Inspection on 20/06/06 for St Matthews Avenue, 1

This inspection was carried out on 20th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Matthews Avenue, 1 05/10/07

St Matthews Avenue, 1 10/11/05

St Matthews Avenue, 1 19/07/05

St Matthews Avenue, 1 05/10/04

St Matthews Avenue, 1 11/05/04

St Matthews Avenue, 1 29/12/03

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 Matthews Avenue, 1 Surbiton Surrey KT6 6JJ Lead Inspector Michael Stapley Key Unannounced Inspection 20th June 2006 09:30 St Matthews Avenue, 1 DS0000013389.V299836.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 Matthews Avenue, 1 DS0000013389.V299836.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 Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Matthews Avenue, 1 Address Surbiton Surrey KT6 6JJ 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) 020 8390 3734 020 8390 3734 www.hft.org.uk Home Farm Trust Mr Stuart Mark Noble Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 7 is undersized at 9.19 sqm - due to inclusion of insulation to the outer wall. To be reviewed annually. 10th November 2005 Date of last inspection Brief Description of the Service: 1, St Matthews Avenue is a registered care home for eight adults with learning disabilities. Seven service users are currently residing at the home. The home is owned and managed by Home Farm Trust Limited, an organization with another care home in the local area. The home is situated in a residential rod in Surbiton, close to local shops and amenities with good transport links. The home is not identifiable as a care home and is in keeping with neighbouring houses. The home is staffed twenty-four hours a day. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 20th June 2006. The home was represented by the Registered Manager, Mr. Stewart Noble and support staff who all contributed to the inspection process. The manager is supported by Tracy Lazell who is the Area Manager of Home Farm Trust. She too is very experienced and well qualified to support the manager in his day to day management of the home. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the registered manager who will be sending an action plan to the commission as agreed at the time of the inspection. What the service does well: Life story – service users are now supported to compile life stories if they wish to. This is achieved by using ICT equipment, staff support and the different types of software that is available, this being video or voice clips, photographs, pictures, so that it is in a format that the service user chooses and has ownership of. Tate – HFT are one partner in a European initiative which is focused on through technology into employment. The focus is to enable development of independence through simplistic tools to enable individual’s greater opportunities in a self directive lifestyle. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 6 PCP – this is to enable service users voices to be heard, their choices, needs, wants to be recognised and identified and again be in a format that the service user and the people supporting them can understand on how they want to live their life. ICT service users – supporting service users in gaining and developing an interest in computers by using software that has been designed to be easily useable and understandable. Also HFT has a strategic plan that each service has increased access to IT equipment both hard and soft ware. Staff training – HFT as an organisation invest in staff training to ensure quality service delivery and personal development of the individual staff. Training is designed around statutory training as well as innovative approaches to service specific needs. Research – throughout the organisation HFT get involved in a diverse variety of research initiatives to help inform both their own practice and the overall provision of services to adults with learning disabilities. Professional passport – This is again linked into staff development. As an organisation HFT have developed a professional passport initiative both to encourage staff to develop as well as encourage them to stay with the organisation with a clear view of possible personal career development. This in turn contributes to the overall quality of service delivery for all of the homes stakeholders. Choice and diversity – Through PCP and professional passport initiatives HFT are encouraging individuals to take more control over their independence and development. Holidays – Service users have had a number of successful holidays to a wide variety of destinations. All holidays have resulted from service user directives linked to aspirations identified within their own PCP. What has improved since the last inspection? New manager – Has been in place since Aug 05. Full staff – The home have had a full staff team since March 06. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 7 Service user guides / guides / statement of purpose – these have been reviewed and improved in a more accessible format. They have been sent to all Stakeholders and all service users have been informed and accepted them. Redecoration – Service users have had full involvement in the redecoration of the communal areas of the house. HFT have invested a great deal of time and money in making the environment a much more pleasant and welcoming place to be. PCP targets and goals – The home have achieved a number of goals and aspirations identified by service users within their own PCP meetings the home continuously review and reset personal goals and targets. Medication – The home has changed their pharmacy provider and now has a much better and effective system in place. NVQ trained staff – Since the last inspection a number of staff has completed their NVQ and a further number have commenced their NVQ training. Shift cover – The home now has a full team and therefore rely less on agency staff to cover shifts at the service. This means greater continuity of care and service delivery for the service users. Communication – Given the home now have a full team there is better communication and consistency of approach and a greater commitment to communication. What they could do better: Organisation – Since the formation of the new team a lot of work has been done within the service to improve service delivery. However the home need to work on being more organised in their presentation of this work. Communication – The home need to continue to focus on this area and improve the areas where it lets the home down. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 8 Networking and share knowledge – Now that the new manager is in place and the home has a full team they need to expand their networks and share their knowledge with other local providers as well as gain from their experience. FSA – The home are planning to set up a Family and Staff association as a means to have a communication sharing forum. The first meeting is planned for the 8th of July. 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. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 9 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 Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, and 5. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users contain all the information required under standard five thus ensuring the rights of the residents of St Matthew’s Avenue. Staff at the home has access to a range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has reviewed its Statement of Purpose and it contains all elements of Schedule One of the Care Home Regulations 2001. The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. Senior staff at the home can visit the prospective service user in their current placement or own home, if appropriate. The importance of any service user coming to the home and St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 11 relating to those already living at the home was clearly emphasised. A number of introductory visits are planned; this may include an activity and a meal at the home. In addition overnights stays can be arranged to ensure the service user is at ease when they come to their new home. It is clear that although this admission process takes some time it does give every chance for the new service user to settle in to their new surroundings and thus give a solid grounding to any placement. All of the service users at St Matthews Avenue have lived at the home for some time and in discussion with the staff it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home monitors service users care plans on a monthly basis when information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The manager advised that all service users have access to an advocate has and when necessary, although the majority of service users were supported by their families and relatives. HFT as an organisation invest in staff training to ensure quality service delivery and personal development of the individual staff. Training is designed around statutory training as well as innovative approaches to service specific needs. Contracts inspected now contained all the information as required under standard 5.2. thus ensuring service user’s rights. A requirement was made at the last inspection that “The Registered Provider must ensure that the home produces a Service Users Guide, gives a copy to all service users and stakeholders as appropriate” The home have now produced a service users guide in an appropriate format and given a copy to all service users and stakeholders. This requirement has now been met. A further requirement was made that “The Registered Provider must ensure that the admissions policy is reviewed to include a minimum three month settling in period of residence is offered for long-term placements, followed by a review with the service user of the trial placement, during which existing users are consulted about the compatibility of the prospective new service user” All of the above information is now contained in the service users guide and contract - a copy of which has been sent to the commission. This requirement has therefore now been met. A third requirement was made under this section that “The Registered Provider must ensure that the contract/statement of terms and conditions includes the rooms to be occupied, rules in place at the home (in agreement with the St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 12 purchasing authority), arrangements for the review of the Service Users Plan, and makes clear the ninety day trial period” All of this information is now contained in the service users guide and contract. This requirement has therefore now been met. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service user care plans contain all the information required as per standard six. Staff at the home has all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans, which are in the process of being updated, contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker who writes a monthly report on his/her service user. It is suggested that service user’s could have their own personal St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 14 file written in a format they understand which they keep could and refer to. Support staff has recently attended ‘Life story workshops’ These workshops will enable staff to support service users to make video clips about their life. They could also include their PCP and could be used at reviews and other meetings as an aide to communication. The home is beginning to be far more service user focused. Service users are encouraged to become far more involved in the home. House meetings that take place every week are used as a communication tool to empower service users. Service users files sampled at random during this inspection all had individual risk assessments and risk management strategies. Risk assessments inspected during the course of this inspection were for the most part found to be up to date. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. During the inspection there were two service users at the home. The staff was observed to interact with the service users in a positive manner. There was awareness from the staff that the service user’s privacy and individual choice must be maintained. The service users were observed moving freely throughout the communal areas and on occasion one of them choice to spend time in his bedroom. The home supports service users to access appropriate activities such as swimming, sports and leisure activities and making use of the library. In addition service users have access to local parks, cafes, theatres and shops. Service users are involved in planning their holidays with the support of the staff at the home. The manager stated that holidays provided new experiences for service users. This year service users were planning holidays in a variety of destinations including Cornwall, France, Spain and the Isle of Wight. Service users spoken to during the course of this inspection stated that they enjoyed the activities on offer at the home and were looking forward to the summer holidays. The home encourages family, friends and parents to visit wherever possible and suggestions/comments about the running/management of the home are always welcome. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. Service user’s spoken to during the cause of this inspection stated they enjoyed what they had to eat at the home. Service user’s weight is monitored and appropriately recorded. Any significant loss or weight gain to discussed with the homes GP. In addition the home seeks the advice and guidance of a dietician to ensure a healthy and well balanced diet. Staff encourage service user’s to help with the shopping, preparation of meals and other chores wherever possible. The manager has drawn up a pro forma which clearly indicates that the service user is involved in planning such activities and that all chores are completed with the agreement of the service user. Service users have access to computers and the internet. The home is very focused on IT – see ‘What the service does well’ The projects that the home and the managing company is involved in can only be of benefit to service users and will know doubt enhance their social and educational skills. The home only uses software that is suitable and accessible to those with a disability. Service users at the home do not have a key to the front door of the home and service users are not able to lock their own bedrooms as outlined in standard 16.2. The manager explained that the home complete a risk assessment for all St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 17 service users which identify that the risk is too great for service users to be given keys. Some of the service users also have epilepsy and in the event of a seizure at night staff would need to gain immediate access to service user’s bedrooms – something they would clearly not be able to do in the event of an emergency. The home has its own mini-bus and the use of other vehicles. There was one requirement made under this section at the last inspection that “The registered person must ensure that storage boxes are supplied in sufficient quantity to allow secure storage of all foodstuffs thus minimising the risk of contamanation/infiltration and the registered person must ensure all ‘out of date’ foodstuffs are disposed of” The inspector noted that appropriate storage boxes had been purchased and that at the time of the inspection there were no ‘out of date’ foodstuffs in the home. This requirement has therefore now been met. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. The home has now established and recorded the service user’s wishes at death in consultation with families and relatives. Thus ensuring suitable funeral arrangements in the event of any service user ‘passing away’ EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 19 All of the staff team have now completed accredited medication training. The inspector suggests that the home introduce a more rigorous audit system than is in place at present. A weekly audit system could be introduced to cover all aspects of medication. It is suggested the manager discuss such a system with the homes pharmacist at the next pharmacy inspection. All other medication records, including MAR sheets were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. It is suggested that the manager ensures that all service users have a ‘medication profile’. The funeral arrangements for all service users are duly recorded on a template known as ‘My Wishes’. This form is signed and dated by the service user, home manager and next of kin. A requirement was made at the last inspection that “The registered person must make appropriate arrangements for the pharmicist to undertake an inspection of all medication issues” The inspector was advised by the area manager that when following this matter up the home were advised by the local PCT that they have discontinued funding for inspections and the only way the home can have a pharmacy visit is if it is paid for by the home. The home have requested a breakdown in cost in order for them to be able to authorise the first visit. The home is also seeking funding for future visits through the PCT. The home hope to have had an pharmacy inspection by the end of September 2006. Given that the home are in the process of making arrangements for a pharmacy inspection this requirement will not be repeated although it will be monitored to ensure such an inspection as taken place at the next CSCI inspection. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The registered manager advised the inspector that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. Most of the staff has received appropriate training in Vulnerable Adult Abuse although there is a need to update this training on a regular basis. The staff team are aware of the action they must take if they need to report an incident. A requirement was made at the last inspection that “The registered person must ensure all staff undertake Adult Protection Training” Evidence was available to show that all staff had completed this training on 30th March 2006. This requirement has therefore now been met. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 21 St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a two story building in a quiet residential road. It is situated in Surbiton and is close to local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The furniture is domestic, flame retardant, and of good quality. There have been major improvements in the décor of the home since the last inspection. Service users have been fully involved in the redecoration of the communal areas of the house. The managing company have invested a great deal of time and money in making the environment a much more pleasant and welcoming place St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 23 to be. In addition new furnishing, fixtures and fittings have been purchased as required. In addition the area manager explained there was an ongoing programme of refurbishment including: 1. Replacing the carpet outside the downstairs shower room, once the alterations to the shower room are complete. 2. Redecorating the exterior of the building. 3. An en-suite facility to be fitted into one of the service user bedrooms. 4. The garden to be maintained by a regular gardener. 5. The wall to the front of the building to be repaired. All of the above works are due to be completed by March 2007. Ongoing maintenance is reported on a weekly basis and addressed by our weekly visit from ‘inspace’ the homes in-house contractors. Bedrooms viewed provided sufficient and suitable furniture. All areas of the premises viewed were clean and free from offensive odours. There are appropriate laundry facilities. Systems are in place for controlling the spread of infection. This includes staff training in this area. The home has one ‘high low’ bath situated on the first floor. The home has thermostatic valves fitted to each of the baths to avoid any scalding accidents. The temperature of the water is taken and recorded on a chart in the office. A requirement was made at the last inspection that “The registered person must send to the CSCI, local office an ongoing maintenance and development programme regarding the renewal of the fabric and decoration of the home both internally and externally” The area manager informed the commission in writing of the above maintanance plan prior to the inspection. This requirement has therefore now been met. A further requirement was made that “The Registered Provider must ensure that the carpet is protected from water damage from the shower room” This work is included in the current works taking place at the home and will have been met when all the work has been finished. The requirement has therefore deemed to have been met. A further requirement was made that “The registered person must ensure an assessment of the home for aids and adaptations is undertaken by an Occupational Therapist or other suitably qualified specialist” The area manager explained that the registered manager and herself undertake an interim review of the service and this will be followed up by the DDA assessment from an expert employed by the organisation during the course of 2007. The area manager agreed to send the commission a copy of the interim assessment by the end of September 2006. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 24 On the evidence provided by the home at the time of the inspection it is evident arrangements to undertake this assessment have been made by the home and therefore this requirement has not been repeated. However it will need to be monitored during the course of the next inspection. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. The staff team have access to a wide range of training programmes which enhance their personal and professional development. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist training courses such as that offered by BILD for staff who work with service users who have a disability. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 26 Criminal Records Checks are completed before a new member of staff can begin work in a home. The home now has a full complement of permanent staff consisting of manager, senior support workers and support workers. The manager is qualified and the home will shortly meet the requirement that they have at least fifty per cent of staff qualified to a minimum of NVQ level 2. The manager and senior staff offer professional support and guidance to the support workers in addition to bank staff. They are currently responsible for the supervision of junior staff which is now in line with the standard. The manager advised that staff meetings usually take place on a monthly basis between 10.00am and 3.00pm. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are three staff members on duty on each shift, plus one member of staff sleeping-in. There are suitable on call arrangements in place in case of an emergency. A requirement was made at the last inspection that “The Registered Provider must review staffing levels at the home to ensure the needs of the service user’s are being met and ensure that the home employ sufficient permanent staff as opposed to continual use of agency/bank staff. Rotas must be submitted to the Commission for Social Care Inspection (CSCI) to ensure compliance with this regulation” The area manager advised the inspector that the home now have a full complement of core staff covering the core staffing hours. However the home have not recruited to the service user individual enhanced hours as these are transient hours based on changing service user needs. These hours are covered through a combination of established staff taking on additional hours, the homes bank staff (relief staff) and very occasionally the use of agency staff. The home have established a large relief bank to facilitate the covering of enhanced hours as well as filling in for training, annual leave and unplanned staff absence. All relief staff is trained to the same level as established staff. Over the past 2 months the home have only used a total of 30 hrs Agency and this has been two named individuals known to the service. Agency staff is always on shift with established staff members. In the light of the evidence submitted in writing to the commission this requirement is deemed to have been met. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 27 A further requirement was made that “Records to be kept in a care home to include a record of all persons employed, name, address, date of birth, qualifications and experience; copies of the birth certificate and passport, each reference; dates on which they commenced and ceased to be employed; position and hours worked; correspondence, reports, records of disciplinary action, CRB Checks and any other records in relation to their employment” All staff records evidenced during the course of this inspection included all the above information. This requirement has therefore now been met. A further requirement was made that “The registered person must ensure that all staff undertake disability equality training, race equality and anti-racism training” The area manager that this training is still outstanding and therefore this requirement has been repeated. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 28 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and senior support workers offer support and supervision to the support workers at the home. There were good support mechanisms in place and the area manager meets with the directors of the trust to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The annual development plan and business plan for 2006-07 were not unfortunately available for inspection during the course of this inspection. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 29 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are now up to date and a fire risk assessment was available for inspection. The home has access to an excellent Health and Safety data base known as Assessnet. This is a corporate system used by all of HFT homes and provides an online resource for risk assessments, COSH, manual handling to name but a few. In addition the manager and Home Farm Trust must ensure all records required for Health and Safety is available for inspection at all times. These include The Landlords Gas Safety Certificate, Legionella Certificate and the results of PAT testing. Generic risk assessments are in the process of being reviewed and the manager advised that these should be completed by the end of August 2006. The residents are beginning to see the benefits of a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties is reasonable although the quality assurance system should include service user, relatives, staff and outside professional questionnaires. In addition there was no evidence of an annual audit. A requirement was made at the last inspection that “A quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and the home must implement a professionally recognised quality assurance or join up their own quality assurance tools into a cyclic quality assurance system” The area manager advised this requirement was still outstanding. The quality assurance review will be carried out by the Assistant regional director as a part of the quality audit on a bi annual basis or as the needs of the service users change. As an interim measure the area manager advised that she would be seeking the views of service users and other interested parties by means of questionnaires. The responses would be analysed and action taken to address any concerns or shortfalls. While the inspector acknowledges that plans are in place to meet this requirement it has been repeated given it was outstanding at the last inspection. St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 30 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 X St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA35 Regulation 12 Requirement Timescale for action 31/10/06 2 YA39 24 The registered person must ensure all staff undertakes disability equality training, race equality and anti-racism training. A quality audit system, including 31/12/06 an annual development plan must be in place to assess whether the aims and objectives of the home have been met and the home must implement a professionally recognised quality assurance or join up their own quality assurance tools into a cyclic quality assurance system. (Partially met as of 30/09/05) The registered provider must ensure all certificates appertaining to Health and Safety are available for inspection at all times. These certificates include Landlord’s Gas Certificate, PAT Testing and Certificate in respect of tests for Legionella. 31/08/06 3 YA42 12 St Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 32 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 Matthews Avenue, 1 DS0000013389.V299836.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 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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