Inspection on 09/02/07 for St Helier Avenue (374)

This inspection was carried out on 9th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Helier Avenue (374) 24/09/07

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 9th February 2007 1:00pm St Helier Avenue (374) DS0000007157.V323177.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.V323177.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.V323177.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.V323177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 3rd May 2006 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. Two of these users currently occupy small independent living flats attached to the main house (one of which is expected to be integrated / ‘mainstreamed’ within the main project building). 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, and a large garden with a patio at the rear. The communal facilities include a large dining / activities room, a separate comfortable lounge area, a smaller 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 most service users needs. In addition, there is a staff sleeping-in room and an office on the first floor. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visit was conducted on an ordinary weekday to the home, the inspector remaining in the home from 1.00pm to close to 8.00pm that evening - enabling him to share supper with service users / staff. In the absence of the new manager, Tessa Riley (who was on leave), the deputy manager, Ken Dhluni was present on site - and able to competently assist the inspector in assessing the progress at the home. Mr Dhluni kindly stayed on ‘after hours’ until the inspector completed his audit - for which the inspector is grateful. He is also grateful to the service users and staff for their welcome, hospitality and their cooperation throughout the visit. The Deputy Regional Manager, Kofi Daaku - arrived at the home at about 4.00pm and stayed at the house for a couple of hours - providing higher management input / comment to the inspection assessment and also supporting the deputy manager and staff at the home. All eight registered places were occupied at the time of the inspection visit this being six within the ‘home’ itself, and the two Independent Living Flats both being occupied. What the service does well: The home provides a generally good service to the service user group, there being noticed an excellent rapport with service users - and a focused interaction with each service user according to their expressed needs. At least four of the eight service users at the service were directly interviewed about ‘how it was’ at the home - and all stated they liked their home and were generally content with the service. Service users - in their questionnaire responses - completed for the CSCI - stated that the only problem encountered was that sometimes they were not able to do what they specifically wanted to do in the evenings and / or at weekends. Clearly this is a challenge when staffing is not provided on a 1:1 basis. The home responds well to equality issues - such as, for example, service users expressing their ethnic origins (through culturally appropriate celebrations and individual needs being identified) and also for some being at peace with their expression of sexuality. Responses by relatives (5) and a care manager to the Commission’s questionnaire sent out evidenced a generally positive attitude to the house. Indicating that all felt they were welcomed at the home and involved in decision-making, with most indicating the home provided a good level of overall care. All agreed that they may visit their friend / relative in private, are St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 6 informed of issues of importance relating to their loved one, and generally felt that the level of staffing was adequate. One respondent felt that more staff should be able to drive - to enable them to take service users to visit their family for the day. What has improved since the last inspection? What they could do better: The home’s Statement of Purpose and Service User Guide are still in a ‘state of flux’ - after the stated intention to integrate at least one of the ILU flatlets into the main building last year was put ‘on hold’, following the arrival of another occupant in this specific service area. It is understood that this service user is seeking to leave 374, and at this point the documents must be re-written to reflect the change in purpose of the house. The home’s viability is also to be confirmed at that point by the submission to the Commission of a current business and financial plan. Issues raised at the time of the inspection included: ensuring the ongoing presence of care plans for each individual; the tightening of ‘prn’ (when required) medication instructions; the strict keeping of finance records relating to bank book transactions; and the regularisation of testing fire alarms points (including those in the ILU flats) by regular rotation. Staff supervision was also found to be ‘wanting’ - the regular routine yet to be fully established. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 7 Premises issues raised covered the need for additional lighting in the dining room, the need to urgently repair the extractor fan ducting from the laundry and to address the safety / hazard problems apparent with the ‘open’ aspect of the front garden leading straight on to the dual carriageway outside the house. 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.V323177.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides service users & other interested parties with full details to enable them to make an informed choice about choosing to live at the home though the planned change of purpose of one ILU must be forward-planned and included in future documentation. Service user’s needs and aspirations are identified, assessed, and translated into a plan of care which is understood and implemented at the home – through the thorough and considered exploration of behaviours, wishes and expressed needs, fully including the service user’s views. EVIDENCE: At previous inspection visits, it was the declared intention of the establishment to convert one of the Independent Living Flats into a long-term care bedroom, thus reducing the tension between the two distinct ‘functions’ of the home. At this present visit the second ILU had been occupied again, though the length of the placement was in question. The occupant – with whom the inspector spent some time talking, was reasonably content with the present situation, but clearly wished to move to more adequate and suitable accommodation. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 10 The home had been required to rewrite its Statement of Purpose and Selection Criteria – being more explicit about the purpose of the home - and the ILUs in particular. It is remains clear that home must establish clarity on these points, and the deadline for the revised Statement of Purpose is set tightly to focus minds on the planning for the future. A business and financial plan is also required to be shared with the Commission - to evidence that any such change would still underpin and support the home’s viability. Most placements were made by differing Surrey County local authority officers, with one placement being funded by Lambeth and one by Merton boroughs. In accordance with the home’s admissions procedure, referrals are only usually be admitted on the basis of a full needs assessments undertaken by representative(s) of CMG, accompanied by the manager, and / or the service user’s Care Manager, representing the relevant Placing Authority. All service users are generally admitted with substantial programmes of care already planned and documented. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally creates and maintains care plan & assessment documents that are designed to ensure that the needs of service users are realistically met in a focused way, though plans must be continually in place to ensure the continuity of service provision. Service users can be assured that their rights to individuality and selfexpression 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 service user. Service users can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. EVIDENCE: St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 12 The house is generally equipped with the necessary paperwork to ensure that each service users is supported with all necessary care input utilising both internal and external assessments alongside the observational records and reports completed at the home. Each service user has day-to-day activity chart, a profile of basic details, their day-to-day notes, a mostly-completed health action plan, local authority review notes, risk assessments alongside the initial assessments carried out prior to admission. It was unfortunate that the one service user who was closely ‘case-tracked’ during the inspection visit was found to be ‘without’ their active care plan - as it had been re-written and was pending typing up by ‘head office’. The inspector reflected to the deputy manager that he would rather know that a hand-written plan was in place - rather than this not being available, but eventually found - being kept in a brown envelope - awaiting the ROM’s collection to deliver it to HQ’s typing ‘pool’. The deputy manager explained that the concept of ‘person-centred planning’ (‘PCP’) is being introduced to staff and it is envisaged that all service users will have a PCP plan within the next year. It is good to see this development and it is hoped that the support offered by the host borough (LB Sutton) is being fully utilised to develop this process. It was evident from individualised care plans that were seen - that based on an assessment of acceptable risk and safety criteria - staff do encourage service users to take ‘reasonable’ risks, whenever possible - and to live life to the full. Risk assessments were in place for service users covering various aspects of care 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 service users 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.V323177.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 - 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home, and involving the local community - and to adopt a lifestyle suited to their individual needs, choices and preferences. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choice and decision-making concerning association. Service users can expect to be provided with a good standard of nutritious and wholesome food, with individual preferences acknowledged and through ensuring that mealtimes are a pleasant and enjoyable time. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 14 EVIDENCE: Holidays undertaken over the past year included four service users going away to Centreparcs at Longleat in 2006 [photos are proudly displayed in the hallway] - and a number of the service users have one-to-one breaks with parents / carers and / or staff. Service users part-fund these activities. Visits to the seaside and countryside are also regular features and when service users are taken home for the weekend, others ‘go for the ride’ - which is enjoyed - and stop for a meal en route. Three service users use a Day Care Centre opportunity in Croydon - one attending once a week, and two attending twice. One service user regularly attends College and three have applied for courses in this up-and-coming new term. All ‘core’ service users (i.e. those not using the ILU flats) enjoy swimming, and most engage with bowling - and cycling at the Croydon Arena. The Cinema is also a popular daytime and evening pursuit. Horse riding opportunities are also being applied for, currently. A Youth Centre is accessed by the home and other CMG services each week on a Wednesday, and a number attend the Tuesday Club at Sutton Civic Centre. Cultural needs have been specifically identified for the one minority ethnic service user; this area covers personal care input by the keyworker & cokeyworker and others, and also ensuring that cultural ‘connections’ / celebrations are maintained - such as recognising significant calendar dates. Mealtimes are generally a positive community time, where both service users and staff eat together - the latter modelling appropriate behaviour, and ensuring that the experience is good for each service user. The inspector shared supper with the community at 374 at this visit, and clearly this routine was the everyday experience of the home. Food was plentiful and well balanced - whilst all were afforded choice and preferences / dislikes were actively acknowledged. St Helier Avenue (374) DS0000007157.V323177.