Inspection on 15/05/06 for Strathleven Road, 94

This inspection was carried out on 15th May 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strathleven Road, 94 23/08/07

Strathleven Road, 94 22/11/05

Strathleven Road, 94 08/07/05

Strathleven Road, 94 02/03/05

Strathleven Road, 94 19/11/04

Strathleven Road, 94 06/03/04

Strathleven Road, 94 12/02/04

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 Strathleven Road, 94 Brixton London SW2 5JF Lead Inspector Ms Rehema Russell Unannounced Inspection 15 & 23rd May 2006 10:00 th DS0000022759.V292942.R01.S.doc Version 5.1 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 DS0000022759.V292942.R01.S.doc Version 5.1 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. DS0000022759.V292942.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Strathleven Road, 94 Address Brixton London SW2 5JF 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) 0207-738 4004 Southside Partnership Mr Mark Wallis Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000022759.V292942.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 places - one of which is used for respite care Date of last inspection 22nd November 2005 Brief Description of the Service: 94 Strathleven Road is purpose built home that is fully wheelchair accessible and situated in a residential area close to a major shopping centre. It is managed by Southside Partnership, a voluntary organisation. The home is close to local shops and buses, and is a short walk from a large shopping centre with full community and public transport facilities. There is metered onstreet parking around the home. There is a paved area at the front of the house and a good-sized garden at the rear of the property. The accommodation is all on the ground floor with six single bedrooms, each with an en suite toilet and wash hand basin. One of the bedrooms is used by two clients on a shared care basis for different sections of the week. At the time of inspection there were no vacancies at the home. Prospective service users receive an information pack that contains the Statement of Purpose and Service User Guide. A copy of most recent CSCI inspection report is available at request at the home. Current fees are approximately £1,300 per week and vary according to the support needs of the individual service user. DS0000022759.V292942.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried on 15th and 23rd May 2006. A preinspection questionnaire had not been received from the home. The inspection took place over two half-days, the first facilitated by the deputy manager and the second by the manager. During the inspection the inspector toured the premises; spoke with the manager, deputy manager and several support workers, one in depth; observed service users and looked at documentation and records. Service users were not able to communicate verbally with the inspector but their behaviours and body language indicated their moods and preferences. One service user is able to write and wrote down what he liked about the home for the inspector. Subsequent to the inspection feedback was also obtained from parents of two service users. The Manager of the home is Ms. Adama Hassan, who took up post in February 2006. She told the inspector that she had been unable to submit the application for registration form received previously from CSCI and requested a new set of forms to be sent to her in order for her to apply for registration as manager of the home. What the service does well: What has improved since the last inspection? The improvement in documentation noted at the previous inspection had continued, with key worker minutes and handover notes seen being particularly thorough and detailed. There is now a permanent manager in post DS0000022759.V292942.R01.S.doc Version 5.1 Page 6 and an increase in afternoon staffing levels was about to take place at the time of the inspection. The majority of the previous requirements and recommendations had been implemented, with the exception of the registration of the manager and the timely carrying out of the annual gas safety check. There is a repeated requirement in regard to kitchen units but the Registered Provider is dependent upon the Housing Association, which owns the property to carry this out. 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. DS0000022759.V292942.R01.S.doc Version 5.1 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 DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ individual aspirations and needs are assessed prior to placement. EVIDENCE: There have been no new admissions to the home for over three years and so no new admissions have been undertaken by the current staff group. Service users files therefore refer to admissions from the past. At the previous inspection it was found that full and detailed information about prospective service users’ needs had been obtained from all relevant professionals and prior placements, including guidelines and risk assessments. However, two files did not have an assessment carried out by Strathleven Road and the acting deputy had said that she had undertaken assessment training and intended to devise an assessment form that would be used in the future for any new placements. At this inspection it was found that a new suitable and detailed admission form had been devised, and would be used in the future for the assessment of prospective service users. DS0000022759.V292942.