Inspection on 17/07/07 for Springbank Road 152

This inspection was carried out on 17th July 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springbank Road 152 31/10/06

Springbank Road 152 12/10/05

Springbank Road 152 25/04/05

Springbank Road 152 22/09/04

Springbank Road 152 05/05/04

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 Springbank Road 152 Lewisham London SE13 5BD Lead Inspector Ornella Cavuoto Unannounced Inspection 17th July 2007 10:00 Springbank Road 152 DS0000025641.V341884.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 Springbank Road 152 DS0000025641.V341884.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. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springbank Road 152 Address Lewisham London SE13 5BD 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 697 3816 0208 778 6145 PLUS (Providence & Linc United Services) Sally Ann Ferguson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 4 persons with learning disabilities of whom 1 may also have a physical disability and be over 65 years 31st October 2006 Date of last inspection Brief Description of the Service: 152 Springbank Road is a small home that provides long term care for up to 4 persons with learning disabilities. There were no vacancies at the time of the inspection and there have been no new admissions since 1999. The home consists of a two-storey house that has been converted. It is located in a quiet residential street in the Hither Green area and is conveniently located near to several bus routes and a mainline station. A variety of shops, pubs, cafes and facilities, such as hairdressers, are within walking distance of the house. The house has a small front garden and a larger one to the rear. There is limited parking available at the home with the majority of the street given over to permit holder parking, although metered parking is available a short walk away. This could be a problem for visiting friends and relatives. The home aims to provide a homely atmosphere where staff can support individuals to develop and maintain their skills and independence as much as possible and lead a fulfilling life. LINC, the company that previously owned and managed the home has recently merged with another company and since August 2005 the management and ownership of the home has been taken over by PLUSProvidence LINC United Services. In terms of making information about the service available to potential service users, relatives or representatives and also CSCI inspection reports this is undertaken by PLUS Head Office. Updated information on fees was not available. Springbank Road 152 DS0000025641.V341884.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 that took place over one day. The registered manager was present for the inspection and was helpful in facilitating the inspection process. On the day of the inspection only two of the four residents were at the home. One of these residents has communication difficulties and therefore they could not be consulted about the home whilst the other resident was spoken to briefly. One bank worker who was on duty was also spoken to briefly. Attempts were made to speak to relatives of two of the residents following the inspection but this proved unsuccessful. Other inspection methods included a tour of the premises and inspection of care records. The inspection found that the home had made good progress in meeting previous requirements with eight assessed as having been met. Five new requirements were specified. What the service does well: What has improved since the last inspection? All residents had a placement review carried out by the local authority to ensure the home is still suitable to meet their needs. All meals provided to residents had been recorded to enable their diets to be carefully monitored and that a balanced diet is provided. Support staff had more consistently completed charts to record treatment to be provided to a resident living at the home. There had been improvements in the administration of medication and all support staff had received training in medication. The home has managed to resolve the issue about appointee ship to ensure Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 6 that the resident who is involved, their rights have been protected. 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. Springbank Road 152 DS0000025641.V341884.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 Springbank Road 152 DS0000025641.V341884.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&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs had been assessed prior to admission. All residents had a statement of terms and conditions that had been signed by the residents, a relative or a representative. EVIDENCE: There have not been any admissions to the home since 1999. Yet there was evidence included in personal files that all the residents presently living at the home had their needs fully assessed prior to their admission All the residents had been issued with a statement of terms and conditions that had been signed by the residents themselves, a relative or a representative of their behalf. A previous recommendation that this document should be drawn up in a more accessible format so that the residents can more easily understand the content had not yet been addressed and is to remain in place (See Recommendations). Springbank Road 152 DS0000025641.V341884.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 &9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ individual plans were generally comprehensive and addressed all their needs although one of the plans had not been fully updated to reflect changing needs. Residents had been supported to make decisions about their lives as required. Risks presented by residents’ needs were generally well managed so they could live as independently as possible. EVIDENCE: The personal files of all the residents were looked at during the inspection. These contained a lot of information about residents’ personal and social support needs with detailed guidelines in place about how to meet individual needs including any specialist requirements. There was also evidence that health care needs had been addressed with referral letters and reports from a range of health care professionals. However, it was noted for one of the residents whose mobility had deteriorated that although new guidelines had been drawn up in relation to supporting the resident to mobilise when going out, the guidelines in respect to their personal care needs to ensure they were Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 10 supported appropriately and the aids provided by occupational therapy were used had not been updated. This needs to be addressed although it was evident from the files belonging to other residents that their changing needs had been reflected. Subject to a previous requirement that all the residents should have placement reviews with the relevant local authority, this had been met. Copies of the reviews that were undertaken in February 2007 were contained in the files. In addition, the registered manager reported and there was evidence to indicate that an annual review for all residents apart from one of them had been undertaken by the home to which relatives and any professionals that are involved in working with them are invited. However, only two of the reviews had been written up. The reviews were comprehensive in that they addressed all areas of need, identified progress made and outlined personal goals to be achieved with residents and issues to be looked at over the forthcoming year. Yet, it was identified at the last inspection that although the reviews did indicate that residents and relatives had attended and had been involved in decisions that were made, further work was needed to ensure residents and relatives where appropriate were more fully involved in the process, for example for residents the outcomes of the reviews being written in a more accessible format and this given to them. It was found at the last inspection that one of the residents who has reading and writing skills had not signed their review and neither had relatives or a representative on the other residents’ behalf to indicate their agreement about decisions made. At this inspection, there was some evidence to demonstrate that action had been taken to address this with outcomes of the reviews for two of the residents having been drawn up in an accessible format using pictures and simple language but relatives where appropriate had still not signed the reviews on their behalf (See Requirements). In respect to a previous recommendation that an alternative format for residents’ plans/ personal profiles should be considered, which is more person centred and makes information about their care and the support they receive more accessible to them, this had still to be addressed. There was evidence of person centred planning being undertaken with some of the residents and the home did have a document ‘Personal Profiles, Person Centred Planning (PCP) and Planning for Individuals’ Needs’ -Policy, Procedure and Guidance drawn up by the provider. However, it was evident progress in this area is still to be made and the recommendation is to remain in place (See Recommendations). There was evidence from the reviews carried out that residents have been supported to make their own decisions where appropriate. Where required the home has organised best interest meetings to discuss how to proceed on particularly important or major decisions affecting residents’ welfare. On an organisational level there is a general service users’ meeting held six monthly to which all residents living within PLUS homes can attend and there is also a service users’ consultation group of which residents can become a member if they so wish. The members of this group are responsible for managing the Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 11 meetings and deciding upon the agenda and feeding back information or decisions made to other residents and the management committee. Subject to a previous recommendation that the home access information about another advocacy service after it was reported the one previously known of had closed down, this had been addressed. Risk assessments for all residents had been completed that covered a range of activities and areas of need. Control measures to reduce the level of risk had been identified and these had been reviewed six monthly. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had been supported to partake in activities that are meaningful and fulfilling and they were very much involved in and part of the local community. Residents have had the opportunity of going on an annual holiday that they were involved in choosing and regular day trips. Routines of the home were aimed at respecting the residents’ rights and promoting independence. Residents had been offered a varied and healthy diet. EVIDENCE: On the day of the inspection two of the residents were attending local day centres where they undertake a range of different activities including music and cookery classes. Also, one resident occasionally attends a day centre that culturally meets their needs and in addition they attend a rambling club monthly. Another resident has been supported by the home with developing their skills as an artist. An art therapist attends the home fortnightly and it was noted that within the annual review that was recently held that the home is Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 13 trying to find an appropriate venue where the resident can exhibit their work some of which has been displayed in the home. Residents are very much involved in the local community. As well as attending the day centres locally they go out to pubs, cafes and use the local shops and hairdresser. One resident is regularly accompanied to go out for lunch at their request and this occurred on the day the inspection was held. Two of the residents also attend the Thursday Club occasionally. This is run by PLUS Community Service and is where individuals living at PLUS homes and those who live in the community with their families meet up and are accompanied by staff to go out locally to bowling or to eat out at restaurants. Only one resident chooses to attend church, which they are supported to do. All the residents apart from one are supported to have an annual holiday. In respect to the other resident, it was decided after discussions with the social worker at the placement review held in February 2007 that attending day trips during the summer months would be more appropriate for them than going on holiday. At the time the inspection was held two of the residents had already been away; one to Holland who was spoken to and confirmed they had enjoyed themselves and one to Kilder Water. In respect, to a previous recommendation that the registered provider should explore alternative ways to prevent residents having to pay staffs’ travel and accommodation costs this is an ongoing issue that had not been addressed although the registered manager reported the