Inspection on 31/10/06 for Springbank Road 152

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springbank Road 152 17/07/07

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 31st October 2006 10:00 Springbank Road 152 DS0000025641.V318013.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.V318013.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.V318013.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 6973816 0208 778 6145 askprovidenceproject.org.uk 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.V318013.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 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. Fees for the service range from £249.40 to £345.00 monthly with no additional charges made. This information was provided to CSCI October 2006. Springbank Road 152 DS0000025641.V318013.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 8 hours. The registered manager was present for the duration of the inspection and facilitated the inspection process. Two staff members were also spoken to and one service user was briefly spoken to. Other inspection methods included inspection of records and a full tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: The statement of terms and conditions and also information within service user plans needs to be put in a clearer and more concise format that uses a person centred approach to make it more accessible to service users. Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 6 Where reviews are held and action plans drawn up these should be signed by the service user, a relative or a representative to indicate their understanding and agreement and a copy issued to them. A more accurate record of meals provided to service users needs to be maintained. Staff need to make sure that where required they consistently record therapy/interventions to be provided to service users to maintain their health and welfare. Improvements around the administration of medication are needed and new staff need to undertake medication training. Where adult protection investigations are carried out details of these and the outcome need to be provided to CSCI. The forms provided by CSCI to record essential information about staff recruitment need to be completed so it is available for inspection. Improvements are required around quality assurance in that the home does not presently have in place adequate systems to ensure that service users, relatives and other stakeholders involved with the home are regularly consulted as part of self monitoring and this information is used to draw up a development plan reflecting aims and outcomes for service users. 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.V318013.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.V318013.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. Service users’ needs have been assessed prior to admission. Service users have all been issued with a statement of terms and conditions that have been signed by the service user, a relative or a representative. EVIDENCE: There have not been any admissions to the home since 1999. However, all the personal files of the service users living at the home contained a copy of a full needs assessment that was obtained prior to their admission. At the last inspection although it was identified that all service users had been issued with a statement of terms and conditions two had not been signed by service users, a relative or a representative on their behalf. At this inspection it was found that these had both been signed. One by a relative and the other by a representative. However, the statement of terms and conditions is not in a format that is accessible to service users and it is advised that this is looked at to so they are able to more easily understand the content (See Recommendations). Springbank Road 152 DS0000025641.V318013.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans include information that demonstrates the personal, health and social support needs of individual service users are addressed but this is still not written in an accessible format for service users. Service users do make decisions about their lives with assistance as required. Risks to service users are well managed so they can live as independently as possible. Confidential information about service users is handled appropriately. EVIDENCE: The personal files of three service users were looked at. These contained extensive information about service users’ personal and social support needs with daily routines being outlined and activities that service users are involved in or enjoy doing on a weekly basis. Health care needs are also addressed with appointment and referral letters included within the file and reports from the Mental Health and Learning Disabilities team that have regular contact with all service users living at the home. The service holds an annual review to which a Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 10 range of professionals such as the GP, social workers and day centre workers and relatives are invited to attend. These reviews are comprehensive in that they look at all areas of individual need and an action plan is drawn up to identify goals to be achieved and issues to be addressed. A further review is carried out after six months to assess the progress made in these areas. The reviews to some extent do reflect the changing needs of service users. However, subject to a previous requirement overall the information contained in the plans is still not easily accessible and is still not in a format that service users can understand. Also, further work still needs to be done to demonstrate service user involvement. Although since the last inspection notes of the reviews indicated service users where appropriate had attended and they had been involved in decisions made within the reviews, neither the reviews nor the action plans are written in an accessible format and they were not signed by the service user one of whom has reading and writing skills, a relative or a representative to indicate their understanding or agreement (See Requirements). With regards to a previous recommendation that an alternative format for service user plans should be considered, which is more person- centred, the registered manager had evidence of several documents that would allow for information to be recorded in a way that would be more appropriate to the needs of the service users but there was no timescale for these to be introduced. It was reported that person centred planning has been brought in by PLUS and within the home this had been initiated with one of the service users living at the home. There was some evidence of this included in their last review but it is still advised that a more appropriate format for care planning is adopted (See