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ assessed and changing needs are reflected in their individual plan. Service users make decisions about their lives and influence life at the home, with assistance as needed, within the limits of their cognitive impairments. Service users are supported to take risks as part of an independent lifestyle. Risk assessments are thorough. EVIDENCE: Three care plans were inspected and found to be well ordered and kept. Each care plan component is reviewed monthly and thorough key worker notes were seen. Two of the four care plan components had been achieved for one service user and so staff were in the process of updating the care plan to state new goals. All care plans also have Personal Centred Plans, which were very detailed and gave a clear and easily accessible picture of individual service users’ needs, desires, abilities and interests. These and other documentation seen evidenced that several individual service users’ “achievements/dreams” had already been realised, for example a trip on an aeroplane and a holiday DS0000022759.V292942.R01.S.doc Version 5.1 Page 10 abroad for one service user. A recommendation had been made at the previous inspection for the home to contact the placing authority to request that their statutory annual reviews were carried out. This had been successful, with all but one of the service users’ having had a statutory annual review. All service users at the home have limited cognitive and communication abilities and only one can verbalise more than a few simple words. Staff told the inspector that nevertheless most service users are able to communicate their choices and wishes very well by their body language and behaviours, and this was observed during the inspection. Three service users can indicate what they want/don’t want by their facial expressions, gestures and movements, with one being able to say a simple “No” and another able to write simple words. A fourth service user is very vocal and smiles often so that quietness would alert staff to a problem, and a fifth service user will indicate unhappiness by making a noise and banging the table. Staff are therefore able to assist service users to make choices/decisions by interpreting their behaviours and have also gained information about service users likes and dislikes from their families. In a similar way, service users’ behaviours influence the day-to-day running and other aspects of life at the home. Risk assessments seen were thorough and reviewed annually, with new information added between reviews as necessary. Only one file did not have any risk assessments and on the day of inspection it was thought that the key worker may have taken them off the premises to update/alter them. However, subsequent to the inspection the risk assessments could not be located and a requirement regarding this has therefore been made (see Requirement 1). DS0000022759.V292942.R01.S.doc Version 5.1 Page 11 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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to access age, peer and culturally appropriate activities, to take part in spiritual and leisure activities and to be part of the local community. Appropriate personal relationships are encouraged and service users are offered a healthy and nutritious diet. EVIDENCE: Three service users are supported to attend places of worship. Two of these are churches whose main service is on Sunday and so two service users used to take it in turns to attend the appropriate service. However attendance has been restricted for some time by the lack of availability of staff to drive the service users to church and it is recommended that with the new staffing level expected, management explores ways of ensuring that service users’ spiritual needs are met more regularly (see Recommendation 1). Service users are supported to attend a local educational facility, accompanied by staff, where they take classes in cookery, creative expression and DS0000022759.V292942.R01.S.doc Version 5.1 Page 12 aromatherapy. One service user used to attend a City & Guilds college for 4 days per week where he studied IT, cooking, independent living skills, music, self-advocacy, budgeting and others, but the placing authority has stopped paying for his transport and providing a support assistant. As the local education facility that other service users attend cannot meet his needs, this service user does not now participate in educational activities, although he clearly formerly derived a lot of pleasure and skills learning from the classes. This is the same service user whose statutory annual review has not yet taken place and a recommendation in regard to this and his educational needs has been made (see Recommendation 2). Service users are encouraged and supported to be part of the local community by visits to the cinema, pubs, restaurants, recreation centres, shops and local events. They are supported to take part in appropriate leisure activities such as football (two service users have season tickets for their local football club), videos, television, drawing, swimming and meals out. All service users require 1:1 support when out of the home and this necessarily restricts the number of times they can be taken out. Several service users would like to go out of the home every day, and one relative told the inspector that she wished her son could be taken out of the home more often than at present. However, the Registered Provider has successfully negotiated with the local authority for funding to obtain an extra member of staff on afternoon shifts, and so it is expected that service users will be taken out more often as soon as this post becomes operational. All but one of the service users have family members who visit regularly. The inspector spoke with two sets of parents by telephone after the inspection and both said that they were very happy with the care provided at the home and were always made to feel welcome by staff when visiting the home. One parent said that the “workers were very nice” and “always keep me informed” and another said that she “would not want him to be anywhere else” and that staff were “very kind to the service users”. Staff liaise closely with service users’ families in regard to service users’ care whilst being sensitive and protective