provider had contributed towards the payment of a holiday for one of the residents who had limited funds. The reviews held by the placing authority with residents specified that the provider needed to flexibly address funding of holidays. This clearly is an issue that needs to be discussed at further length between the provider and the commissioning authority and it is advised this consultation takes place (See Recommendations). Information within residents’ personal files indicated that those individuals with family and friends are supported and encouraged to maintain contact with them. In addition, residents have opportunities for social contact with others through their attendance of parties at other PLUS houses, day centres and clubs which includes the Gateway club. This provides a social event where individuals with or without a learning disability can attend. The routines of the home do promote independence, individual choice and freedom of movement within a risk management framework. Residents are supported where possible to do housekeeping tasks within the home such as cleaning their own rooms, doing their laundry, helping prepare the evening meal and to wash up. In respect to mealtimes the home does not have a weekly menu. Instead, for breakfast the residents are provided with a choice of toast and cereals during the week and at weekends are given a full English breakfast. Lunchtimes they are provided with a light meal or sandwiches. For supper, residents are asked Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 14 the evening before what they would like the following day. Residents are involved in the weekly shopping so they are able to choose the foods they like and prefer. All meals are noted down in residents’ personal diaries apart from one resident whose food intake has to be monitored carefully and any supplements given recorded so a food chart is completed daily. At the last inspection it was identified that there was some repetition of foods provided to residents at lunchtimes and also that support staff had not consistently recorded meals eaten by residents in the diaries. At this inspection the diaries indicated that there was less repetition and more varied foods were being provided to residents at lunchtimes. Also, meals had been consistently recorded. A previous recommendation that the recording of meals should be added to the handover sheet used by support staff to remind them to do this had not yet been addressed and will remain in place (See Recommendations). It was noted within the reviews carried out by the placing authority that it was specified that the provider needed to address the funding of food more flexibly. This was discussed with the registered manager who stated this arose due to residents’ having to use their personal allowance when going out to eat, for example for lunch as well as paying a contribution to the weekly food budget for the home. No action had been taken to address this. As mentioned in respect to the issue of the funding of holidays (For further details see Standard 14) it is evident that this matter needs to be discussed further between the provider and the commissioning authority and it is advised this consultation takes place (See Recommendations). Springbank Road 152 DS0000025641.V341884.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&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support had been provided to residents in a way that meets needs. Overall, residents’ physical health needs and emotional needs had addressed although not all records in respect to health care had been updated. There are robust medication policies and procedures that had adhered to consistently by support staff to protect residents. EVIDENCE: The home has a key worker system in place to ensure consistency of support is provided. Residents’ personal files included detailed information and guidelines outlining individual residents’ personal care needs although as mentioned in respect to Standard 6 for one resident these had to be updated to reflect a change in their needs. Residents were observed as well dressed and groomed on the day of the inspection. There was evidence within individual residents’ files that their physical and emotional needs had generally been well met with liaison with a range of different health professionals including the GP, physiotherapists, occupational therapists, speech and language therapy and dentists. A consultant psychiatrist Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 16 their been kept been at the Community Mental Health and Learning Disabilities team reviews residents at least annually. In addition, residents’ health needs are looked at as part of the annual reviews held by the home and they had health risk assessment plans in place that looked at their individual health needs, including information about when they had last had a medication review and any appointments that were to be attended. However, it was noted these had not been reviewed since January 2006. This needs to be addressed. Furthermore, at the last inspection it was identified that for one of the residents who has to be given regular physiotherapy after mealtimes for specific health reasons that the monitoring chart that should be maintained as a record that this has been performed had not always been completed by support staff. All staff receives training to be able to carry out this procedure safely and there are serious implications for the resident if they do not receive this therapy. At this inspection it was found that support staff had regularly completed the chart demonstrating the resident had received the therapy as required (See Requirements). The home has robust policies and procedures in place and a community pharmacist regularly visits the home. The last visit was carried out 01/06/07 and the report that was written was seen. This indicated that the home‘s medication system was effective and no major problems or issues were identified. Yet, at the last inspection on checking the medication records errors were noted in the administration and signing of medication. These included medication being signed for but not given on one occasion and gaps in medication records where medication was given but not signed for. It was also identified that some of the support staff had not completed medication training. However, at this inspection all the medication records looked at were accurate. There was also evidence that support staff had completed medication training. The home had introduced weekly audits of the medication since the last inspection and it was evident these had been effective in ensuring support staff adhere consistently to procedures in the administration of medication. In respect to homely remedies it was noted that the lists detailing those remedies that could be given to residents had not been reviewed since 2005 and it is advised this is looked at with the home’s GP (See Recommendations). Springbank Road 152 DS0000025641.V341884.