Recommendations). At the last inspection it was reported that social workers /purchasers are invited to attend the annual reviews held at the home but they do not attend. This was also reported at this inspection. There were concerns about this as evidence indicated that the local authority had undertaken only one placement review for a service user in 2004. The registered manager reported this had been addressed with the local authority via telephone calls. However, the local authority should be contacted in writing that all service users living at the home require a review of their needs and the placement (See Requirements). As mentioned there was evidence contained in reviews that service users have made decisions about their lives such as where they want to go on holiday, making choices about how they spend their time and activities they want to be involved in. None of the service users are able to manage their own finances. The registered manager reported the home is still waiting for a response to a referral made to Speech and Language Therapy (SALT) on behalf of all the service users to look at other ways of facilitating communication to support them further with being able to make decisions and to generally increase their involvement in different aspects of their care and living within the home. The Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 11 home did have links with a local advocacy service but this has since closed down. It is advised information about another service where service users can access advocacy is obtained (See Recommendations). All service users’ had risk assessments in place that covered a range of activities and areas of need and included control measures to reduce risks identified. These had been reviewed six monthly. Subject to a previous requirement the home has purchased a lockable cabinet to keep all confidential information secure. The home also has a robust confidentiality policy in place. Springbank Road 152 DS0000025641.V318013.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. Service users are supported to access activities that are age and culturally appropriate and also to be able to continue their education. Opportunities are provided for service users to take part in the local community and to engage in a range of leisure activities. Service users are able to maintain appropriate personal and family relationships. Routines of the home do respect service users’ rights and to promote independence. Service users do appear to eat a healthy diet although staff are not always recording meals provided. EVIDENCE: On the day the inspection was held two of the service users were attending local day centres where they undertake a range of different activities. Also, one service user occasionally attends a day centre that culturally meets their Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 13 specific needs. There was evidence in one of the service user plans that they are involved in doing classes in music, cookery and are also learning makaton a form of sign language whilst another service user is supported with developing their skills as an artist and an art therapist attends the home fortnightly. Service users are very much involved in the local community. As well as attending day centres locally they go out to pubs, cafes and use the local shops and a hairdresser. One service user was accompanied to go out for lunch to a nearby café on the day of the inspection and they also attend the Thursday Club occasionally. This is run by PLUS community based service and is where service users living at PLUS homes and also those who live in the community locally are accompanied by staff to go out for example, to go bowling and to eat out at restaurants. Only one service user chooses to attend church, which they are supported to do. Service users are supported to pursue their own interests and hobbies with one service user as pointed out previously being supported with their painting whilst another attends cookery and music groups. Service users tend to be involved in leisure activities away from the home such as attending parties at other PLUS homes. One service user attends a disco organised by the voluntary organisation MIND and as mentioned one attends the Thursday Club occasionally. All service users have an annual holiday of their choice. Subject to a previous recommendation that the registered provider should explore alternative ways to prevent service users having to pay staffs’ travel and accommodation costs to support them on holiday, this has still not been addressed (See Recommendations). Information within service user plans indicated that those service users with family are supported and encouraged to maintain contact with them and also to have other personal relationships. Service users have opportunities for social contact with others through their attendance of parties at other PLUS houses, day centres and clubs this includes the Gateway club, which 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. Service users are supported to do housekeeping tasks within the home such as cleaning their own rooms, doing their laundry, helping to prepare the evening meal and do the washing up. It was also observed during the inspection that service users were able to choose to spend time in their room or in the company of others. Staff were observed as spending time and interacting with service users. In respect to mealtimes the home does not have a weekly menu. Instead for breakfast service users are provided with a choice of toast and cereals during the week and at weekends are given a full English breakfast, lunchtimes they are generally provided with sandwiches although it was reported a choice is Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 14 offered. For supper service users are asked the evening before what they would like the following day. Service users are involved in the weekly shopping so they are able to choose foods they like and prefer. All meals are noted in individual personal diaries for service users apart for one service user whose food intake has to be monitored carefully and any supplements given recorded so a food chart is completed daily. Looking at the diaries for the other service users there was some repetition of foods given at lunchtimes with egg sandwiches and ham sandwiches both being provided on consecutive days. More variety at lunchtimes needs to be provided. Generally, evening meals provided were varied and nutritious. However, it was noted on several occasions that staff had not recorded the meals eaten by service users. It is important that an accurate record is maintained. Also, if a choice is offered this should also be written down. As a way of ensuring that staff do record this information it is advised that this is added to the handover sheet that staff have to complete on a daily basis (See Requirements and Recommendations). Springbank Road 152 DS0000025641.V318013.