspector viewed a sample of the medication systems. The home has a monitored dosage system in place, although there were also unblistered medications. The Inspector was informed that staff count and check medication on a daily basis. The senior members of staff also carry out spot checks. The Inspector had difficulty in carrying out a full audit due to how medication is recorded onto some of the Medication Administration Records. The amount for one resident’s medication did not add up and there was not a clear trail to follow. This was discussed with the Manager Designate and the senior member of staff and a requirement was made for a simple and effective system to be introduced so that errors, should they occur, can be quickly identified and dealt with. Staff receive training before they administer medication however the Inspector spoke with the Manager Designate regarding providing ongoing refresher training on this important subject so that staff have the up to date skills to carry out this role competently. Staff had completed a competency booklet on medication in 2006 and this could be one way of continuing to support staff on the various aspects of mediation. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to voice their concerns and have the ability to raise any complaints they might have. Residents are safeguarded from abuse and systems are in place to protect them. EVIDENCE: The Inspector noted that the complaints procedure is freely available and was located in the main hall of the home. Those residents asked stated they would talk to staff or the Manager Designate if they were unhappy or wanted to raise a concern. The Inspector viewed the complaints file and none had been recorded for some time. The CSCI had not directly received any complaints or concerns. The home has not had any adult abuse concerns or investigations. Some staff had received training in 2005 and the Inspector advised that training on this sensitive subject should be offered on an ongoing basis. The Manager Designate acknowledged this and will look into booking staff onto refresher courses. (A requirement was made in relation to training being up to date, see Standard 35). Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 19 The home has the Local Authority’s safeguarding adults policies and procedures and the Inspector suggested to the Manager Designate that the Department of Health’s “No Secrets” document be obtained for the home. A small sample of resident’s monies was counted and this was found to be correct. Systems are in place to clearly record any financial transactions and all residents’ monies are counted on a daily basis. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sofa covers that had holes in them need replacing in order to provide a homely environment to live in. The home had an area where there was an odour. Addressing this problem would make the home more comfortable to live in. EVIDENCE: The Inspector carried out a tour of the home. Generally the home is well maintained and the Inspector acknowledged the ongoing maintenance issues as all, bar one resident smokes. Several times the covers on the sofas have been updated, as they are prone to having cigarette holes in them. Once again the Inspector found on this inspection visit that the furniture in the living room had several holes in the covers. This was brought to the attention Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 21 of the Manager Designate and a requirement was made for this to be addressed. The Inspector discussed with a resident who does not smoke where they sit so that they do not have to be with smokers. There is one small room where other residents are not supposed to smoke, but it was clear from the room that smoking does occur in this room. Although this resident stated that they did not mind where they sat, a strong recommendation was made for a nonsmoking communal room to be made available for those who do not wish to sit with smokers. The home has domestic support to keep the home generally clean and tidy. The laundry room is located in a separate room and residents are supported to do their own personal laundry. The Inspector noted that on the second floor there was a strong small of urine. This had been noted at the last main inspection. The home is aware of the problem but it has not been effectively dealt with. This must be managed more appropriately and a requirement was made for the home to eliminate this continuous smell. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent staff team who have the various skills and knowledge to understand resident’s needs. A review of the staffing numbers at night would ensure the residents are safeguarded and supported quickly should there be an emergency. Recent photographs of staff ensure staffing records are kept up to date and residents are protected. Training records were incomplete and did not clearly evidence the courses staff attended. Providing mandatory training and specialist training promotes good practice and an awareness of the residents needs. EVIDENCE: The staff team work together in the interests of the residents and the majority have worked together for sometime. The home is meeting its target of 50 of staff either having an NVQ or in the process of completing this qualification. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 23 Although there is a need for staff to have training and information on the different aspects of mental health, (see Standard 35), staff did demonstrate an awareness and understanding of the individual needs of the residents. Those observed interacted in a positive way and spent time with residents responding to requests and queries. Those residents asked commented favourably on the attitude of the staff supporting them. Staff commented positively on how they all worked well together and that they had managed without a Manager in the home, although they were positive about now having a person, the Manager Designate, to go to for advice and support. The Inspector discussed with the Manager Designate the benefits of having a team-building day at some point in the future to assist the team to work towards the same aims and objectives. This is an annual event and the hope is that this will soon be planned. The Inspector raised concerns regarding the staffing numbers in the home at night, as there is only one member of staff who sleeps in the home. This sleeping in member of staff is there to support not only the residents in the registered home, but also those in the adjoining supported eleven flats. Through seeing the residents in the home and noting that at least two have some form of mobility issues and two other residents do not respond to the fire alarm, the Inspector made a requirement for the home to seriously consider how to evidence that one member of staff working could quickly and safely evacuate all those concerned in the event of a fire or any other emergency. The Inspector strongly advised the Manager Designate to contact the local fire officer to arrange an inspection from their team. The Inspector viewed a sample of recruitment files. The main employment files are located at the main head office and so the home has a checklist with details that two references have been verified, that the new member of staff is fit to work and a Criminal record Disclosure number is obtained and recorded. The Inspector noted that the file did not have an up to date photograph of the members of staff and a requirement was made for this to be addressed. Training was looked at and the Manager Designate explained that he was going through and sorting out individual training files, providing an overview of the training needs of the team and individuals. The Inspector viewed the induction process a new member of staff would work through and this covered various areas such as safety and the keyworkers role. The home also has its own brief in house induction checklist and this is more relevant to the needs of the residents and the running of the home. Existing staff confirmed that new staff spend time shadowing them. Staff mentioned the lack of mental health training and a requirement was made for this shortfall to be addressed, as there was no evidence in training files that staff receive training on this wide and varied subject. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 24 In addition, it was difficult to fully view exactly the training staff have attended, due to some certificates being absent in the files. A requirement was made for all training records to be kept up to date and that any outstanding mandatory training is identified and booked as soon as possible. Overall staff were happy with training and the Manager Designate is aware of where there are areas needing to be addressed. The Inspector also made a recommendation for staff to receive training and information on the new Mental Capacity Act 2005, as this is a recent piece of legislation that could have an impact on how staff support the residents living in the home. The Inspector spoke with the Manager Designate regarding the benefits of also running in-house workshops and information sessions for staff that should also be recorded onto their individual training records. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager Designate is new to the position of Manager Designate and has the experience and qualifications to ensure the residents benefit from a well run home. The quality assurance systems in place to do not include a report or summary regarding the work the home has undertaken. This report needs to be developed and available for residents so they can see the work the home has been doing to monitor and improve the care the residents receive. An environmental risk assessment needs to be completed in order to identify any unsafe areas and to address any shortfalls, thus protecting the residents. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Manager Designate had been in post for a few weeks prior to the inspection. They have a background in mental health and a certificate in management and other relevant qualifications relating to care and management. They were aware of the areas needing to be addressed and were still familiarising themselves with the general running of the home. Those staff asked stated they felt able to seek advice or direction from the Manager Designate. The home has some systems in place to monitor and review the care being provided in the home. Monthly Regulation 26 visits take place and reports are forwarded on to the CSCI. In addition, surveys take place to gain the thoughts and feedback from residents; these surveys look at various areas such as choice, about the home itself and staff attitudes. Furthermore the Manager Designate completes a quarterly report that encompasses information on training, health and safety and information regarding the residents. The Inspector spoke about the home bringing all of these reports together and providing a summary or small report that evidences the general work the home has been doing over the past twelve months and work that is still to be done to address any shortfalls. This type of summary or small report must then be available for inspection and for the residents. Currently this information is not available and therefore a requirement was made