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure and the adult protection policy and procedure had been updated to ensure residents’ rights were protected. Residents’ personal finances had been managed effectively by the home. EVIDENCE: The home has a robust complaints procedure that sets out the different stages and timescales for the process. The home has a complaints log to record both informal and formal complaints but none had been received since the last inspection. Given some of the residents have communication difficulties it was recommended at the last inspection that all family members and representatives be sent a copy of the complaints policy as a measure to ensure they are fully aware of the procedure and can support residents’ if necessary to make a complaint or do so on their behalf. The registered manager reported they were still in the process of sending these out to relatives where appropriate. Consequently, the recommendation will remain in place. As mentioned in respect to Standard 7, information about an advocacy service has now been obtained to provide independent support and representation to residents if required (See Recommendations). At the last inspection the registered provider was in the process of updating the home’s adult protection policy and procedures and so this was not available for inspection. However, at this inspection this was seen and was very comprehensive detailing the different types of abuse and what action staff at different levels should take on the identification or suspicion of abuse. The Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 18 home also has a robust whistle blowing policy. All support staff undertakes adult protection training as part of the LDAF (Learning Disabilities Award Framework). All staff have to complete units 1-4 of this award as part of their probation (For further details see Standard 35). For bank staff this is not compulsory but a bank worker who was working at the home on the day of the inspection reported that as part of their induction they were taken through key policies and procedures of which adult protection was one. It was evident through talking to the worker that they did have a good working knowledge in this area. At the last inspection there had been two adult protection investigations that although had been reported to CSCI, details of the investigations carried out by the home were not sent and these were unable to be seen on the day of the inspection as the records were kept at the provider’s head office. A requirement was specified that copies of any future adult protection investigations should be sent to CSCI. Since this inspection no investigations in relation to the home have had to be carried out. As a result, this requirement was unable to be assessed and a decision was taken not to restate the requirement but that this would continue to be monitored at future inspections. In respect to residents’ finances all of them are under appointee ship. The registered manager is the appointee for two of the residents and the second signatory for another. There have been ongoing issues with the remaining resident who has one bank account that is under a corporate appointee ship but another bank account that is still under the appointee ship of a previous manager who worked at the home and there have been difficulties getting this transferred. This has been subject to a requirement of several inspections. At the last inspection the registered manager reported that a best interests meeting had been held to discuss the matter with the social worker and family. At this inspection, the registered manager reported and there was evidence within the residents’ individual file that a relative of the resident had agreed and was in the process of applying for court of protection, which would resolve the matter. This meets the requirement that had been specified in relation to this issue. The home has robust procedures for the management of residents’ finances. A sample of financial records was looked at and all these were found to be accurate with receipts maintained for all transactions undertaken. Springbank Road 152 DS0000025641.V341884.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): 24,26,28&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment and there was a programme in place for decoration and maintenance work to be carried out within the home. Generally residents’ bedrooms suited their individual needs although one of the bedrooms notably smelt of urine. There are adequate communal spaces to supplement residents’ individual rooms but work in the garden needs to be completed to ensure residents can use it safely. Apart from one of the residents’ bedrooms, the home was clean and hygienic. EVIDENCE: The home is comfortable and homely and is generally well-maintained although there were areas that were in need of attention, for example the paving of the front drive was very uneven and cracked and the outside of the home was in need of being painted. However, there was evidence that a programme for works to be carried out on the home over the forthcoming year had been drawn up and both these were on the list to be done. The registered manager also reported that estimates for work on the front drive to be completed had Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 20 already been obtained. In addition, approximately three years ago the home had problems with subsidence, which was addressed with works carried out but the registered manager reported that there were concerns this had recurred due to cracks appearing in certain parts of the house. This had been reported and the home was waiting for a surveyor to visit. Residents’ bedrooms are a good size and are furnished to required standards. One of the bedrooms is on the ground floor and is wheel chair accessible with a large en-suite bathroom that has specialist equipment to assist the resident. All the rooms are personalised reflecting individual residents’ needs, interests and culture. All the bedrooms were clean and tidy but there was a strong smell of urine in one of the rooms. The