towards service users’ rights and best interests. The midday lunch was seen at both inspection visits and was nutritious and well presented on both days. On the first day the meal was not that stated on the menu but the alternative prepared was popular and an alternative choice was available. On the second day the lunch followed the menu but variations were given according to indications by service users, for example one particular vegetable that the service user didn’t like was removed from his plate. On both days the lunch for one service user, who likes to have a late breakfast and therefore is not ready for lunch with the others, was set aside. The service user indicates to staff when he wishes to have his lunch later on in the afternoon. Menus indicated that service users are given a nutritious and varied diet, tailored to their individual likes and dislikes. As service users are from a variety of cultural backgrounds staff have provided culturally DS0000022759.V292942.R01.S.doc Version 5.1 Page 13 appropriate foods, such as jollof rice, when there have been staff from the same cultural backgrounds as service users. Staff said that they hope to make one day a week a cultural day, which would be commendable, and it is recommended that the home tries to ascertain how often service users would want to eat culturally appropriate food so that this can be catered for (see Recommendation 3). DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive and flexible personal support and service users’ physical and emotional health needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines but permanent staff should be vigilant over medication administration by agency staff. EVIDENCE: Staff were observed to treat service users with respect and dignity and verbal evidence indicated that personal care is given in the same way. Staff spoken with demonstrated a detailed understanding of the behaviours and preferences of service users and demonstrated how service users make choices in regard to daily routines and activities. Service users were well groomed and ageappropriately dressed. Case files and evidenced that staff seek specialist support and advice from physiotherapists, the behavioural support service, psychology services and others as service users’ needs arise or change. Verbal and documentary evidence indicated that service users are supported to access the full range of health care services, as appropriate. All service users are registered with a local General Practitioner with the exception of the two shared-care service users who each have their own GP. Each service user has DS0000022759.V292942.R01.S.doc Version 5.1 Page 15 a record of health appointments in the handover file and these evidenced that service users are supported to access the full range of healthcare professionals such as the dentist, optician, chiropodist, speech therapist and physiotherapist. The storage, administration and recording of medication was checked and only one problem was found. One of the monitored dosage systems had a tablet in it although the signed record indicated that it had been given to the service user. By the second inspection day this had been investigated and it was found that the error had been made by an agency staff. The deputy manager said that this would be reported to the agency and that it would also be followed up with the permanent staff who had given out the next dose of medication without reporting the extra tablet (see Requirement 2). No other problems were found and it is creditable that staff ensure that service users’ medication is reviewed a minimum of once per year, and that over the years the amount of medication given to all service users at the home has been reduced. DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and thorough complaints procedure and carers’ views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: There is a clear and detailed complaints procedure which meets all requirements of regulation. No formal complaints had been received by the home since the previous inspection. As good practice the home now keeps a book in which conversations between staff and carers/parents are recorded. This was seen, with all entries dated. There is an effective abuse policy and all staff have undertaken relevant training. A new member of staff who had just completed the probation period was spoken with and demonstrated a good understanding of the various types of abuse and what to do if these were suspected. The home has a copy of Lambeth’s recently published Adult Protection procedure, and recent abuse allegations have been thoroughly investigated with proper procedures followed and appropriate action taken. DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment, with bedrooms that suit their needs and lifestyles. The home is clean and hygienic but there are some outstanding maintenance issues in the kitchen. There is a large rear garden that has the potential for development to enhance facilities for service users. EVIDENCE: The home is safe, accessible and generally well maintained. Although it is purpose built and has few architectural features, staff have ensured that bedrooms and communal areas are homely. Staff said that the Registered Provider was considering re-decorating the hallway, lounge, kitchen and one bedroom, which would be welcomed as it would make these areas brighter and cover the wear and tear marks. There is a very large garden to the rear, mostly under grass but with a seating area and access via the lounge or door at the end of the hallway. There is plenty of scope for the garden to be developed so that there are flower /sensory/raised bed areas, which the Registered Provider should consider as DS0000022759.V292942.R01.S.doc Version 5.1 Page 18 these would be suitable to the needs of service users. Currently there is an arrangement for a bank worker to