Inspection on 16/10/07 for Southwest Road (7)

This inspection was carried out on 16th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southwest Road (7) 05/05/06

Southwest Road (7) 08/12/05

Southwest Road (7) 10/08/05

Southwest Road (7) 03/02/05

Southwest Road (7) 23/09/04

Southwest Road (7) 25/02/04

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

CARE HOME ADULTS 18-65 Southwest Road (7) 7 Southwest Road Leytonstone London E11 4AW Lead Inspector Sarah Buckle Unannounced Inspection 16 October 2007 11:00 th Southwest Road (7) DS0000007298.V346095.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 Southwest Road (7) DS0000007298.V346095.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. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwest Road (7) Address 7 Southwest Road Leytonstone London E11 4AW 020 8556 4286 020 8539 1770 mail@mindinwf.org.uk www.mindinwf.org.uk Mind in Waltham Forest 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) Mr Felix Nii Ankrah Otoo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. For one named service user over the age of 65 to be accommodated in the home 5th May 2006 Date of last inspection Brief Description of the Service: Southwest Road is a care home for 3 adults with mental health histories, managed by MIND in Waltham Forest (a registered charity) and operating as part of the Forest Community Project, which offers a range of dispersed social housing - together with outreach support. This is the only registered provision in the project, although the service offered is the same for all service users i.e. support, supervision and accommodation. Staff members are not on the premises for the full 24 hours and are only on duty for five and a half hours or less each day, with a member of staff asleep on the premises at night. Staff members are contactable via a 24-hour pager system and can respond within 20 minutes. The Forest Community Project is an innovative scheme, offering flexible support to service users. However, the way it is organised, run from a central point with peripatetic workers does not sit comfortably with the law governing registered care homes. The premises consist of a 3 bed roomed terraced house in a residential area of Leytonstone, with community facilities accessible by public transport. The residents at the home share a sitting room, kitchen/ diner and back garden. There are two bathrooms, one on each floor. There is no lift and the kitchen is on the first floor so the home is not suitable for people with limited mobility. The home opened at a time when a lighter touch was used in the registration and inspection of small homes. The home therefore does not meet some current environmental standards e.g. no wash hand basins in bedrooms, inadequate office space, and limited facilities for the storage of staff belongings. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced key inspection. The inspection included a site visit to the service on 16th October 2007. At this visit, a tour of the premises was undertaken; one resident was spoken with, as was one member of staff and the registered manager. The registered provider also came to the home to introduce himself. Various documents and records were examined as part of the inspection process, and surveys were sent to residents and staff members. Two residents surveys and three staff surveys were completed and returned to the Commission. Along side this, the random inspection report, was used in the planning of the inspection, as was the AQAA, which was completed in detail and returned appropriately. Southwest Road does not provide any personal care to the residents who live there. The Commission usually only registers and inspects services which do provide a level of personal care. The Care Standards Act 2000 Part I, 3(1) states, “For the purposes of this Act, an establishment is a care home if it provides accommodation, together with personal or nursing care,…”.This was discussed with the manager during the course of the inspection. What the service does well: What has improved since the last inspection? There has been a lot of improvement made at the home since the last key inspection and this is reflected in the findings from a random inspection, which Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 6 took place in November 2006. The random inspection was carried out to see whether improvements had been made in specific areas, and it was positive to note that the inspector found most of the requirements made at the last key inspection had been met or addressed to some level. For example, the random inspection on 27/11/06 found that some risk assessments had been compiled and were placed in residents care plans, written protocols were in place regarding what may constitute an emergency in relation to resident’s health needs and the recording of medical appointments had improved. Daily care notes were found to be kept on resident’s individual files, thereby addressing a requirement in relation to confidentiality. The random inspection report stated that security arrangements had been put in place to protect residents from bogus callers, that NVQ training had improved and that all complaints are now appropriately and promptly dealt with. What they could do better: 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. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 7 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 Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides sufficient up to date information to help prospective residents choose a home that will meet their needs. The needs of the residents within the home are assessed on an on-going basis. EVIDENCE: There have been no new admissions to South West Road since the last key inspection. All of the people living at the home have been there for a considerable length of time. There were no recent pre-admission assessments to examine as part of this inspection, however, it was positive to note that reassessments of the residents needs take place on a six monthly basis. The ‘statement of purpose’ and ‘service user guide’ were viewed. Both of these documents were up to date and reflected the service that is provided. The Annual Quality Assurance Assessment completed by the home states that each resident is issued with a copy of the service user guide and that an additional copy is available in the lounge. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provided by South West Road appropriately recognises the importance of residents being supported to make decisions and choices about their lives. Care plans are person centred and agreed with the individual. Risk is not managed comprehensively. Risk assessments are basic and do not adequately keep the residents at Southwest Road safe. EVIDENCE: Three care plans were sampled during the site visit to South West Road. It was positive to note that these were all thorough and detailed and contained information specific to the needs of each individual resident. The appropriate key worker reviewed the care plans on a weekly basis and any changes in need were recorded. None of the people currently living within the home require any support regarding personal care needs. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 10 One care plan examined contained a list of emergency symptoms that the resident may experience and which the staff members should be aware of. This was a comprehensive list, which also detailed the symptoms of hyper and hypo glycaemia. However, it was of concern to note that there was not a risk management plan in place in relation to how a situation of emergency would be managed in the significant periods of time when there are no staff members present at the home. There were no emergency symptoms lists for the other two residents at the home. Support plans covered areas such as mental health; physical health; personal care; domestic and home life; work and social activities; relationships; culture and religion etc. Daily care notes were completed and contained in individual residents care plans. It was clear from these that residents are able to make choices about the way that they choose to live their lives. For example, one resident chose to spend long periods of time in their own room. Staff members were aware of this and supportive of the decision, although they did offer alternatives to this. There was evidence in all three files of clinical risk indicators, which were completed and updated regularly. Risk assessments were completed for the residents around areas such as ‘using the cooker without support’ and ‘non-response to fire drill’. The risk assessment regarding ‘non-response to fire drill’ stated that the resident had been given the relevant fire safety information and that they were exercising their choice in deciding not to adhere to it. The risk assessment then states that a fire drill a week later was responded to appropriately. The final outcome recorded states that the risk assessment was to be reviewed in November 2006 and if the resident responded appropriately to the fire drill it would be discontinued. There was no further information recorded, so the final outcome is unclear. It was of concern to note that there was no risk assessment in place regarding how the residents would manage this situation if a fire were to break out during the period of time when no staff member were present in the home. It was clear that risks assessments were devised within the home to encourage and support an independent life style. However, as the home is not staffed on a full 24-hour basis there was concern that residents might open the door and allow bogus callers access. The registered manager stated that a police liaison officer has visited the home and given advice on how this should be managed, there are security notices in place by the front door, outlining what residents should do. The security process is reiterated to residents on a monthly basis. The registered manager stated that residents do answer the door as friends or relatives could be visiting but that they are aware of the procedure to follow. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 11 However, on the day of the site visit a resident opened the door to me and did not use the security chain. I did show my I.D. to them, and then I was granted unsupervised access to the house. The resident returned to their bedroom and I went up the stairs to the kitchen where the member of staff on duty was cooking lunch unaware that I was in the house. Also, on 11/12/06 a friend of a resident visited the home. It transpired that they had absconded from a medium secure unit. The friend left when the night staff came on duty. At approximately midnight, the police visited the home to search for the alleged absconder, a resident answered the door and gave them access to look around the house. The resident tried to awaken the sleep-in staff but was unable to. At the last key inspection a requirement was made regarding community care assessments for two of the residents within the home, to establish whether the current staffing levels were sufficient. Evidence of the letters sent requesting this were seen, as were letters from appropriate GP’s detailing that the residents care needs were met under the current staffing level. However, there are clear areas of risk to the residents during the un-staffed hours within this home. There is also well-recorded conflict between two of the residents, which does result in one resident choosing to spend long periods of time in their room. Without staff presence this could significantly add to the vulnerability of the residents within the home. One of these residents suffers from on-going paranoia to varying degrees i.e. the daily care notes for the resident on 28/08/07 stated “(The resident is) extremely paranoid with (another resident) and staff”. In discussion the manager stated that this has been the residents presentation for years and that the two residents had been co-existing at the home for approximately fifteen years. However, information regarding the second resident in this conflict stated that the, “Client continues to be stressed by the unpleasantness of one of her sharers”. It is of concern that there is no risk management plan in place regarding how the residents should proceed if one of them becomes increasingly paranoid to an unmanageable level during the periods of time when the staff members are not present, and that there is no clear risk management regarding the impact of on-going conflict on the residents within the home. Information contained within the AQAA regarding what the home could do better for the outcome group concerned with ‘individual needs and choices’ states, “Become more proactive in ensuring CPA (Care Programme Approach) reviews for our residents are held on a regular basis” and what could be improved within the next twelve months states, “Ensure by means of an audit that every resident receives a CPA review within their stipulated period. This will be part of the care plan review”. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 12 Three resident surveys were sent to Southwest Road to gather the views of the people who live there and two of these were completed and returned to the Commission. One of these stated that they always make decisions about what they do each day and that they can do what they want during the day, in the evening and at the weekend, the second survey said that they sometimes make decisions about what they do each day and that they can do what they want during the day time. Three staff surveys were completed and these all stated that they were always given up to date information about the needs of the people they support. All of the residents within the home were offered the opportunity to speak with me during this site visit, however none of them wanted to do so. One resident said that everything was ok and that they didn’t need to speak with me. Southwest Road (7) DS0000007298.V346095.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Southwest Road are able to make choices about the way they live according to their individual interests and capabilities. The meals within the home are appropriately varied and balanced. EVIDENCE: There was evidence in each of the care plans sampled of residents being involved in activities that were suited to their individual needs. One resident had been to the cinema, on a trip to Epping Forest and to see Arsenal football club during the course of 2007, another resident had been out for a pub lunch, and on a number of visits to Whipps Cross lake to feed the ducks and to Ikea. They also visited the local shops on a regular basis, help prepare the food, wash up and listen to music. A third resident accessed a lunch club, a Jewish club, went to the cinema a couple of times and went shopping. Residents Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 14 were also encouraged to take a holiday to Great Yarmouth for a week. According to the AQAA, one resident did go on holiday. All of the care plans examined had support plans in place regarding social activities. One resident who likes to spend time in their room had support plans in place which identified means of reducing the risk of isolation by assisting the resident to balance time alone with time spent with others. The support was identified as the resident possibly re-starting the Sunday lunch club, by making time to talk to them or engage them in an activity within the house twice weekly; to ensure the resident is aware of the facilities available within the community and to organise regular outings on a monthly basis and encourage short outings to local shops/café. All of the residents within the home are encouraged to maintain family relationships and friendships. The residents make their own breakfast and tea, and a member of staff cooks lunch. During the site visit to the home a member of staff was cooking chilli and rice, which looked and smelt appetising. Food records were examined and these demonstrated that the residents have a choice about what they eat i.e. on the Monday before the inspection one resident had planned to have salmon salad for lunch, and two others had sausage, egg and chips. The nutrition record stated that one resident had rice krispies instead of salmon salad. On Tuesday one resident had vegetable curry, another had spaghetti bolognese and the third resident had pasta with pasta sauce. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal health care needs of the residents are clearly met and documented within their care plans. The home has an efficient medication procedure, which is well managed. EVIDENCE: None of the people living at South West Road require support with personal care. All of the care plans examined had clear records of health care appointments for the residents with health care professionals. The home uses a Healthcare Monitoring form, and details of appointments are documented on this. One resident had evidence of visits to the dentist, chiropodist, the practice nurse, GP, opticians etc, with the date, the reason for the visit and the outcome recorded. All of the residents within the home have regular reviews to assess their identified and changing needs. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 16 The medication procedure within the home was looked at during the site visit. The home uses a dossett box system for administering medication and a pharmacist fills these on a weekly basis. The registered manager stated that staff members administer the medication from the dossett boxes. He stated that all staff have had medication training and have just completed formal training. One member of staff spoken with confirmed that they had just undertaken external medication training. One dossett box was seen and the drugs contained within it tallied with the amount on the MAR sheet. The AQAA states that none of the residents have been assessed as being able to self-administer medication. However the what we could do better section states that the home will “Consider or review self-medication during the care plan review. This is to help promote independence for the residents. This will have to be looked at within the CPA arrangement system”. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Southwest Road are clearly aware of the complaints procedure within the home and are comfortable using it. A comprehensive record of complaints and their outcomes are maintained within the home. There are clear policies in place within the home regarding Safeguarding Adults and the training of staff in this area is arranged regularly by the home. EVIDENCE: The complaints log at Southwest Road was looked at. The AQAA completed and returned to the Commission stated that there had been seven complaints in the last twelve months all of which had been upheld. The complaints recorded between May and August 2007 were examined. A staff member made one of the complaints and residents within the home made two. In all instances, the manager of the home formally acknowledged the receipt of the complaint, and a record of the investigation was completed along with the outcome. The residents within the home were obviously aware of the procedure for making a complaint, as they had been involved in making them. Both of the residents surveys returned to the Commission stated that they knew who to speak to if they are not happy and they know how to make a complaint. One staff member spoken with stated that training at the home is on going and that they had received Safeguarding training. The registered manager stated Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 18 that all staff members are given a summary of the policy regarding safeguarding in their handbook. The information contained within the AQAA regarding this outcome area states that residents are protected from abuse by the policy within the home which is in line with the Department of Health guidance in ‘No Secrets’. It states “Residents have access to this policy….and a summarised version has been placed on notices in the home and in their service user guide. All staff have received training on adult protection and this is one of our regular training courses. Staff are assessed after the training on Adult protection especially in the area of recognising abuse and reporting it”. There have no been no POVA referrals made at the home. One resident within the home made an allegation on behalf of another resident about a third resident. However, when this was investigated by the home the person who was supposed to have made the allegation stated that they did not know anything about it. The accidents and incidents log was examined and was completed in detail. The outcomes of any accident or incident were also recorded. It was concerning to note that in January 2007 no sleep in staff had arrived for duty at the home and the duty officer did not arrange cover leaving the home without a member of staff throughout the night. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is, in the main part, appropriate to the specific needs of the people who live there. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, or else these are in the process of being installed. The home has an appropriate infection control policy and is clean. EVIDENCE: A partial tour of the home was undertaken during the site visit. Southwest Road is homely and comfortable. There is one lounge, which during the inspection was occupied by one resident, while two other residents spent time in their rooms. From reading documentation it is clear that there are some issues within the home concerning conflict between the residents. There is a communal dining area within the kitchen, but no other space within the home for residents to relax or engage in activities outside of their bedrooms. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 20 On speaking to the registered manager it transpired that two of the residents had lived in the home for more than ten years and one resident had been at the home for six years. The registered manager stated that although there is some difficulty within the home the residents are able to manage this. There are three bedrooms in the home and two bathrooms, one on each floor. The ground floor bathroom has recently been adapted into a shower room to meet the specified needs of one of the residents. A second resident has been assessed as requiring disability aids and adaptations in the upstairs bathroom. The registered manager stated that the measurements have been taken for this. The upstairs bathroom is worn and in need of refurbishment. The registered manager stated that this should happen when the aids are fitted. There has been no further development regarding the ventilation of one resident’s bedroom, in relation to the cigarette smoke. The registered manager stated that because of the new smoking legislation, the residents have been advised that the premises are non-smoking, however, he could not be certain the residents do not smoke within their bedrooms. On the day of the site visit there was not a strong odour of cigarette smoke. Residents do not have hand wash basins within their bedrooms, however, all three residents have signed to state that they do not want the home to be ‘institutionalised’ and do not wish to have these installed in their rooms. The AQAA states that, “There is an Infection Control policy, procedures and associated work instructions which we follow. Our two hot water tanks…have been checked for risk of Legionella…. The home continues to follow recommendations from the Environmental Health Officer’s visit. We have in place colour coded chopping boards, First Aid box, aprons, hand wash basin in the kitchen etc”. The home was found to be clean and hygienic. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are appropriate numbers of staff at Southwest Road to meet the health and welfare needs of the people who live there, however, the length of time staff spend out of the home does pose potential risks to the residents. The service has a good recruitment procedure in place and all staff members receive relevant training, which is on going. EVIDENCE: According to the AQAA, there are six permanent care staff at Southwest Road and three of these have achieved NVQ Level 2 or above and one is currently working towards NVQ Level 2 or above. One staff member spoken with stated that they were registered to start the training but had not done so yet. In discussion, the registered manager said that two of the staff team were registered to begin the training. Staff members on duty at the time of the site visit to the home were observed to treat residents respectfully. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 22 The staff rotas were examined. It was noted that there are care workers on duty at the home between 10:30 and 14:00, and between 15:00 and 17:00. The sleep in shift starts at 22:00 and ends at 06:30. On Wednesdays there are care workers on duty between 10:30 and 12:30 and between 16:00 and 17:00. Consequently there are long periods of time during the day and evening when there are no staff members present at the home. The registered manager stated that there is always an on-call duty officer. Staff recruitment files are kept at head office, however, there is a procedure in place whereby evidence of recruitment checks can be examined for inspection purposes. Two staff files were looked at and each of these contained a ‘Confirmation of checks and references undertaken’ pro forma, and these were appropriately completed. These documents contained all of the required information, including proof of identity, photograph, CRB check, references, exploration of gaps in employment history etc. A list of the planned training for the staff team within the home was examined. The registered manager stated that all training was mandatory and was held at a period of time set aside for staff meetings, training or team meetings. The training planned and undertaken this year included, CSCI Regs 1 and 2, Pensions, Using computers, fire safety, lone working, appraisals, suicide, medication, general health and safety, diabetes and healthy eating. One staff member spoken with confirmed that training is frequent and ongoing within the home. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. EVIDENCE: The manager at Southwest Road has completed his RMA and is awaiting the certificate to demonstrate this. He has been registered with the Commission and in post for approximately eighteen months. There have been improvements made at the home in terms of meeting the regulations (Care Standards Act 2000) (Care Homes Regulations 2001) since he has been in post. However, the registered manager does not spend all of his time at Southwest Road, and is also the co-ordinator for the Forest Community Project, of which the home is a part. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 24 During the site visit to the home, the registered manager was available to answer any questions and for the purposes of discussion. The AQAA which was completed and returned to the Commission states in the ‘What we do well’ section of this outcome group, “The registered manager visits the home and also covers shifts on a regular basis. He attends house meetings every Monday morning. The registered manager has a constant twoway communication with care staff and residents. There is a regular ongoing evaluation and monitoring of the service”. The house meetings minutes book was examined and it was positive to note that matters arising from the meetings are addressed and their outcome discussed as an agenda item at the following meeting. Questionnaires are sent to the residents regarding the quality of the service provided and a copy of the collated information was forwarded to the Commission as requested at the site visit. However, the summary of the consultation was in relation to the whole Forest Community Project and consequently did not make clear the areas of good practice or for improvement with Southwest Road as a service on it’s own. The registered provider carries out monthly Regulation 26 visits. The AQAA states, “Appropriate health and safety checks are carried out monthly and recorded. Fire door closures continue to be in position. The home is appropriately insured”, It goes on to state that the “Fire folder…contains fire risk assessments, false alarm records, fire testing dates, maintenance of fire equipment”. Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 25 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 3 X 3 X 3 X X 3 X Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 26 NO 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 YA9 Regulation 13(4) Requirement The registered person must ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated. This is in relation to the home being un-staffed for long periods of time each day, and to residents having complex needs, which should be placed within the context of a risk management plan. For example, a risk management plan should be in place regarding how residents will manage an escalation in conflict if a member of staff is not present, how residents will manage an emergency situation such as a fire or sudden illness if a member of staff is not present etc. The registered person must ensure that there are appropriate numbers of staff are working at the home for appropriate periods of time to meet the health and welfare needs of the residents. DS0000007298.V346095.R01.S.doc Timescale for action 31/12/07 2. YA32 18(1)(a) 31/12/07 Southwest Road (7) Version 5.2 Page 27 This is in relation to the potential risks residents face when in the home without any staff presence. 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 YA9 YA39 Good Practice Recommendations The registered person should ensure that risk assessments are completed and signed off when no longer posing a risk to the person concerned. The registered person should ensure that quality assurance systems are in place for the home at Southwest Road as a single establishment, as well as part of the project as a whole. The proprietor to submit to the Commission a business plan for Southwest Road for the next 12 months. (This is a repeated recommendation, which has been outstanding from the report of 10.9.02 and each subsequent report). 1. YA43 Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Southwest Road (7) DS0000007298.V346095.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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