Inspection on 11/05/06 for Streatham Common South, 22

This inspection was carried out on 11th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Streatham Common South, 22 27/07/07

Streatham Common South, 22 19/10/05

Streatham Common South, 22 19/05/05

Streatham Common South, 22 06/01/05

Streatham Common South, 22 06/10/04

Streatham Common South, 22 25/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Streatham Common South, 22 22 Streatham Common South Streatham London SW16 3BU Lead Inspector Sonia McKay Unannounced Inspection 11th May 2006 08:15 Streatham Common South, 22 DS0000022760.V293438.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 Streatham Common South, 22 DS0000022760.V293438.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. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Streatham Common South, 22 Address 22 Streatham Common South Streatham London SW16 3BU 0208 769 0668 0208 679 2364 crownwise@yahoo.com 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) Crown Wise Limited Mr Emmanuel Wilson-Addo Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2005 Brief Description of the Service: 22 Streatham Common South is a private residential home for seven adults with mental health issues. It is one of three homes in the locality owned by the same proprietor. The home is in a residential street overlooking Streatham Common, within walking distance of transport links, shops and leisure facilities. It is located in the ground floor and basement of a large house and is decorated and furnished to a good standard. The majority of service users have been at the home for many years and the home aims to provide them with the various degrees of support. Where appropriate, the home also helps to prepare service users for independent living. Prospective service users are provided with an information pack about the home that includes a copy of the Service Users Guide and Statement of Purpose. The CSCI inspection report is available on request at the home and a copy is available in the communal lounge. Fees range between £320.79 per week and £663.00 per week and vary in accordance with the level of support required for an individual. Streatham Common South, 22 DS0000022760.V293438.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 out in nine hours over one day. It involved talking with the three of the service users, the registered provider, the deputy manager, the director of care and a member of the staff team. Records relating to care, support and health and the safety of the premises were examined and there was a tour of the building. A health professional who was visiting one of the service users provided feedback about the service and the ability of the staff team to work with other professionals and a mental health professional involved in the care of four of the service users was contacted by telephone. The registered manager also provided information in a pre-inspection questionnaire. What the service does well: What has improved since the last inspection? A bedroom and the dining room have been redecorated and the front patio seating area has been improved and there are flowers and hanging baskets. The home has implemented a healthy eating strategy and low fat/low cholesterol meal options are now available. There are more full time staff and more staff have a vocational qualification in care. There is also time for staff to discuss important issues with staff coming on duty for the next shift. Written information about the ways that service users like to be supported is much more detailed and the records that staff keep about healthcare appointments has also improved. Service users are consulted more often about how the home runs and what they think about activities, staff and meals. Staff are more methodical in the ways that they think about keeping service users safe and any dangers they may be exposed to. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 6 Staff are better trained to meet the needs of a service user who has epilepsy and are keeping better records about seizures. This is useful information for the health professionals involved in his care. The handling of medicines is safer and staff are keeping better records of medications that are administered. There is more information available about possible side effects. Fire safety has improved and service users have had more opportunities to practise what to do in the event of a real fire. What they could do better: The registered manager must obtain a vocational qualification and management qualification and a staff-training plan must be put in place. There must be a record of the homes own assessment of the needs of any new service user and there must be a copy of the plan for care that the home has been asked to provide. Service users should be supported to develop their independent living skills and have more opportunity to be involved in shopping and cooking. Service users should have more information about college courses and employment opportunities. Service users should have more involvement in the running of the home. There should be wider consultation about the quality of the service that the home provides, so that the views of health and social care professionals and family members are taken into consideration when assessing whether the home is helping service users achieve their goals. The actions that staff take when a service user makes a complaint must be recorded and checked by senior staff on a regular basis to ensure that service users are being listened to and their complaints are being acted upon properly. Service users on long-term placement should be offered the option of having a holiday away from the home every year. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 7 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. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 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 Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is adequate. This judgement is made using the available evidence including a visit to this service. Prospective service users individual needs are assessed and they have an opportunity to test drive the service. However, the manager must retain a copy of his own needs assessment and a copy of the local authority care plan must be obtained to ensure that there is a clear understanding of the service users aspirations and the desired outcome of the placement. EVIDENCE: Prospective service users have an opportunity to visit the home and test drive the service before moving in. There are several visits to the home and a chance to have a meal with other service users and staff. A service user said, Staff made me feel at home as soon as I came, but didnt pressurise me to socialize. The home manager completed an assessment of the service users needs whilst he was still in hospital and the local authority generated summary of assessed care needs was also obtained. The homes written assessment of needs and the local authority generated care plan are not available. (See requirement 1) Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 10 Each service user has a written and costed contract/statement of terms and conditions with the home. The contracts are signed by the service users and the home manager. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. This judgement is made using the available evidence including a visit to this service. The assessed and changing needs of service users and their personal goals are reflected in their individual plans. Service users are able to make decisions about their lives but would benefit from information about and contact with local advocacy groups. More must be done to support service users to take risks as part of developing a more independent lifestyle. EVIDENCE: Each the service user has an individual care plan. These plans have being revised to include information from recent care management assessments and care programme approach reviews (C.P.A), as required in the previous inspection report. The plan is drawn up with the involvement of the service user together with relevant specialists. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 12 Each service user has a key worker, who meets with them each month to look at progress with planned care. Weekly meetings and informal discussion are also available if the service user prefers. The plans are reviewed with the service user to reflect changing needs, at the request of the service user or at least every six months and are updated to reflect changing needs. Staff respect service users rights to make decisions, and that right is limited only through the assessment process, involving the service user and as recorded in the individual service user plan. Service users choose when to get up and went to go to bed and how to spend their time. They are involved in making decisions about daily menus, activities and house issues. None of the service users are involved in local independent advocacy/self advocacy groups. It is recommended that information about these resources and support to contact them be made available to service users if they wish. (See recommendation 1) The registered provider is the state benefit appointee for all of the service users. Four of the service users are able to manage their own finances and three service users require staff support with budgeting and to keep their money safe. A spot check of money held in safekeeping showed that detailed and accurate records are maintained. The provider sends each service user a questionnaire every month. This consultation relates to a wide range of user satisfaction topics and provides service users with an opportunity to inform decisions about activities provided and ways in which service users can be involved in the running of the home. The issues raised in the questionnaires and the results of the prior questionnaires are also discussed in house meetings. In August 2005 60 of service users who completed the questionnaires said that they would like to be more involved in the running of the home. One service user requested involvement in staff recruitment. (See recommendation 2) As a result of another consultation, service users decided that they do not want student nurses to be offered training placements in the home. This decision has been honoured. The registered provider has introduced new formats for the assessment of risk. Each service user has detailed risk assessments that reflect the risks identified in care needs assessments and CPA review notes. Risk assessments are reviewed along with care plans or when new risks are identified. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 13 Missing persons procedures are in place and the home responds promptly to unexplained absences by service users. There is a need for a general risk assessment audit tool that will enable staff to make assessments and then safely develop programmes for increasing independence (for example, using kitchen equipment and self-medication). This will enable rehabilitation. (See recommendation 3) Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 14 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 & 17. Quality in this outcome area is adequate. This judgement is made using the available evidence including a visit to this service. Service users are able to take part in a range of activities but opportunities for personal and skills development should be better promoted and supported by staff. Service users are offered a healthy diet and their privacy is respected. EVIDENCE: Service users maintain their relationships and friendships themselves. Family and friends are welcomed, and with the service users agreement are involved in meetings and activities. Service users choose whom they see and when and can see visitors in the privacy of their bedrooms (although one of the bedrooms is shared by two service users and this reduces the opportunity for privacy). A range of the recreational activities is available and has increased since the last inspection. There is a pool table and board games available in the communal lounge and there is a vehicle available to take staff and service Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 15 users out during the daytime and evening. Recent trips include Dulwich Park, Richmond Park, bowling and the London Eye. One service user said I really enjoy going out on the trips, seeing familiar places brings back memories for me. Another service user said that he enjoyed watching the deer in Richmond Park. On the day the inspection one service user was going out alone for a regular swimming session at a local pool. None of the service users are currently involved in education or employment, although one service user has expressed interest in local colleges. Staff should ensure the up-to-date information about college courses and employment skills development opportunities are available. (See recommendation 4) Service users on long-term placements are not offered the option of an annual holiday away from the home. (See recommendation 5) Service users have individual choice and freedom of movement, subject to restrictions agreed in the individual