visit the home every few months to do gardening and for the staff team to keep the grass cut, but this is not sufficient to develop and maintain a garden of this size and the Registered Provider should consider providing regular weekly gardening hours, at least during the spring and summer months (Recommendation 4). Three requirements arose from the previous inspection, two of which had been implemented. The moveable bath has been properly repaired and is now in working order and the freezer has been replaced. A third requirement related to the new kitchen units that had been installed by the Housing Association but were of poor quality, unsuitable for the high level of use in the home. The unit drawers are not well made and one broke off almost immediately, and since the previous inspection a further cupboard door had broken off its hinges and a handle had broken off another cupboard. (See Requirement 3). The inspector was told that the Registered Provider had managed to get the Housing Association to agree to change the wall units and drawers and to re-align all of the cupboards. A new requirement has also been made for the home to obtain a fridge thermometer so that temperatures can be checked daily (Requirement 4). All bedrooms are spacious and have been personalised according to individual service users’ needs and interests. Following a visit by the physiotherapist, one service user had a new portable turning aid in his bedroom, and another had a new walking frame. Staff said that the use of the walking frame at least twice per week would be written into shift plans to ensure the service user benefits from it. On the days of inspection the home was found to be clean and hygienic throughout. A previous recommendation, that the home was given a full spring clean, had been implemented. After the inspection one parent, who was otherwise very happy with the care received by her son at the home, said that there was often a mix up with clothes and that she often found someone else’s clothes in her son’s cupboard (see Recommendation 5). DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent and effective staff team and are protected by the Registered Provider’s recruitment policy and practices. Service users’ needs are met by a well-trained staff group, who are regularly supervised. EVIDENCE: The staff team consists of a manager, deputy manager, 7 support workers with an eighth post kept vacant to provide flexibility, and two night workers. All posts are full time, although the manager works her hours over four days per week rather than five. Half of the staff group have several years experience with this or a similar staff group. The inspector spoke in depth with a newer member of staff, who was just finishing his probationary period, and found that he had a good knowledge of the client group and how to meet their needs. Four of the 7 support workers are new and have been in post for just 6 months or less and none of these workers have attained NVQ Level 2 yet. Of the remaining 3 support workers, one has NVQ Level 3 and one has NVQ Level 2 and is currently undertaking Level 3. Because of recent staffing changes therefore, the home does not currently meet the 2005 training target of 50 of support workers with NVQ 2 (see Recommendation 6). DS0000022759.V292942.R01.S.doc Version 5.1 Page 20 Rotas were inspected. Three support workers are on the rota during the early shift and 2 during the late (afternoon) shift. As most service users require 1:1 staff support to be taken out (three requiring wheelchairs) there is insufficient staffing numbers during the afternoons for all service users to go out as much as they would wish to, and would meet their needs. The Registered Provider has therefore successfully negotiated additional funding to increase staffing numbers to three support workers for each afternoon shift. This will enable service users to go out more often. One parent spoken with after the inspection said that she didn’t feel that service users were able to get out enough and that sometimes their classes were “cancelled” because of meetings, so this increase in staffing is very positive development at the home. The parent company has a recruitment policy that meets all of the requirements of legislation. One of the support workers who has just finished the probationary period (6 months) was able to describe in detail the recruitment procedure carried out, and this included all of the checks necessary to ensure the protection of service users. The staff member was also able to describe the induction programme in detail, and this also met all of the requirements and recommendations of legislation. Since beginning work at the home the support worker also confirmed that regular, minuted supervision had taken place and that this supervision had been found to be helpful. The Registered Provider has a very thorough and comprehensive training programme, incorporating in-house and external courses, which is also available to bank and agency staff. All mandatory training is updated quarterly, and a range of other relevant training is available throughout the year. Training needs are discussed during supervision and staff are directed to look through the training book to find courses they wish to attend. The inspector was told that the Registered Provider had recently consulted with all staff teams across the organisation to update the courses offered. New courses now include areas such as working with families, meeting spiritual needs, qualities needed for key working and moving from support work into management. DS0000022759.V292942.