for this to be considered and developed. The Manager Designate and senior member of staff acknowledged the benefit of clearly demonstrating the work that has been done to improve the home and outstanding areas to be worked on over the next few months. The Inspector spoke with the Manager Designate regarding the current system of a fire door that is used for residents to come and go out into the community without necessarily informing staff of when they are going and to where. This practice has been long-standing and those residents that are independent are able to just walk out of the home whenever they so choose. The Inspector acknowledged that some residents can and will want to leave the home several times during the day, however the Inspector was concerned that in the event of a missing person or fire, staff would not know where each resident is or when they might have left the home. A requirement was made for the home to introduce a more robust system to monitor the movements of the residents. As noted in Standard 9, risk assessments must be completed on those residents who do leave the home without a member of staff. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 27 Samples of maintenance records were viewed and the Gas Safety Record and Portable Appliance test were up to date. The Legionella testing and results certificate could not be located at the inspection but shortly afterwards a copy was forwarded on to the CSCI. A monthly routine maintenance check is carried out on the home and the Inspector discussed with the Manager Designate and senior member of staff considering using additional systems in the home to prevent the possibly build up of limescale and Legionella, such as descaling shower heads and taps. Water temperatures had been taken on a regular basis and were within an appropriate range. An external fire company carry out a detailed fire risk assessment and the Manager Designate was looking at this report and actioning any of its recommendations. The Inspector made a requirement for a detailed environmental risk assessment to be completed, as this had not been carried out. Fire call points are tested regularly and the fire alarm had been held at different times and had highlighted those residents who did not respond to the fire test/drill. As mentioned throughout this report, a risk assessment must be completed on those who might pose a safety issue to others should they fail to respond to a fire. It is advisable to complete a new fire capability form for all of the residents. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 29 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Timescale for action A new resident must be fully 20/04/07 assessed, prior to moving into a home, to ensure the home can meet their individual needs. This assessment must be available for inspection. Risk assessments must be completed on all identified potential risks relating to the resident living in the home. (Previous timescale 29/12/06 not met). 04/05/07 Requirement 2. YA9 12(1)(3)&13(4)(c) Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 30 3. YA9 12(1)(3)&13(4)(c) 4. YA20 13(2) New residents admitted into the home also need to have risks identified and recorded, to enable staff to support the person safely and appropriately. The home must introduce a more simpler but robust way to monitor medication arriving in the home and count it carefully when doing spot checks. This system must ensure that the health and safety of the residents living in the home is promoted. 20/04/07 07/05/07 5. YA24 23(2)(d) 6. YA30 7. YA33 8. YA34 9. YA35 The furniture in the living room needs re-covering as it has cigarette holes on the covers, making them look shabby and uninviting for the residents living in the home. 16(2)(k) The odour on the second floor must be addressed to ensure the home is a pleasant place to live in. 13(4)(c)18(1)(a) The staffing levels during the night must be reviewed and if appropriate increased, to ensure the safety of the residents is considered and their welfare is protected. 19(b)(1)(i) A recent photograph must be obtained of all members of staff to ensure the Registered Person is confident of their identity. 18(1)(a)&(c)(i) The residents living in the home would benefit from receiving support from a staff team who have received information and training on the subject of mental health. 31/07/07 07/05/07 31/08/07 07/05/07 31/08/07 Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 31 10. YA35 18(1)(a) Training records must be up to date and mandatory training must be up to date for all members of staff, to ensure they can support the residents competently. A quality assurance report or summary must be developed that is then available for inspection and for residents. An environmental risk assessment must be completed and available for inspection, to ensure the home is safe and free from potential hazards to those living in it. The Registered Person must ensure that there are robust systems in place to monitor the whereabouts of those residents who come and go throughout the day independent of staff. 31/08/07 11. YA39 24(2) 31/08/07 12. YA42 13(4) 31/05/07 13. YA42 13(4)(c) 30/06/07 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. Refer to Standard YA28 YA35 Good Practice Recommendations It is strongly recommended for there to be a clear nosmoking area for the residents living in the home. It is strongly recommended that all staff receive information and training with regards to the Mental Capacity Act 2005. Shirley Gardens, 43 DS0000027714.V334277.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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