plan. A service user confirmed that staff always knock his bedroom door before entering and he receives his post unopened. Times for getting up and going to bed are not fixed. Service users are offered a key to the front door and to their own bedroom and all bedrooms and bathrooms can be locked from the inside. Staff were observed to talk to and interact with service users, although service users can choose to be alone if they wish. One service user said, Theres no pressure to be sociable, I have all the privacy I want and socialise at mealtimes. The meals are very good! . Records are kept of all main meals served in the home. Meals are served in the communal dining room at reasonably set times, although service users wishing to have a meal later can do so. A reasonably varied range of meals is provided, including culturally appropriate meal options. All service users spoken with thought that the meals were good. Service users have access to a hot and cold drinks and snacks at all times. There is a small fridge and drinks preparation area in the communal lounge. The bulk of the food provisions are stored in a locked pantry. Provisions available include fresh produce and food is stored hygienically. Fresh fruit and snack items are stored in the kitchen and service users can make themselves a snack or request them of staff. The home has recently introduced a healthy eating plan and low fat/low cholesterol meal options are now available. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 16 Staff on duty prepare the main meals. Service users contribute to menu planning during house meetings. One service user goes to the local supermarket each week and two of the service users help to prepare some of the meals. One service user also assists with household chores on a regular basis. One service user prefers not to eat any meals in the home; instead she is given her food allowance to buy meals of her choice outside of the home. Although each service user has an individual daily programme of household activity and community participation, there is a need for staff to continue to support and encourage increased service user participation in the areas of menu planning, budgeting, cooking and shopping. This will enable service users to develop their independent living skills and confidence. (See recommendation 6) Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is good. This judgement is made using the available evidence including a visit to this service. Service users receive personal support in the way they prefer and require and their physical and emotional needs are met. The homes policies and procedures for dealing with medicines provide service users with protection. EVIDENCE: Service users are able to get up and go to bed at times of their own choosing. They have their own clothes and their appearances reflect their personality. Six of the service users are male and one is female and the supporting staff team is comprised of both males and females. Three of the service users require assistance with their personal care. The nature of the assistance required is now adequately documented in individual care plans (as required in the previous inspection report). Records of health care have improved since the last inspection. Each service user has a brief written account of the health-care appointments they have attended and of any medical advise or treatment provided. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 18 The records of health-care appointments attended indicates that service users have access to an appropriate range of health care in keeping with their individual health needs. If a service user refuses to attend a healthcare appointment appropriate records are kept and staff advise the multidisciplinary teams involved. These issues can then be discussed with the service user to ensure that they are making an informed decision. A health professional from the community mental health team said that home staff are communicating with the team on a regular basis. One service user has epileptic seizures. The staff have sought advise on an appropriate method of recording seizure duration and frequency and are now keeping appropriate records in the individuals personal file. Certificated training on epilepsy has been provided to all staff (as required in the previous inspection report). Accidents are recorded in an accident book that is in accordance with Data Protection legislation. Medication is stored in a secure medicine cabinet in the office and is administered by staff. Medication policy and procedures are in place and are adequate. Staff training includes the safe administration of medicines. Medicines are supplied by a local pharmacy in blister packs. The supplying pharmacist inspected the handling of medication in January 2006 and the report of this inspection indicates that medications are being handled properly. The handling of medication has improved since the last inspection visit and the medication stocks and records examined during this inspection were accurate and properly recorded. One service user administers his own insulin. Stocks of which are stored in a medication fridge in the staff office. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 19 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 & 23 Quality in this outcome area is adequate. This judgement is made using the available evidence including a visit to this service. Service users feel their views are listened to and acted on and they are protected from abuse. High risks of self-neglect and self- harm are being addressed appropriately with professionals involved. EVIDENCE: There is a complaints procedure, which includes timescales for investigation and feedback. The complaints procedure is given to service users in their service users guide and includes contact information for the CSCI. There have been two complaints made since the last inspection visit (when the complaints book could not be located). Both complaints have been addressed appropriately and a letter of response written to each complainant. One complaint was about having a greater range of lunch options available (omelettes as well as sandwiches). This was addressed. The other complaint was about a service user repeatedly going to another persons room to use his cigarette lighter. This was addressed. The complaints are detailed in a hard backed complaints book. The deputy manager described the actions taken. These actions, outcomes and timescales involved must be detailed in the complaints book and the registered manager and registered provider must