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a permanent, experienced manager in post but the manager has not yet been registered with CSCI. Service users views are sought within the limits of their cognitive disabilities and the views of their relatives and carers are also regularly sought. Record keeping is generally good and the health, safety and welfare of service users is promoted and protected. EVIDENCE: After a period of nearly one year, there is now a permanent manager in post at the home. The previous requirement for a permanent manager to be in post and to apply for registration by 1/3/06 had been met but the manager told the inspector that she had had a problem with the application for registration forms and requested that a new set be sent. As the home has not had a registered manager for over a year, the manager must progress her application as a matter of urgency (see Requirement 5). The ‘new’ manager is well qualified and experienced for the post. She has worked with people with DS0000022759.V292942.R01.S.doc Version 5.1 Page 22 challenging behaviour for 6 years, is familiar with the home because she worked there as a support worker some years ago, and has NVQ Level 3, NVQ Level 4 and the Registered Manager’s Award. All service users at the home have limited cognitive abilities and only one can verbalise more than a few simple words. It is not therefore possible to canvass service users’ views on the running of the home and service provision in general but staff try to interpret this using their knowledge of service users’ preferences and needs and by interpreting their behaviours. The Registered Provider has very recently provided training for all managers in communicating with service users with limited communication, in order that better feedback can be obtained. Currently staff at the home also seek the views of relatives and visitors and feed these back to management via staff and management meetings, and the Registered Provider holds 3-4 monthly Carers Meetings at their head offices. The Registered Provider also operates an externally verifiable quality monitoring and assurance system for the home, and has a Service Users’ Committee which service users can be supported to attend. A range of records and documentation was seen and the majority were found to be well kept and ordered. Keyworker meeting notes were particularly thorough and detailed and shift handover notes detailed relevant information on each service user. The exceptions were the missing risk assessment forms and the wrongly recorded medication dosage, referred to above. A range of health and safety documentation was seen and was found to be in good order. This included fire call points, drills and alarm safety checks, pest control contract, Arjo and Malibu bath service certificates, safety poster and weekly health and safety checks. Dangerous substances were stored safely. At the previous inspection in November 2005 it was found that the annual gas safety check was overdue and a requirement was made for evidence of the gas safety check for 2005 to be sent to CSCI. This was not done and at this inspection there was a gas certificate but the date was indistinct and may have been either 14/4/05 or 14/4/03. If this date is 14/4/05 then the gas safety check is overdue again. The Manager said that the Registered Provider’s Housing Department had been informed of this. A requirement has been made, which now includes the Registered Provider instituting a system that will ensure annual gas safety checks are carried out in a timely manner. DS0000022759.V292942.R01.S.doc Version 5.1 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 X 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 4 X 3 2 X DS0000022759.V292942.R01.S.doc Version 5.1 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 YA9 Regulation 13 (4) (b) & (c) Requirement The Registered Person must ensure that the missing risk assessments from one service user’s file are found or new ones written. The Registered Person must ensure that permanent staff regularly check medication to ensure that accurate medication records are kept. The Registered Person must ensure that the drawer and cupboard units in the kitchen are repaired satisfactorily. The Manager must obtain a fridge thermometer so that temperatures can be checked daily. The Registered Person must ensure that the application for registration of the new manager is progressed as a matter or urgency. The Registered Provider must (i) send a copy of the annual gas safety certificate for 2006 to CSCI as soon as it is received and (ii) must instigate a system that ensures that annual gas safety checks are carried out on DS0000022759.V292942.R01.S.doc Timescale for action 30/06/06 2 YA20 13 (2) 30/06/06 3. YA28 23(2)(b) 30/09/06 4 YA42 16(1)(g) 30/06/06 5 YA37 CSA 01/07/06 6 YA42 12(1)(a) 31/07/06 Version 5.1 Page 25 time each year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA11 YA12 Good Practice Recommendations The Manager should explore ways of ensuring that service users who wish to are supported to attend places of worship on a regular basis. The Manager should ensure that the issues affecting the home’s inability to provide for the service user’s educational needs are highlighted with the placing authority at the service user’s statutory annual review. The Manager should ascertain how often service users would like to have culturally appropriate foods so that this can be catered for as appropriate. The Registered Provider should consider providing regular weekly gardening hours, at least during the spring and summer months, so that the garden can be developed and maintained. The Manager should ensure that care is taken by staff to always return cleaned clothes to their rightful owners. The Registered Person should ensure that the home works towards attaining the 50 NVQ Level 2 training target that it had formerly achieved before the recent staff changes. 3 4 YA17 YA28 5 6 YA30 YA32 DS0000022759.V292942.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000022759.V292942.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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