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 adequate. This judgement has been made using available evidence including a visit to this service. Personal support is provided to service users in a way that meets their individual needs. Generally service users’ physical and emotional needs are met although charts in place to record that necessary interventions are being carried out to maintain service users’ health have not been consistently completed. There are robust medication policies and procedures in place but these are not being used consistently by staff to protect service users. The individual wishes of service users in respect to illness and death are being obtained. EVIDENCE: The home has a key worker system in place to ensure consistency of support is provided. Service user plans included detailed information and guidelines outlining individual service users’ personal care needs in terms of their preferred routines, where support is required and what they are able to do for themselves. Service users were all observed as being well dressed on the day of the inspection. Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 16 There was evidence within service user plans that the physical and emotional needs of individual service users have generally been well met and that there has been liaison with a range of different health professionals including GPs, physiotherapists, speech and language therapy, dental services, audiologists and opticians. All service users are reviewed on a regular basis by a consultant psychiatrist who is linked with the Community Mental Health and Learning Disabilities team. Also, service users’ health needs are looked at as part of the annual reviews held by the home and service users have a health risk assessment plan in place, which ensures that service users’ medication is reviewed every six months as well as attending necessary appointments. Furthermore, one service user living at home has to be given regular physiotherapy after mealtimes for specific health reasons. Staff are given training to be able to carry out the physiotherapy and a chart is kept in the service user’s room where it needs to be recorded that this has been carried out or where staff are not trained to deliver the therapy they need to at least turn the service user. This should also be recorded on the chart. However, it was noted that there were gaps where staff had not recorded when they had delivered the therapy or turned the service user as required. It is important this is addressed (See Requirements). The home has robust policies and procedures in place and the community pharmacist checks the medication every six months. The last visit was carried out in May 2006 and the report that was written was seen. This found that the home’s medication systems were generally satisfactory. Recommendations were made that audits of the stock should be recorded and all medication including those prescribed ‘to be given as required’ should have clear dosage instructions. Both these matters were identified as having been addressed but a sample of Medication Administration Record (MAR) sheets was inspected and as was found at the last inspection errors were noted in the administration and signing of medication. These included medication being signed for but not being given and gaps in MAR sheets where medication was given and not signed for. There has been a turnover of staff since the last inspection and although subject to a previous requirement medication training was arranged for staff, all new staff need to undertake this training (See Requirements). Subject to a previous recommendation that where arrangements have been made with service users, their family members or representatives in respect to illness and death these are clearly recorded in the service user plan, this has been addressed. It was clearly evident within the annual reviews that this had been discussed and plans were being arranged. Springbank Road 152 DS0000025641.V318013.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a new complaints policy in place that is robust. Service users are generally protected from abuse although where adult protection investigations are carried out copies of this should be sent to CSCI. EVIDENCE: The home has revised its complaints policy and this is very robust. There was evidence that there was also a complaints policy in place that is in a more accessible format for service users, which it was reported had been issued to service users. This was not checked. The home has a complaints book in place to record all formal and informal complaints which was inspected No complaints have been made since the last inspection. A previous recommendation was made that a copy of the complaints policy should be visibly displayed within the home to increase its accessibility to service users, their family and friends. This had not been done as it was considered inappropriate and contrary to providing a homely environment. Instead, it was agreed that all family members and representatives would be sent a copy of the complaints policy (See Recommendations). It was reported that the home’s adult protection policy and procedure was in the process of being updated but there was an updated whistle blowing policy in place that was robust. All staff undertakes adult protection training as part of the LDAF (Learning Disabilities Award Framework), which they are required to complete following their induction training. Staff spoken to did have good knowledge around abuse and what action to take if abuse was suspected or Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 18 identified. There have been two adult protection investigations since the last inspection. One involved a service user making an allegation that a staff member had pushed them. The other involved a staff member whistle blowing about another staff member who had forced a service user to wipe their nose and then locked them in the utility and conservatory area so they were unable to access the main part of the house. The registered manager reported head office was informed of the incidents. The procedure is that they then contact social services and take responsibility for carrying out an investigation. It was reported the outcomes of both investigations were that they could not be fully substantiated. However, both staff members are no longer working at the home. CSCI were informed of the incidents but copies of the investigations and the outcome of these had not been sent to CSCI. Details of the investigations were not available for inspection as they are kept at head office. Therefore, in future copies of any adult protection