Inspection on 24/09/07 for St Helier Avenue (374)

This inspection was carried out on 24th September 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Helier Avenue (374) 09/02/07

St Helier Avenue (374) 27/01/06

St Helier Avenue (374) 04/11/05

St Helier Avenue (374) 07/02/05

St Helier Avenue (374) 12/08/04

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 St Helier Avenue (374) 374 St Helier Avenue Morden Surrey SM4 6JU Lead Inspector David Pennells Key Unannounced Inspection 24th September 2007 11:30 St Helier Avenue (374) DS0000007157.V346534.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 St Helier Avenue (374) DS0000007157.V346534.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. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Helier Avenue (374) Address 374 St Helier Avenue Morden Surrey SM4 6JU 020 8648 0661 020 8646 4165 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Post Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 9th February 2007 Brief Description of the Service: 374, St Helier Avenue is managed, maintained and staffed by the Care Management Group (CMG). The care home is registered with the Commission to provide residential care for up to eight adults with learning disabilities and associated challenging behaviours. One user of the service currently occupies a small independent living flat attached to the main house. A similar flat is expected to be integrated / ‘mainstreamed’ within the main building soon. The home itself is a large detached brick built house converted to its current use in 1999. Situated close to the ‘Rose Hill’ roundabout on the A297 at its junction with the A217, the home is conveniently situated close to a variety of local shops, eating establishments and bus links. There is a hardstanding at the front of the home for parking a few vehicles, and extra free ‘on street’ parking is available nearby on the designated dual carriageway verges. Accommodation within the home comprises six single bedrooms - one on the ground floor and five on the first in the main building, and self-contained flatlets attached to either side of the property (see first paragraph above), and a large garden with a patio at the rear. Communal facilities include a large dining / activities room, a separate comfortable lounge area, a conservatory at the rear of the house overlooking a pleasant back garden, a well-organised kitchen, and a laundry room. There are sufficient bathroom / shower and toilet facilities located throughout the home to meet service users’ needs. In addition, there is a staff sleeping-in room and an office on the first floor. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We visited the service on a surprise visit, from late morning to late afternoon, this allowing the majority of those using the service to be met, alongside two shifts of staff and the Acting Manager, who was available for most of the inspection time. We spent time looking at documentation, checking records, and were given free access to any papers requested. A number of bedrooms were seen with the permission of their occupants, as well as all the communal facilities. The Acting Manager had previously provided an Annual Quality Assurance Assessment (AQAA) document concerning the service to the Commission; some elements within this report are taken from that statement. We are grateful to all at the home for their welcome, co-operation and hospitality during the visit. What the service does well: What has improved since the last inspection? Medication proformas and records seen have been kept rigorously well and were in very good order. Such rigour was also now noted with regard to fire alarm checks. Care plans and finance records were also accurately and carefully kept. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 6 The defunct extractor fan in the laundry had been replaced. It was noted that additional lighting for the dining room was on order and would be provided therein at the point of integration of the ILU flat to the main house. The Acting Manager has clearly continued to ensure that the recording and focus on person-centred care has continued; the philosophy of the home is positively focused on encouraging each individual to fulfil themselves to the best of their abilities - through engagement and having fun. 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. St Helier Avenue (374) DS0000007157.V346534.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 St Helier Avenue (374) DS0000007157.V346534.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): 1, 2, 3 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides those who live at the home and interested parties with full details to enable them to make an informed choice about choosing - and continuing to live at the home - however the planned change of purpose of one ILU must be forward-planned and included in future documentation. The needs and aspirations of people using the service are assessed and understood, with related plans carried out at the home. A thorough and considered exploration of behaviours, expressed wishes, and identified needs ensures each person using or coming to the service is treated as an individual. EVIDENCE: We found that the revised (though not thoroughly proof-read) ‘Statement of Purpose Information Handbook’ is in place, this giving reasonably clear details about the services the home offers, though detail about the difference of living in the independent flat was not spelled out clearly. The home is now required to rewrite its Statement of Purpose and Selection Criteria – being more explicit about the purpose of the home - and the single ILU in particular. It is clear that home must establish clarity on these points; the revised Statement of Purpose will focus minds on the planning for the future. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 9 Due to the moving of a person currently living at the service, the Acting Manager was able to speak of the assessment of a prospective newcomer to the home. As the home accommodates people who have challenging behaviour, the issue of ‘compatibility’ of a newcomer within the current community of people living at 374 is very important. CMG have a separate Assessment Team that assesses prospective people who might use the service, and the manager is then referred people who they feel are likely to ‘fit’. The manager then visits the prospective resident and they visited the home, then from this, a group of people discussed how the newcomer could be supported as they moved into 374. The home is moving towards adopting a person-centred approach to care planning. In this particular case, it was planned, for instance, that a member of staff would go to where the newcomer is living - so that they get to know them, and photos of the ‘new’ and the ‘old’ will act as memory-joggers to assist the connection between the two homes and staff. These steps were planned to take place before the newcomer visits the home on a phased but regular basis. We found that the Acting Manager is focusing on providing an excellent service to those using the service; with the second flatlet now being ‘broken through’ to the main building [this leaving just one independent living flatlet for use], this will end up with a ‘larger home’ - with seven bedrooms within the main house. We remain confident that standard 3 will be very well ‘met’, once the Statement of Purpose is revisited / revised and suitably amended following the integration of the ILU flatlet within the main premises. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 10 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. The home generally creates and maintains care plan & assessment documents that are designed to ensure that the needs of those using the service are realistically met in a focused way. People using the service can be assured that their rights to individuality and self-expression are protected, whilst acknowledging the community aspect of living in a shared environment. Consultation and sharing of information involves, and takes into account, the wishes and aspirations of the individual. People can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. EVIDENCE: We found that the house has the necessary paperwork to ensure that each person using the service is supported with all necessary identified care input, their plan using both in-house and external assessments alongside the St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 11 observational records and other reports completed at the home. Each individual has a day-to-day activity chart, a profile of basic details, their dayto-day notes, a fully completed health action plan (‘My Health Booklet’), local authority review notes, and risk assessments - alongside the initial comprehensive assessments carried out prior to admission. We were told that the concept of ‘person-centred planning’ (‘PCP’) is being introduced to staff, and it is planned that everyone living at the home will have a PCP plan soon. We saw the plans for two people using this new approach. It is good to see this development, and it is hoped that the training support offered by LB Sutton is being fully utilised. From reading individualised care plans, we found that, based on an assessment of acceptable risk and safety criteria - staff encourage people using the service to take ‘reasonable’ risks whenever possible, and to ‘live life to the full’. We found risk assessments were in place for all people - this covering various aspects of support, including: personal hygiene, community presence, and specific behaviours likely to challenge the service. Each assessment identifies the risk, the likely consequences, and the action required to minimise the risk’s negative effect. Individualised guidelines (i.e. risk management strategies) for those assessed as likely to be aggressive or to self-harm have also been drawn up, with the involvement of - and following the advice of - specialist professionals. St Helier Avenue (374) DS0000007157.V346534.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): 11 - 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that the home provides opportunities for them to engage in fulfilling activities both within and outside the home, and involving the local community - and they may adopt a lifestyle suited to their individual needs, choices and preferences. Relatives and friends can expect a positive welcome from the home, within the context of respect for the choice and decision-making of those using the service. People using the service can expect to be provided with a good standard of nutritious and wholesome food, with individual preferences acknowledged, thus ensuring that mealtimes are a pleasant and enjoyable, sociable time. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 13 EVIDENCE: Some people use a day care centre in Croydon, another had been booked into regular College sessions, and three had just started courses in this up-andcoming new term at SCOLA - following courses of their preferred interest. All ‘core’ residents (i.e. those not using the ILU flats) enjoy swimming, and the majority go bowling - and cycling at the Croydon Arena; this is so well enjoyed that they now go twice a week. The person using the ILU flat engages in some of the home’s activities now, as well. Cinema trips are also a popular daytime and evening activity. Aromatherapy is also provided within the home. A Youth Centre is accessed by the home and local CMG services each week on a Wednesday, and a number attend the Tuesday Club at Sutton Civic Centre, and enjoy going to the pub and out for meals. The Westcroft Leisure Centre is used for ‘Gym’ / Trampoline and the Mencap Club in Wallington is also used. Visits to the seaside and countryside are regular features and when people are taken home for the weekend, others ‘go for the ride’ - which is well enjoyed and they stop for a meal en route. Holidays undertaken over the past year included four service users going away to Disney World Florida, and others holidaying in Clacton-on-Sea [photographic memories are once again well displayed in the hallway]. A number of individuals also have one-to-one breaks with parents / carers / or staff. Service users part-fund these activities. Relatives and friends of people living at 374 receive a positive welcome; all but one person has close contacts with relatives or friends, up to five going home for bank holidays / weekends at varying frequencies. Cultural needs have been specifically identified for the one person with minority ethnic needs; this covers personal care input by the keyworker, cokeyworker and others, and also ensures that their cultural ‘connections’ / celebrations are maintained - such as recognising significant calendar dates. We found that mealtimes are still generally a positive community time at the home, where both service users and staff eat together - the latter modelling appropriate behaviour, and ensuring that the experience is good for each and every person at the table. The inspector shared food with the community at lunchtime, and clearly this relaxed routine was the everyday experience of the home. Food was plentiful and well balanced - whilst all were afforded choice and preferences; dislikes are actively acknowledged. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 14 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 - 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their personal, health care and emotional needs will be recognised and met by the home’s service input, through timely medical practitioner interventions, and through the home’s longer-term assessment and personal and health care planning programme. The systems regarding medication adopted by the home ensures the general safety and consistent treatment and support for each service user. EVIDENCE: We saw that care and support provided to those using the service by the home’s staff members were appropriate, friendly, and sensitive to the needs of individuals. Routines were needfully flexible, and guidance, observation and support was generally ‘second nature’ to staff, working alongside people, whilst integrating support and assistance. Service users clearly chose their own clothes and initiate their own activities of choice; they are supported in activities and day-to-day routines by staff and by keyworkers. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 15 We found that Health Action Plans are being gradually introduced for each individual service user - enabling a more focused and involving process. These ensure that service users are empowered and engaged with the wider issues affecting them in relation to healthcare, and informed about reactive / proactive inputs - to the point of making personal choices about accepting appointments or not. Staff members encourage engagement if there is fear or anxiety about taking up an appointment. The Plans also ensure - as is the case - that each person using the service has their annual health check and other entitlements provided by the medical professionals. Medication records and storage were examined, and found well kept. Active administration processes were observed - and followed best practice. Previous concerns regarding the parameters of ‘prn’ (‘when required’) medication were not an issue at this visit. Boots the Chemist have provided training for staff in ‘The Management of Medication’. We found that the home was also working closely with the psychiatrist / psychologist to ensure where behaviours were a cause for concern, through careful monitoring and recording, a better picture of the issues could be understood by all providing a care input - to the eventual benefit of that individual. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 16 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. People using the service and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescales. The home provides adequate support and guidance to people using the service, their advocates and to staff to ensure that they are protected from harm, neglect and any form of abuse. EVIDENCE: The Complaints Procedure is openly displayed and available in symbols and large print. Relatives / friends have previously commented that complaints made by either themselves or their relative (2 made in the last year) were dealt with promptly. Relatives were aware of the Complaints Procedure. Adult Protection issues are handled well by the home and CMG in general. Where adult protection issues have been raised in the past twelve months, the Commission has been involved in monitoring the home’s conduct, and is satisfied that they have been handled with competence and a sound knowledge of supporting the individual(s) concerned. Service users generally receive help with managing their financial affairs, some having a greater capacity in this regard than others. Records in this regard were well kept; the home having audits undertaken by staff from CMG Head Office - thus providing an external overview and independent check. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 17 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 - 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once concerns about the exterior driveway’s drainage and boundary protection is addressed, the home will be a safe environment in which to live, without unnecessary risk to service users or staff. EVIDENCE: We found the service to be again significantly brighter in décor, and homely; the lounge and dining areas are comfortable and in an excellent state; new dining room and lounge furniture has been provided. The remaining ILU flat’s décor has also been improved. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 18 Service users have control - to some degree - around their own private space a number having been involved in, and are proud of, recent decoration of their rooms. The main home kitchen has recently been refurbished - with the walls and doorways now ‘finished off’. The previous request for the lighting in the dining area to be improved is now planned for inclusion in the renovation work when the redundant ILU flat is incorporated in the house. Adequate illumination over the tables will better facilitate both mealtimes and other activities in this area. Documentation showed us that many maintenance requests remained outstanding for some time before being addressed and completed; there appears to be a problem with having adequate input from an overstretched peripatetic team of maintenance workers. The home was generally found to be clean and odour-free at the time of the visit - and warm and comfortable for service users. We found the rear garden has been greatly improved and was reportedly well used during the summer; the pond being filled in and grassed, and the general garden area now being more inviting to spend time in. The frontage of the house - the walled driveway area - still awaits attention to ensure that suitable drainage is provided to avoid the problems of flooding, and that the fencing / gating is provided in a more consistent way to provide at least immediate ‘front line’ protection to those using the service, should anybody chose to step out from the house / car unescorted straight onto the busy dual carriageway that is St Helier Avenue. It is understood that the house is a leased property, and therefore the works may have to be agreed with the leaseholder, however the need for this additional health & safety / protection provision is still considered essential. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 19 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 - 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that they will be supported at all times by staff who are experienced, duly competent, and well-trained, and being provided in sufficient numbers to meet service users’ identified needs. The home’s recruitment processes and staff support mechanisms are organised so as to ensure the safety, protection and wellbeing of those using the service. EVIDENCE: Staffing levels at the house are provided with four support workers to the six who are resident within the main home and then the daytime 1:1 with the ILU service. The Acting Manager’s input is generally supernumerary. Two staff are available on site at night: one awake - and one, on call, asleep. Three support worker posts were vacant at the time of the visit. The Head Office HR department was recruiting to these vacancies; two were due to start work once their checks (references / passport and CRB checks) had been completed. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 20 The home has access to a bank of ‘known’ casual workers - and these are regularly used to ensure the essential continuity / familiarity in care. The staff register evidences a high percentage of core staff retention, with only one staff member leaving in the past 12 months. Staff training continues to develop well, with the home accessing local authority training as well as that provided by the registered provider. It is good to see the ongoing positive attitude in the staff team generally - staff training in NVQ at Level 2 or above is now becoming more focused, with three staff starting their Level 2 qualification, two already undertaking the qualification with an external provider and five already having the qualification to level; 2 or above. This brings the proportion of staff members who are qualified to over 50 of the staff team - and therefore meeting the current National Minimum Standard. Staff training in Emergency First Aid was being provided in early October - this ensuring that First Aid cover continues to be provided ‘24/7’, through nine out of the eleven staff being qualified. Staff supervision was found now to be ‘up to speed’; the chart of two-monthly 1-to-1’s showing that of most were clearly going to achieve the six sessions over the span of the coming year. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 21 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, 38, 39, 41 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates management systems that ensure that people using the service benefit from a well-run, competently managed environment. Quality is assessed through both the quality assurance and complaints mechanisms - and embodied in the Company’s policies and procedures, contributing to both the wellbeing and safety of those residing at the home. People using the service can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policy & procedure, and the day-to-day conduct of the home. People using the service can be assured that their welfare, health and safety are, in general, safeguarded through the home’s knowledge base, monitoring and adherence to appropriate related guidance. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home’s Acting Manager - Tessa Riley - has the respect of the staff team and those using the service, and has clearly stabilised the service well. Sadly, she is not submitting her application for registration to the Commission as she has decided to find ‘pastures new’ - and at the time of writing this report is present at the home only until New Year 2008. We understand recruitment is already underway to find a new manager - and that there will be a formal handover period before Ms Riley leaves and the newcomer takes over fully. A comprehensive ‘Quality Assurance’ file is in place, and the contents are quite close to completion; the purpose of this binder and its contents is to bring together all salient aspects of assessment of the service (from CSCI inspection reports to records of complaints and service user / relative responses). Examples of user involvement included CMG staging a Conference in Ewell in October 2007, and there are weekly meetings in-house. A more user-friendly annual ‘Service user questionnaire’ is also circulated by CMG each year (also to relatives / friends / other professionals) and there is active involvement in a Policies and Procedures Group. A regular ‘CMG Times’ publication - is published to ‘link’ the many services within the company, and to keep people abreast of developments. Surprise visits by representatives of the registered provider are being carried out on a regular basis, and the subsequent reports are being forwarded to the Commission. The report format is currently being changed to reflect the Commission’s newer Key Lines of Regulatory Assessment (KLORA) - to encourage self-auditing. Such visits involve checking documentation and the premises - and also cover interviewing both service users and staff. CMG has a comprehensive set of policies and procedures which cover the broad spectrum of needs identified for care home’s operation; they have been very recently revised, and the inspector is generally impressed by the clear focus and guidance provided by these documents. They would be that more accessible if these over-fat volumes were split down into easier-to-handle folders under different section headings. Health & safety aspects of the home were generally well managed - the home’s maintenance and servicing contracts, details of which were included in the AQAA, were found up-to-date, and covered all necessary health and safety aspects. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 23 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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X 3 3 X St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1) & 6 Requirement A fully revised Statement of Purpose must be provided for the home - to reflect the change to the home and the independent living units. Timescale for action 30/12/07 2. YA24 13(4) & 23(2) 30/12/07 The front driveway area must be overviewed, with suitable drainage provided to avoid the problems of flooding, and the fencing provided in a more consistent way to provide ‘front line’ protection to service users, should anybody choose to move away from the house / car. Previous timescale of 30/05/07 exceeded. St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Helier Avenue (374) DS0000007157.V346534.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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