resident does suffer from incontinence and the registered manager acknowledged that it had become increasingly difficult to eliminate the odour through cleaning and airing of the room. It was evident that the carpet in the room needed to be changed and the home may need to consider the option of using alternative flooring that would be more hygienic and able to be cleaned more easily (See Requirements and Recommendations). The home has sufficient communal spaces including a large kitchen and dining area that is domestic in nature. It was noted that one of the doors of the kitchen cupboards fixed to a wall was broken and could easily fall off posing a health and safety risk to residents and staff and so needs to be fixed. The registered manager reported that there are future plans for the kitchen to be renewed and a new conservatory also may be built. This would be an improvement to the home as the present conservatory is bare of furniture and used more for storage purposes. There is also a lounge area off from the kitchen. Subject to a previous requirement the carpet in the lounge had been cleaned and the stains had largely been removed so did not need replacing at this stage. Previous inspections have highlighted concerns about the accessibility of the garden for residents. There is an old air raid shelter at the top of the garden and so this part cannot be used. However, it was reported due to financial implications for the home that there were no plans to have this removed. At the bottom of the garden there is a patio area. At this inspection it was found that some work was being done on the patio. The registered manager reported this had been started by a staff member to try to even up the paving stones but unfortunately due to sick leave this had delayed the completion of the work. This needs to be addressed as the loose paving stones that were in the garden posed a health and safety risk for residents. Furthermore, this area could be made more attractive for residents, for example by purchasing a chairs and table set for them to sit outside (See Requirements and Recommendations). Apart from the resident’s bedroom in which an offensive odour was detected (For further details see Standard 26), the rest of the home was clean and hygienic. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 21 Springbank Road 152 DS0000025641.V341884.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): 32,34 &35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff working at the home have been supported to gain appropriate qualifications to ensure that they are competent and can meet residents’ needs. There was insufficient information to be able to assess whether or not residents are protected by the home’s recruitment practices. Staff had received a thorough induction and individual training needs had been identified through an appraisal system to ensure the individual and collective needs of residents can be met. EVIDENCE: Of the six support staff presently employed to work at the home, one had completed a National Vocational Qualification (NVQ) Level 3, one had completed a NVQ Level 2 and two were in the process of working towards a NVQ Level 3. It was reported the two remaining support staff are due to commence studying for NVQ Level 3 September 2007. All staff had completed the LDAF (Learning Disabilities Award Framework) Units 1-4 as part of their probation. The National Minimum Standards (NMS) specifies that at least 50 of the staff must have obtained or working towards a relevant qualification, therefore this standard is deemed met. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 23 Since the last inspection three support staff have been employed to work at the home. Staff recruitment records are not kept on the premises but at the provider’s head office. However, the Commission for Social Care Inspection (CSCI) had issued the provider with a proforma to be filled in for all employees to record all the necessary recruitment information required for inspection and it was agreed these would be kept at the home. However, at the last inspection it was identified that these forms had not been fully completed so the standard could not be adequately assessed. At this inspection it was identified that the CSCI proforma was not in place for new staff. The registered manager stated these had not been received from head office. Following the inspection, a service manager was contacted to discuss this matter at the main head office. It was explained that the procedure is that home managers are required to fill in the proformas with the staff. It is evident that the provider needs to clarify the procedure for the completion of these forms so that they are available for inspection (See Requirements). All new staff are required to undergo a five day induction that is held at the provider’s head office in which they complete all mandatory training including manual handling, first aid, fire safety and food hygiene. This is updated as required. Also, as part of the induction programme staff are given an introduction to working with individuals with learning disabilities and then as mentioned they have to complete LDAF Units 1-4 within their probationary period before then being assessed to go onto to do either the NVQ Level 2 or 3. The home also accesses training courses via Lewisham Partnership. Staff records looked at all included an individual training profile which detailed training completed. In addition, there was evidence that appraisals had been carried out with all staff apart from two due to individual circumstances and there were personal development plans that detailed training to be completed over the forthcoming year. Training that had been completed included refresher mandatory training, medication training visual awareness. Subject to a previous recommendation that a record of the basic induction undertaken by support staff within the home that looks at systems and procedures should be maintained, this had been addressed. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed for residents’ benefit and resident surveys in an accessible format had been drawn up by the Provider as part self monitoring although these were yet to be completed. Residents’ health, safety and welfare were promoted and protected. EVIDENCE: The registered manager has been working at the home for the past three years and is well qualified having obtained a NVQ Level 4 in care, a Certificate in Management Studies and also has a Diploma in Youth and Community Work. She is very familiar with the needs of the residents and ensures the home is well run and managed for their benefit. In respect to quality assurance, at the last inspection it was identified that on an organisational level a Quality Action plan had been drawn up outlining Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 25 measures to be taken to ensure all PLUS services monitor the quality of the service being provided and standards were maintained. Part of this plan had seen the piloting of a formal quality assurance system (PQASSO) in one of the PLUS homes. However, at that time the home did not have any systems in place to carry out self- monitoring such as using customer satisfaction questionnaires/ surveys to seek the views of residents, relatives or other professionals involved in the home. At this inspection the registered manager reported that that they understood the pilot had proved successful but they were not clear if and when this would be implemented at other PLUS homes. However, there was evidence of resident surveys that had been drawn up in an accessible format using pictures and simple language. These were yet to be completed and it was recommended that the home should consider bringing in an independent advocate when seeking residents’ views on the areas specified within the surveys. Also, since the last inspection as mentioned in respect to Standard 20 the home had introduced weekly medication stock checks. However, evidence within the home indicated that monthly provider reports had not been regularly carried out. The last report received by the home was dated December 2006. This needs to be addressed (See Requirements and Recommendations). There was evidence that the health, safety and welfare of residents was promoted and protected. There were up to date maintenance certificates in place for gas, electrics and fire equipment. Fire call points had been tested weekly and fire drills had been carried out on a regular basis. The home had a fire risk assessment in place but this had not been reviewed since April 2006. However, this was done during the inspection. Subject to a previous requirement that copies of the health and safety checks carried out every three months should be kept in the home had been met. Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 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 2 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) &(2) Requirement Timescale for action 30/11/07 2. YA6 15(1) 3. YA19 12(1)(a) 4. YA26 16(2) (k) The registered person must ensure that the information within the service user plan is easily accessible and understood by service users and all aspects of the plan are drawn up with the involvement of the service user and are signed by the service user whenever capable and or by family or a representative. (Previous timescale of 30/05/06 not met, timescale of 30/04/07 partially met) The registered person must 30/11/07 ensure that all the support guidelines for the resident whose mobility needs have increased are updated to ensure their needs are being fully and safely met. The registered person must 30/11/07 ensure that the health actions plans drawn up for individual residents are updated following annual reviews to enable the health needs of residents to be monitored. The registered person must 30/11/07 DS0000025641.V341884.R01.S.doc Version 5.2 Springbank Road 152 Page 28 5. YA28 6. YA28 7. YA34 8. YA39 ensure that measures are taken to keep the resident’s room that smelt strongly of urine clean and free from any offensive odours as part of maintaining resident’s dignity and also as part of infection control. 23(2)(b) The registered person must ensure that the door of the wall kitchen cupboard is fixed to maintain the health and safety of staff and residents. 23(2)(o) The registered person must ensure the works being carried out in the rear garden are completed and any debris removed to maintain the health and safety of staff and residents. 19 The registered provider must (4)(b)&17(2) ensure that the forms provided by CSCI to record the required information on recruitment are fully completed and made available for inspection within the home. (Previous timescale of 30/04/07 not met) 24 & 26 The registered person must ensure that an effective quality assurance system is in place based on seeking the views and reporting back findings to service users, their families and other stakeholders. Also, to ensure as part of quality assurance that monthlyunannounced visits are carried out by the responsible individual and copies of the report sent to the commission. (Previous Timescale of 30/05/06 not met, timescale of 30/04/07 partially met). 30/11/07 30/11/07 30/11/07 30/11/07 Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations The registered person/provider should try to draw up a terms and conditions that is in a more accessible format for residents to facilitate their understanding of the document. The registered person/ provider should consider a format for residents’ plans that uses a more person centred approach and is more accessible to them. The registered provider should try to ensure that there is consultation with the commissioning authority on the present funding arrangements of holidays for residents within the home and if any changes are required to these. The registered provider should try to ensure that there is consultation with the commissioning authority on the present arrangements of residents paying for their own lunches/ meals out and if any changes are required to these. The registered person should consider modifying the handover sheet to enable staff to record information about the meals provided to residents. The registered person should try to ensure that the homely remedies lists are reviewed and updated. The registered person should try to ensure that a copy of the home’s complaints policy & procedure is sent to relatives, friends and representatives of residents for their information. The registered person should consider the use of alternative flooring for the resident whose room smelt offensively that would be more hygienic and able to be kept clean more easily. The registered person should try to find ways of making the rear garden more attractive to residents, for example purchasing a table and chair set. 2. 3. YA6 YA14 4. YA17 5. 6. 7. YA17 YA20 YA22 8. YA26 9. YA28 Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 Springbank Road 152 DS0000025641.V341884.R01.S.doc Version 5.2 Page 31 - 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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