investigations carried out and the outcomes of these should be sent to CSCI (See Requirements). In respect to service users’ finances all the service users are under appointee ship with the registered manager being the appointee for two of the service users and the second signatory for another. The remaining service user has one bank account that is under a corporate appointee ship. However, they have another account that is still under the appointee ship of a previous manager who worked at the home and there have been ongoing problems in trying to have this appointee ship transferred and this has been subject to a requirement of several inspections. At this inspection the registered manager reported that the issue is still ongoing but that there has been a ‘ Best Interests’ meeting with a social worker from the local authority that are now taking the lead in the matter. The requirement is to be restated until the situation is brought to a satisfactory conclusion (See Requirements). The home has robust procedures for the management of service users’ finances and a sample of financial records was looked at and was found all to be accurate. Springbank Road 152 DS0000025641.V318013.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): 24,26,27,28 & 30 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable environment though repairs to cracks in a wall that posed a potential health and safety risk to service users had not been repaired. Service users bedrooms suit their individual needs and toilets and the bathroom provides sufficient privacy. Communal areas are adequate to supplement service users’ individual rooms but the carpet in the communal lounge needs to be replaced. The home was clean and hygienic. EVIDENCE: The home is suitable for its stated purpose, is accessible and generally well maintained and decorated although two large holes/cracks were identified on the day of the inspection on the stairs landing that was reported as being caused by a service user punching the wall. The plaster was buckling under the wallpaper and inside the holes was a lot of debris that was spilling out. It was evident this needed to be repaired as it was posing a health and safety risk to Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 20 service users. An immediate requirement was issued on the day of the inspection specifying that repairs should be carried out by the end of November 2006 and evidence of this sent to CSCI. Following the inspection evidence was sent to CSCI that the matter was in the process of being addressed. Therefore, the immediate requirement is deemed met. Service users’ 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 service user. The other bedrooms do not have en-suite facilities. All the rooms are personalised reflecting individual service users’ needs, interests and culture. At the last inspection it was noted that the carpets in two of the service users’ rooms were stained and in need of cleaning. At this inspection it was found both carpets had been replaced. Also, at the last inspection one of service users had a curtain missing but it was seen at this inspection that new blinds had been purchased. Subject to a previous requirement the flooring in the bathroom had been changed. In terms of communal areas the home has a large kitchen/dining area, which is domestic in nature. Also, off from the kitchen is a lounge that is bright and airy and suitably furnished although the carpet was quite heavily stained and in need of being cleaned or replaced. Subject to a previous requirement that the rear garden is made more accessible to service users and is well maintained this is deemed met. The old air raid shelter at the top of the garden is still in place making it difficult for service users to access this part but the registered manager reported that there are no plans to remove this in the for see able future due to the financial implications for the home. However, there is a large patio area at the bottom of the garden by the conservatory and it was reported service users do use this in the summer months (See Requirements). The home was clean and hygienic on the day the inspection was held. Springbank Road 152 DS0000025641.V318013.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 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are supported to gain appropriate qualifications to ensure service users’ needs are met. There was insufficient information available to fully assess whether service users are protected by the home’s recruitment practices. Staff receive a thorough induction and additional training to meet the needs of service users. EVIDENCE: There has been a turnover of staff since the last inspection two staff have been transferred to work at the home from within the organisation so have had previous experience whilst another has been recruited externally. In terms of qualifications, all staff are required to complete the LDAF (Learning Disabilities Award Framework) which is accredited training within their probationary period prior to progressing on to do either a NVQ Level 2 or 3. Of those staff working at the home one was studying for a NVQ Level 2 and two for the NVQ Level 3. One had achieved a NVQ Level 3. The new member of staff was studying for the LDAF and the two bank staff used by the home, one had completed the LDAF and the other has a qualification higher than NVQ. Given that four of the Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 22 seven staff either have or are progressing towards achieving a NVQ, this standard is deemed met. The home does not keep staff recruitment records at the home these are held at head office. However, CSCI gave PLUS some forms where all the necessary information on staff required for inspection could be recorded and maintained within the home. These were inspected but had not been fully completed so this standard could not be assessed. This needs to be addressed (See Requirements). All new staff have to undergo a five day induction held at head office in which they complete all mandatory training including manual handling, first aid, fire safety, health & safety and food hygiene. This is updated as required. Also, as part of the induction staff are given an introduction to working with individuals with learning disabilities and then as mentioned they have to complete the LDAF units 1-4 within their probationary period before being assessed to go on to do either a NVQ Level 2 or 3. In terms of more specific training the home can access courses from Lewisham Partnership. Staff records included an individual record of training and evidence that appraisals had been carried out last year. These were still to be completed for this current year. It was reported that training is discussed within appraisals from which a personal development plan is drawn up and also within supervision. Courses are identified to enable staff/ key workers to be able to meet the individual needs of service users more effectively. Evidence of training undertaken since the last inspection included mandatory training refreshers, medication training, personcentred planning and key working, visual awareness, cerebral palsy, capacity to consent. In terms of new staff including those that were transferred internally as well as the organisational induction, it was reported a basic induction around systems and procedures is also carried out. Staff spoken to confirmed this. However, it is recommended that a record of this be maintained (See Recommendations). Springbank Road 152 DS0000025641.V318013.