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 - 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users 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 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: Care and support provided by the home’s staff members was observed to be appropriate and sensitive to the needs of individual service users. Routines were flexible, and guidance and support was generally ‘second nature’ to staff, working alongside service users, 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.V323177.R01.S.doc Version 5.2 Page 16 Health Action Plans are being introduced for each individual service user enabling a more focused and involving process. These seek to ensure that service users are empowered and engaged with the wider issues affecting them in relation to healthcare and informed about reactive / proactive inputs. Medication storage and records were examined, and found generally well kept. Administration processes were observed and followed best practice. Previous concerns regarding the parameters of ‘prn’ (‘when required’) medication were the subject of a focused audit trail undertaken by the inspector - and all but one was well supported by documentation. In this one case, a service user had PRN (‘when required’) medication prescribed but, inexplicably, there was no sign of the ‘PRN guidance’ sheet relating to this medication. This would - the deputy assured the inspector - be put in place immediately. The inspector recommends that service users who receive medication to selfadminister via the home are encouraged to ‘sign for’ their medication - this emphasising the fact of themselves taking responsibility, and providing the home with a clear audit trail of the handing over of the said medication. A question arose as to whether the lockable medication cabinet had to be sited in the office - where it is a substantial presence, but where it is not always easy to access medication at any time. The most important issue is for the cabinet to be secured away from unauthorised access - and beyond this, any reasonable dry and accessible storage area would be sufficient. St Helier Avenue (374) DS0000007157.V323177.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. Service users 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 to service users and to staff to ensure that service users are protected from harm, neglect and any form of abuse. EVIDENCE: One complaint has been handled this last year, and was handled appropriately by the home. The complaint was substantiated - and satisfactorily resolved. Adult Protection issues are now handled well by the home and CMG in general. Service users generally receive help with managing their financial affairs, some having a greater capacity in this regard than others. A concern regarding the records of finances relating to bankbook management was raised, when an audit did not fully agree between the hand-written record and the specific bankbook under scrutiny. Where such manual recording systems are in place, the records of withdrawals must be exactingly kept - to ensure that a full audit trail to each transaction is always present. It must be said that - generally the 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 of the home’s general accounting systems. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 18 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, 25, 26, 28 & 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: The home was noted to be significantly brighter in décor and more homely than of late; the bathrooms were improved, the lounge and dining areas comfortable and the ILU flats were also improved. Service users have control to some degree of their own private space - a number being involved in - and proud of - the recent decoration of their bedrooms. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 19 A new kitchen area has been fitted in one of the ILU flats and the principal kitchen has recently been refurbished - with the walls and doorways waiting to be ‘finished off’. The inspector found, during the evening of the visit, that the lighting in the dining area was not so good - and it is required that a second pendant light be provided hanging over approximately where the second table (closer to the window) is located. Adequate illumination over both tables is essential to properly facilitate both mealtimes and other activities using the tables. It became apparent to the inspector that a second staircase banister - on the ‘external’ wall, passing the landing window - would be beneficial, both to assist anybody with mobility impairment, and also - on a health & safety basis - to provide additional protection to the windows on the way down. The extractor fan in the laundry was found not to be working, and must be repaired to ensure that this difficult enclosed working environment is kept as hygienic and useable as possible. The home was, however, generally found to be clean and odour-free at the time of the visit - and warm and comfortable for service users. The rear garden has been greatly improved, with the pond being filled in and grassed, and the general garden area being more inviting. A new garden shed was also present on the patio, awaiting construction. The frontage of the house - the walled driveway area - must be urgently overviewed, and suitable drainage provided to avoid the problems of flooding, and the fencing / gating provided in a more consistent way to provide at least ‘front line’ protection to service users, should any body chose to step out from the house / car unescorted. 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 safety / protection provision is essential. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 20 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 - 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be supported at all times by staff who are experienced, duly competent in the work, 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 service users, though ongoing staff supervision arrangements should be improved. EVIDENCE: Staffing levels at the house are provided with three support workers to the six who are resident within the main home and then the daytime 1:1 with one of the ILU service users. The manager’s input is supernumerary. The second ILU service user has a high level of independence, so support input not being at such a high level - this being provided more on a support / monitoring basis with all necessary records relating to this service user’s stay being maintained. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 21 Two staff are available on site at night: one awake and one, on call, asleep. Four staff members drive during their duties - and this is an important skill for support workers to have - to be able to support service users in a number of their varying activities. Two Support Worker posts were vacant at the time of the visit - and staff absences due to annual leave were also being covered. The vacancies were being recruited to by Head Office HR department. The home has access to a large bank of ‘known’ workers - and six support staff members are regularly used to ensure that continuity and familiarity in care are maximised. Staff training is developing well; it is good to see a more positive attitude in the staff team generally - this due in part to staff members feeling a greater sense of investment in them - and their skills base is consequently improved. Staff training in NVQ at Level 2 or above is now becoming more focused, with two staff having completed their Level 2 qualification recently and now awaiting their certificates. This brings the proportion of staff members who are qualified to 50 of the staff team - and therefore meeting the National Minimum Standard. Examination of staff training records revealed that nine full time & bank staff members are trained in First Aid - this ensuring that First Aid cover is provided ‘24/7’. Many other ‘statutory’ qualifications are well supported. Staff training booked in the near future included four staff attending ‘Fire Safety’ training, three on ‘Safer Manual Handling’ and two on ‘Understanding Challenging Behaviour’. Staff supervision was found not to be ‘up to speed’ the chart of two-monthly 1to-1’s showing that of 18 staff sessions booked (nine sessions each month), only 5 sessions had actually taken place. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 22 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, 40 & 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 service users 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. Service users 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. Service users can be assured that their welfare, health and safety is, in general, safeguarded through the home’s adherence to appropriate guidance. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has had a new manager appointed, and it was apparent that Tessa Riley has the respect of the staff team - and clearly the service is stabilising which is most encouraging to see. It was mentioned that her ‘listening approach’ is greatly appreciated. The manager is submitting her application for registration to the Commission and she commences her registered manager’s award (RMA) in April 2007. A comprehensive Quality Assurance file is in place, and the contents are ‘coming together’; the purpose of this binder 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). It was good to see the office well organised and generally fit-for-purpose - though just a little cramped. Unannounced 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. Such visits involve checking documentation and the premises - and 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 fat volumes were split down into easier-to-handle folders. Health & safety aspects of the home were generally well under control - there were no concerns regarding hazardous chemicals (under COSHH Regulations) this time round, and the home’s maintenance and servicing contracts, counterchecked from the pre-inspection questionnaire, both corresponded and were found up-to-date. It was noted that the ‘new’ call bell system was not in operation at the time of the visit - this was due for repair - and this was to be undertaken urgently. Although the system may not be so actively used so much by service users, in the challenging behaviour environment that is 374, staff would benefit just as positively from such a facility as the service user group. The only other aspect raised again in this health & safety section - and repeated from the last visit’s requirements - is to ensure that the fire alarm checking is routinised to ensure that each area is checked in stricter rotation than currently continues to be the case. St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 24 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X 3 X 3 2 St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 25 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. Timescale for action No. 1. Standard YA3 Regulation 4(1) & 6 Requirement A revised selection criteria and 15/06/07 Statement of Purpose are required to be developed for the home - to reflect the change to the independent living units. Timescales of 15/01/06 & 07/04/06 not met. If the home is not intending to change its SoP, the Commission must be duly advised. Absence of care plans - whether due to plans being revised and awaiting typing up or not - must always be kept on file and be available to inform staff. ‘PRN’ medication must always have precise and inconvertible instructions attached, to ensure that neither error nor misadministration takes place. Records of service users’ finances - such as the bankbook recording system - must be kept accurately and consistently to ensure that audit trails agree. 09/02/07 2. YA6 15 3. YA20 13(2) 16/02/07 4. YA23 17(2) Sch 4.9 09/02/07 St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 26 5. YA24 13(4) & 23(2) 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 chose to run off away from the house / car. A second pendant light must be provided in the dining room to ensure adequate lighting is provided locally for mealtimes at both tables. 30/05/07 6. YA28 23(2)(p) 15/05/07 7. YA30 23(2)(p) The extractor fan in the laundry 28/02/07 must be repaired to ensure that this difficult environment if kept as hygienic / useable as possible. Part of the previous report’s 28/02/07 requirement - timescale not met: Systematic checks of the fire alarm system must be conducted, and these checks must be fully recorded. A copy of the home’s Business & Financial Plan (as required immediately above) must be made available to the Commission. 15/06/07 8. YA42 23(4) 9. YA43 25(2) St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 27 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 YA20 Good Practice Recommendations That service users who receive medication form the home to self-administer are encouraged to ‘sign for’ their medication - this emphasising the fact of themselves taking responsibility and provides the home with a clear audit trail of the handing over of the said medication. That a second staircase banister - on the ‘external’ wall passing the landing window - would be beneficial, both to assist anybody with mobility impairment, and also to provide additional protection to the windows on the way down the staircase. That the policies and procedures files within the house be split down - to enable ease of access to such documents by staff members. 2. YA24 3. YA40 St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI St Helier Avenue (374) DS0000007157.V323177.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!