check the book on a regular basis. (See requirement 2) Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 20 One of the complaints had been written in the complaints book by the service user themselves. There is an issue of confidentiality here as other complaints are clearly visible. This could also lead to conflict. Loose-leaf complaints forms should be provided to service users wishing to write their own complaint and the details of the complaint entered into the complaints book by a member of staff. (See recommendation 7) A service user said that he felt able to raise any concerns that he might have and that he felt safe in the home. Regular house meetings and key-worker meetings also provide an opportunity to raise concerns. Procedures are in place for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) and for referring staff that may be unsuitable to work with vulnerable adults for inclusion on the protection of vulnerable adults register. Staff demonstrate an understanding of the occasional verbal aggression by service users and deal with it appropriately. Physical intervention is not used. The homes policies and practices regarding service users money and financial affairs ensure their protection from financial abuse. Staff have received training in the protection of vulnerable adults and the recently appointed director of care regularly poses situational scenarios to staff to identify further training needs. One service user is at high risk of self-neglect. Home staff are working with mental health professionals to develop strategies to increase her safety. Another service user is at high risk of self-harm. This has been a difficult situation for staff to manage effectively and the service user has had repeated admissions for emergency hospital treatment. Staff are working with mental health professionals to develop a better understanding of the service users needs. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 21 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 & 30. Quality in this outcome area is good. This judgement is made using the available evidence including a visit to this service. Service users live in a clean, comfortable and safe environment with sufficient communal space and toilets and bathrooms that provide sufficient privacy. Use of a shared bedroom should be phased out. EVIDENCE: The home is well decorated, furnished and clean. There are five single bedrooms and one double bedroom. (See recommendation 8) There are an adequate number of bathrooms and toilets, with appropriate privacy locks and thermostatically controlled hot water temperature controls to prevent scalding. There is a communal lounge, dining room and laundry area in the basement section of the home. One bedroom and the dining room have been redecorated since the last inspection. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 22 The home is not suitable for people with significant mobility needs. There is a pleasant level access patio area with seating and flowers at the front of the property. Adequate safeguards are in place to ensure good home security. There is good access to local amenities, local transport and relevant support services. A service user said, I give my room 8 or 9 out of 10, I am very happy with it! Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 23 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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement is made using the available evidence including a visit to this service. Service users benefit from clarity of staff roles and they are being supported by an increasing number of qualified staff. Staff numbers are adequate and the number of full time staff has increased making key-working more effective. Recruitment procedures are adequate and staff are appropriately supervised. A staff-training programme for 2006 and 2007 is being developed and must be supplied to the CSCI. EVIDENCE: Roles and responsibilities are clearly defined in job descriptions for support staff. Staff are able to get to know and develop relationships with the service users as there is a core team of ten staff (excluding the managers). A neighbouring home provides additional staff cover when needed. An adequate number of staff are on duty in the home. Two staff are on duty between 8 am and 12 pm. Three staff are duty between 12 pm and 4 pm. Two staff are on duty between 4 pm and 8 pm. And one member of staff is in waking night duty. Two members of staff also provide support for activities in the community (one driver/support worker and one support worker) Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 24 The managers provide out of hours on-call emergency cover and advice. There are two full-time staff and eight part-time staff (both managers are also full time). Five members of staff have obtained a national vocational qualification (NVQ) at level 3. One member of staff has obtained an NVQ 2 and two staff are currently undertaking the course. Staff duty rosters show the registered provider has introduced sufficient time for staff on one shift to verbally hand over information to staff coming on duty on the next shift, as required in the previous inspection report. Staff recruitment records examined were satisfactory. Each member of staff has an enhanced criminal records bureau check in place. The recently appointed Director of Care is undertaking a staff training needs analysis. The resulting staff-training programme must be supplied to the CSCI as required in previous inspection reports. (See requirement 3) Training in the safe handling of medication, health and safety, manual handling, the protection of vulnerable adults and diabetes has been provided since the last inspection visit and training in equality and diversity is scheduled. The registered manager has supervision meetings with each member of staff on a regular basis. The format for recording these meetings has been revised to include a record of the issues discussed and any actions to be taken, as recommended in the previous inspection report. Staff team meetings are held regularly. Service users said of staff, I like the staff, they are alright, They are fair and They are as good as gold! Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 25 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, 39, 40, 41 & 42. Quality in this outcome area is adequate. This judgement is made using the available evidence including a visit to this service. The home manager is experienced but must obtain a relevant care and management qualification. There has been improvement in record keeping and fire safety. A quality assurance system is being developed and progress has been made with consultation since the previous inspection. EVIDENCE: The registered manager has been in post for seven years and has experience of working with service users with mental health needs. He has yet to complete an NVQ 4 in care and management but has enrolled to commence the course later this year. (See requirement 4) A deputy manager assists the home manager and has taken over a number of key management areas. The deputy manager is experienced and works in a Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 26 full-time capacity. She has obtained an NVQ level 3 and intends to complete an NVQ level 4 and RMA (Registered Managers Award). Record keeping and organisation the office has improved since the last inspection and staff can now locate information with ease. The processes of managing and running the home are more open and transparent with service users and staff being able to contribute more effectively. The registered provider has a development plan for 2005 2006 in place. The plan reviews the achievements of the past year and sets targets for this year. Targets include: • Service user empowerment • Enhancing staff understanding of mental health needs and better training • Health and Safety improvement • A review of documentation in use • Refurbishment of the physical environment There are quality-monitoring systems in place that are based on seeking the views of service users and regular visits by the registered provider. The results of service user surveys are published and made available to service users. The views of other stakeholders (for example health professionals, families and advocates) in regard to how the home is achieving goals for service users are not sought. (See recommendation 9) The home has progressed action within agreed timescales to implement the majority of the requirements identified in the previous inspection report. Policies and procedures are reviewed regularly and up-to-date copies of current procedures and codes of practice are available in the home. Confidential information is stored securely in the staff office. Health and safety records available include: • Annual small electrical appliances safety test certificate (January 2006) • Electrical fixed wiring certificate, valid for three years (February 2006) • Annual gas appliance safety test certificate (February 2006) • L.F.E.P.A (Fire Authority) satisfactory inspection report (January 2006) • Food Hygiene inspection report (February 2005) • Pharmacy inspection report (January 2006) • In-house health and safety checks that include hot water temperatures and fridge and freezer temperatures. • Fire evacuation drills records showing drills are held with the required frequency (as required in the previous inspection report) • Professional fire equipment tests were last carried out in March 2006. • Weekly tests of fire call points Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 27 Records of incidents and accidents are kept appropriately and social workers, mental health professionals and the CSCI are notified as required. Employers Liability Insurance is in place and the certificate displayed in the staff office. The registration certificate is displayed in the office. Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 28 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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 3 3 3 X Streatham Common South, 22 DS0000022760.V293438.R01.S.doc Version 5.1 Page 29 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 YA2 Regulation 14 17 Requirement The registered person must retain evidence of the homes own assessment of prospective service users needs and must obtain and retain a copy of the local authority generated care plan. The registered person must ensure that there is a record of the investigation of any complaint, the action taken and outcome. The registered persons must check this record on a regular basis. A training and development plan formulated on conclusion of a training needs assessment of the staff team as a whole must be supplied to the CSCI Southwark office. Previous timescale of 28/09/05 and 31/12/06 not met. The registered person must ensure that the registered home manager is supported to commence the appropriate care and management qualifications (N.V.Q level 4 in Care and the Registered Managers Award) by DS0000022760.V293438.R01.S.doc Timescale for action 30/06/06 2. YA22 17 Sch 4(11) 30/06/06 3. YA35 18(1) 31/07/06 4. YA37 10(3) 30/09/06 Streatham Common South, 22 Version 5.1 Page 30 2005. 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 YA7 YA8 Good Practice Recommendations The registered persons should assist service users to find out about and participate in local independent advocacy/self advocacy groups. The registered persons should develop a plan about how service users can have more input into the running of the home (in response to the results of the service user consultation of August 2005). The registered persons should develop a risk audit tool in relation to daily living skills and self-medication to enable rehabilitation. The registered persons should ensure that up-to-date information about college courses and employment skills opportunities are available in the home. The registered persons should provide service users on long-term placements with the option of a minimum seven-day annual holiday outside the home, that service users help to choose and plan. Group trips should be planned and chosen by users who share the same interests. The registered persons should ensure that service users are supported and actively encouraged to develop their independent living skills, for example, shopping, cooking and budgeting. The registered persons should provide service users with loose leaf complaints forms so that they do not read complaints made by other service users when writing a complaint in the hard backed complaints book. The registered person should ensure that service users who are currently sharing a bedroom are offered the option of a single bedroom when a room becomes available. The registered persons should seek the views of family, friends and health and social care professionals in regard to how the home is achieving goals for service users as part of the quality assurance programme. DS0000022760.V293438.R01.S.doc Version 5.1 Page 31 3 4. 5. YA9 YA12 YA14 6. YA11 7. YA22 8. YA25 9. YA39 Streatham Common South, 22 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. 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