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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run and managed. Although there are plans in place on an organisational level to address quality assurance the home still did not have any formal systems in place to monitor the quality of service provided. Service users’ health, safety and welfare are 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 service users and generally the home is well run. Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 24 At an organisational level a Quality Action plan has been drawn up outlining measures to be taken to ensure all PLUS services monitor the quality of service being provided and standards are maintained. Part of this plan has seen the piloting of a formal quality assurance system (PQASSO) in one of the PLUS homes. However, as yet the home itself does not have any systems in place based on seeking the views of service users, relatives or other stakeholders by the use of customer satisfaction questionnaires. The issue of monthly provider reports was not discussed at this inspection although copies of these reports have not been sent to CSCI and so this is to be assessed as remaining unmet (See Requirements). The home has robust policies and procedures in place. Maintenance certificates for fire, gas and electrical equipment were in place and up to date. Water temperatures have been regularly checked and also in respect to fire procedures, fire alarm call points have been tested weekly and fire drills carried out. Subject to a previous requirement that a comprehensive health and safety risk assessment of the building should be completed to include fire safety this has been partially met. It was reported that health and safety checks of the building are carried out every three months but these are sent to head office. Copies of these should be kept at the home so they are available for inspection. An up to date fire risk assessment was seen to be in place (See Requirements). Springbank Road 152 DS0000025641.V318013.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 X 2 X X 2 X Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 (1) &(2) Requirement 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) The registered person must ensure that the placing authority of those service users living at the home are contacted about the need for service users to have a placement review. A record of the contact made by the home must be maintained. The registered person must ensure that staff record all meals provided to service users and where a choice is offered this is also recorded. The registered person must ensure that where charts are DS0000025641.V318013.R01.S.doc Timescale for action 30/04/07 2. YA6 14(2)(a) 30/04/07 3. YA17 16(2)(i) 30/04/07 4. YA19 12(1) 28/02/07 Springbank Road 152 Version 5.2 Page 27 5. YA20 13 (2) 6. YA20 13 (2) 18(1)(c)(i) 7. YA23 20 (3) 8. YA23 13(6) 9. YA28 23(2)(d) put in place to record interventions / treatment to be carried out with specific service users to maintain health and welfare that this is consistently recorded by staff and if this is not carried out the reason is specified. The registered person must ensure that the systems in place for recording and monitoring the administration of medication are used consistently and effectively specifically staff sign the medication administration records correctly for all medication administered. (Previous timescale of 31/01/06 not met) The registered person must ensure all staff receive formal training in medication delivered by a pharmacist. (This is an updated requirement) The registered person must ensure that the issue of appointee ship is fully resolved to enable the service user full access to their finances and ensure their rights are fully protected. Previous requirement of 25/04/05 &30/05/06 partially met. The registered provider must ensure that where adult protection investigations are carried out details of the investigation and the outcome of this are sent to CSCI. The registered person must ensure that the carpet in the lounge is cleaned and if the stains cannot be removed a replacement carpet is acquired DS0000025641.V318013.R01.S.doc 28/02/07 28/02/07 30/04/07 30/04/07 30/04/07 Springbank Road 152 Version 5.2 Page 28 10. YA34 19 (4)(b)&17(2) 11. YA39 24 & 26 12. YA42 12(1)(a) 13(4)(a)&(c) The registered provider must 30/04/07 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. The registered manager must 30/04/07 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 monthly unannounced 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) The registered person must 30/04/07 ensure that where health and safety checks are carried out that records of this are maintained within the home and available for inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA2 YA6 Good Practice Recommendations The registered provider should consider drawing up a copy of the terms and conditions issued to service users in a more accessible format. The registered manager should consider a format for service user plans that use a person centred approach and that sets out clearly objectives, targets action and timescales. DS0000025641.V318013.R01.S.doc Version 5.2 Page 29 Springbank Road 152 3 4. 5. 6. YA7 YA14 YA17 YA22 7. YA35 The registered person should try to access information for service users where advocacy support can be accessed. The registered manager should explore alternative ways to prevent service users having to pay staff’s travel and accommodation costs to support them on holiday. The registered person should consider modifying the handover sheet to enable staff to record information about the meals provided to service users. 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 service users for their information. The registered person should try to ensure that where staff undertake the induction used by the home that a record of this is maintained. Springbank Road 152 DS0000025641.V318013.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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