Inspection on 19/05/05 for Streatham Common South, 22

This inspection was carried out on 19th May 2005.

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 26 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 11/05/06

Streatham Common South, 22 19/10/05

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 22 Streatham Common South Streatham London SW16 3BU Lead Inspector Sonia McKay Unannounced 19 May 2005, 12:00 th 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 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 Stationary 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. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 22 Streatham Common South Address Streatham London SW16 3BU Telephone number Fax number Email 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 8769 0668 020 8679 2364 Crown Wise Limited Mr Emmanuel Wilson-Addo CRH care home PC care hom only 7 Category(ies) of MD mental disorder registration, with number of places 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 6th January, 2005 Brief Description of the Service: 22 Streatham Common South is a private seven bedded home for adults with mental health issues. It is one of three homes in the locality owned by the same proprietor, one of which, Park View, is a few doors away. The home is in a residential street overlooking Streatham Common, within walking distance of Streatham High Road with all its transport and other facilities. It is located in the bottom half of a large house (ground floor and basement), the top half of which is a separate privately owned flat. It was taken over by the current proprietor approximately six years ago and has been modernised and upgraded in that time. It 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 that they need with daily living. Where appropriate, the home also helps to prepare service users for more independent living, although it is recognised that for some of the service users, this may not be feasible due to the extent of their mental health needs. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unnannounced inspection was carried out as one of the two inspection visits required of the home in this financial year. It was an opportunity to examine the progress that the home has made in meeting the requirements made during the previous inspection, carried out in January 2005. The inspection was conducted over the course of an afternoon and involved talking to individual service users, having an evening meal with a group of service users, talking to the home manager, examining records and touring some areas of the premises. What the service does well: What has improved since the last inspection? What they could do better: The homes own care plans are in need of review and must be completed in more detail to ensure that service users plans are monitored and updated in line with the recent external reviews. Formal plans to reduce identified risks to service users and to train staff to better meet their needs must also be developed. Record keeping must be better organised and planned. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 6 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. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4 & 5. Although there was evidence that a service users needs had been assessed prior to admission to the home and the home had obtained a copy of the placing authority plan of required care, there was insufficent evidence that the home had ensured that the prospective service user knew how the home would meet his individual needs. EVIDENCE: In recent months placing authority social work teams had held placement review meetings with all of the individuals living in the home. Service users and, if appropriate members of their family, attended the meetings along with staff from the home and a social worker. A full assessment of needs had been arranged for one service user next month. A service user had moved into the home in recent months. He, and his family had visited the home on a number of occasions before he moved in to allow an opportunity to met staff and other service users and familirise himself with the home and the services provided. His care file contained the required local authority generated care plan, although the information is not detailed and there is an acknowledged limit to the information on which the assessment was based. The home has completed a full risk assessment based on the local authority care plan. The man was in hospital at the time of this inspection visit as a result of a serious incident of self injury, occuring only weeks after the 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 9 placement began. The deputy home manager was attending hospital ward round meetings to discuss future discharge plans. The homes original care plan indicated that staff were to make observations of the service user at 15 minute intervals. Discussion with the home manager indicated that the service user had objected to the constant observation programme. It was not clear what observations should be made, or what action to take if anything of note was observed. It is therefore essential, for the safety of the service user, that staff are made fully aware of how to conduct these observations, what is to be noted and what action to take if significant observations are made as part of the re-assessment of need and revised care plan. The care plan must be developed with the service user and advised and ratified by the health professionals and placing authority involved in his care. (See requirements 1 & 5). Each service user had an individual contract detailing the terms and conditions of occupancy. The contracts had been revised to include the specific bedroom number to be occupied under the agreement, as required in the previous inspection report. However, it was noted that one of the service users had not signed the contract. (See requirement 2). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10. A degree of service users consulation has been facilitated by home staff, this must be increased to ensure thats service users are able to influence the running of the home to a greater degree. Service users assessed and changing needs and personal preferences are not adequately reflected in their individual plans. Risktaking had not been sufficiently considered or documented. EVIDENCE: Service users are each allocated a designated keyworker. The four service users who commented on the keywork arrangements were happy with them and found them a useful way of keeping up to date with appointments and any issues arising. Records of the issues discussed in these meetings are inadequate, do not relate to care plan objectives and had not been signed by the service users concerned. (See recommendation 1). Decisions made in recent external placement reviews had yet to be fully transferred into the homes own care plans. Care plans are brief and do not provide sufficient detail. (See requirements 2 & 5). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 11 Service users are able to make decisions in regard to their day to day lives, although staff were observed to discourage one service user from a chosen activity by diplomatically reminding him of the professional health advice that he had been given (he had been advised not to smoke too many cigarettes by a health specialist, treating him for a specific health condition). Again, this advisory support must be detailed in the individual care plan. (See requirements 2 & 5). Another service user, who has epileptic seizures on occasion, discussed his need to maintain his independence in the community, and that although it would be safer to go out with a member of staff, he did not want to be restricted in this way. Discussion with the home manager indicated that care had been taken to negotiate with the service user to ensure that he at least kept a written record of who he was and where he lived in a small belt pouch when he went out alone. Arrangements in place for the service user to return to the home after hospital admissions (as a result of seizures occuring whilst out alone) are inadequate and must be revised to ensure the safety of the service user. (See requirement 5). The home staff facilitate service user house meetings on occasion. Two meetings had been held so far in 2005. One service user had subsequently expressed an interest in attending a management meeting, which is yet to be arranged. The frequency of house meetings should be increased to allow service users to effectively contribute their ideas about the running of the home. (See requirement 4). All written confidential information is securely stored in a cabinet in the staff office. The office is locked when not in use. The home is registered for the storage of information under data protection legislation. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 16 & 17 Arrangements for supported activities had improved and increased. Services users are part of the local community and can engage in appropriate leisure activities of their choice. Service users have household responsibilities and are provided a healthy diet. Information about local college and employment opportunities should be more readily available and television reception should be improved. EVIDENCE: Discussion with the service users and home manager indicated that although none of the service users were employed or in education, a variety of activities were available if service user chose to access them. (See recommendation 3). Streatham common South joined in activities arranged with another home in the group, Parkview, which is situated close by. Party nights are held on Saturdays and day time and eveining activities are facilitated by a designated member of staff using a people carrier vehicle to visit places of interest. The Parkview home also hosts regular weekly art and crafts sessions. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 13 A snooker table and two televisions are available in the communal areas, although television reception is poor. (See recommendation 2). One service user commented that he particularly enjoys the homes close proximity to Streatham Common park, a favourite area to relax in good weather. The location of the home provides good links to public transport services, supermarkets, shops, restaurants, cafes and cinemas. One service user regularly helps staff with the main shop for food provisions and all service users have responsibility for areas of household cleaning. During lunch, served in the small basement dining room, service users offered a choice of meals (chicken casserole with rice/potatos and ice –cream for dessert) commented that the meals were good. The record of meals eaten provided evidence that a range of culturally appropriate meals had been available and fresh fruit and vegetables were a regular feature. Meals are served at reasonably set times and service users commented that they were also able to prepare snacks and hot drinks in the small kitchenette the communal lounge. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 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 standard(s) 19, 20 & 21. Steps had been taken to improve the way that written records in relation to healthcare are maintained. This will ensure consistent follow up between appointments and a way for staff to track the need for routine healthcare appointments to be offered and made for service users. Monitoring of one service users mental health is inadequate and must be better advised and further developed to ensure his safety. EVIDENCE: The recording of the outcomes of health appointments attended by service users has been revised to ensure that each service user has an accurate individual record on file. It is hoped that these individual records will assist staff in making the necessary arrangements for routine health checks, in addition to specific appointments for known health conditions. Health records should be stored in service users individual care files instead of a central folder for all. (See recommendation 4). The accident record book had not been kept up to date. A recent injury sustained by a service user had not been recorded. (See requirement 6). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 15 Inadequate mental health monitoring systems for one service user must be addressed. (See requirement 1) The frequency of the occurrence of epileptic seizures for one individual had been recorded to enable accurate feedback to the neurology team. The CSCI pharmacist had visited the home as part of the previous inspection visit. The home manager had made good progress in meeting the requirements made as a result of that inspection. The homes policies and procedures had been revised in January 2005 and now cover all areas required. Staff are being trained in the safe administration of medication by accredited training providers. The receipt of all medicines, including topical products, is now recorded. However, medication administration records do not have a photograph of each service user attached to ensure correct identification. (See requirement 7). Unfortunately one service user, with long term health problems, had died in the interim period between inspection visits. The home manager had tried to contact family members overseas without success. He had made every effort to ensure that the service users funeral arrangements were conducted as the service users had requested. The service users, with whom he had shared a home for many years, and also a number of staff, were supported to attend the funeral service. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 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 standard(s) 22 & 23. Service users felt that their views and complaints were listened to and acted upon by staff. Further work is required to ensure that service users are proected from abuse, neglect and self harm. EVIDENCE: A record of complaints made by service users was noted to contain a complaint made by a service user in regard to unpleasant side-effects he was experiencing from medication he had been prescribed. Records examined indicated that a review of medication was swiftly arranged with the GP. The complaints procedure and complaint forms are available in files kept in the service users individual bedrooms. The complaints procedure is adeqaute and contains contact information for taking a complaint to the local CSCI office if dissatisfied at any stage, with the homes response. Service users commented that they felt able to complain and express their views to staff if they needed to. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 17 The home has an Adult Protection Policy and procdures to be followed if abuse is suspected. The registered manager confirmed that issues relating to protection of vulnerable adults are discussed with staff in supervision to ensure that the policy and its implementation is understood. Recent events have indicated a need to ensure that service users are better protected from self injury. (See requirement 1). There is also a need to strengthen arrangements for one service user returning to the home after discharge from hospital (on occasions when he had experienced an epileptic seizure whilst out in the community alone and been admitted for observation via accident and emergency departments). On two occasions he has gone missing as a result of experiencing problems on the return journey to the home. (See requirement 8). Service users commented that they felt safe living in the home. Environmental safeguards such as radiator covers and thermostatic hot water controls were also in place to protect service users from contact burns and scalds. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 & 29. The home is reasonably comfortable and safe, but the layout of the building is not particularly homely. Toilets and bathrooms provide sufficient privacy and meet the needs of individual service users in terms of adaptations. The home is clean and hygenic. Service users bedrooms were personalised but further work is required to ensure that each service user has the fittings that they require. EVIDENCE: The homes location offers good access to local amenities, local transport and relevant support services. The home is indistinguishable as a care home and is in-keeping with other houses in the area. The entrance to the home is via a steep step and the dining room, lounge and kitchen are located in the basement area. Although the premises are suitable for the current service users, should any user develop a physical disability or mobility problem it would be impossible for them to access the communal areas. (See recommendation 5). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 19 Stairway and basement lighting has been improved and the stairway floor covering replaced with a lighter coloured material, making it easier to see the edges of the steps and prevent falls. Fire authorities conducted an inspection of the premises in February 2005 and confirmed that the adjustments they had required to the self-closing fire doors during their previous inspection were adequate. The home has five single bedrooms and one shared bedroom. Discussion with the service users sharing a bedroom confirmed that they were happy to share a room and were making a positive choice to do so. Bedrooms briefly seen during this inspection were adequately decorated and furnished. The home manager indicated that a requirement to audit bedroom furnishings to ensure that service users have access to the facilities listed in the national minimum standards had been completed, but could not be located. It is essential to maintain a record of items that service users have refused and that this record has been signed by the service user. (See requirement 9). The home has four toilets, two bathrooms and three shower facilities. Some of which are en-suite to the shared room. The facilities are well decorated and clean. However the communal areas are located in the basement area and the nearest toilet is on the ground floor. This is not ideal. Hot water thermostatic controls have been fitted to all hot water outlets to prevent scalds and radiator and hot pipe covers have been fitted in areas accessible to a service user who has epileptic seizures. A record of regular temperature checks of the hot water had not been maintained, this is essential to ensure that action is taken in the event that a thermostatic valve develops a fault (making the water run either too hot or too cold). (See requirement 10). The services of a domestic cleaner are employed three days a week, and this, in addition to the cleaning undertaken by the service users and staff, has helped to maintain a clean home, free from offensive odours in all areas. The communal areas are not very comfortable or homely and are dominated by a large pool table. (See recommendation 6). The main entrance has also been fitted with an entry system that allows staff to see who is at the front door before opening it for additional home security. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 & 35. Staff roles are yet to be formally clarified, although staff had informally defined roles that service users understood. Staff training was in progress but must be matched to the needs of the service users and developed into a plan of training for individual staff and the team as a whole. Service users were protected by the homes recruitment procedures. The lack of a defined handover period of information between shifts poses limitations on the amount of information about individual and joint needs that can be exchanged on a regular basis. EVIDENCE: Discussion with the home manager indicated that staff job descriptions were still in the process of revision. (See requirement 11). Staff were observed to be approachable and accessible to the service users. A programme of staff training has been developed since the last inspection visit. Staff have received training in administering medication, challenging behaviour, schizophrenia, communication, the enhanced care programme approach and cultural awareness and ethnicity. Other appropriate topics were 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 21 scheduled. The progress of the training programme will be further examined during the next inspection visit. Staff had not received training in supporting a service user with epilepsy, and it did not feature on the planned training programme. This is essential to ensure that one of the service users is supported by staff trained to meet his needs. (See requirement 12). The home is on course to achieve the 50 requirement of staff with an NVQ level 2 and 3 in Care. Staff duty rotas indicated that one night waking staff was on duty at night, And 2 to 3 staff were on duty during the daytime. The presence of a third member of staff on duty for some parts of the day is flexibly timed to ensure that service users have opportunity for supported community access during the evening as well as during the daytime. Service users commented that they enjoyed the activities provided by the additional staff member and were keen for him to come on duty. The staff handover meeting period between shifts is not indicated on the staff duty rotas. These meetings are essential opportunities for staff to communicate with each other and to discuss any concerns or progress reports that they have about the service users. (See requirement 13). A previous requirement to identify the amount of hours that the manager spends on administration and not as part of the direct care team has not been met. This must be done to calculate the true level of staff support available to the service users and to ensure that there is sufficient time to supervise staff during their normal working hours. (See requirement 14 & recommendation 7). The home manager supplied an audit of recruitment records that indicated that appropriate records are in place for each member of staff, including disclosure numbers of enhanced criminal record checks and in one case a POVA First check. These records will be examined during the next inspection visit. Individual staff training records are not kept in the home. Although a training programme has been identified it was not clear which members of staff would be attending training. (See requirements 15 & 16). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 40, 41 & 42 The manager has been in post for a number of years but must complete training to increase his management and care skills. Record keeping had improved but must be better organised to ensure that staff are able to access them easily. EVIDENCE: The registered manager has experience of working in this field and is competent to manage the service. Discussion with the home manager during the inspection visit indicated that he intended to commence the NVQ 4 in Management and Care in the later part of 2005. The registered manager is supported to manage the home by a full time deputy home manager. The home has a comprehensive set of policies and procedures available to provide staff with the necessary guidance in how to deliver care and support and what to do in a crisis. These documents are being reviewed during 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 23 management meetings at a rate of two at each meeting to ensure that they are applicable and in accordance with any updates in good practice. (See requirement 18). A selection of records examined during the inspection visit included :Records of care needs assessment, planning and care provided to service users. Monthly monitoring reports of the checks made on the home by the home owner. These reports had also been sent to the CSCI on a regular basis. A personnel/recruitment records audit. Duty rota’s for staff. Costed accommodation contracts between the service users and the home. The Complaints Log, which contained one entry. The Accident book, which had not been completed as required. (See requirement 6). The record of incidents and notifications had been maintained in good order. The record of the meal eaten by service users had been kept. The visitors log was well used. Fire evacuation drills had been held and recorded with the required frequency. Fire procedures and reports by the LFCDA (fire authorities) were available. Missing Persons Procedures were available. A certificate of confirmation that small electrical appliances in use in the home had been annually safety tested in March 2005. Records of regular hot water temperature testing were not available. (See requirement 10). Records were generally well maintained, but the home manager had difficulty locating some records as they had been stored in numerous files. The files containing the records kept for each service user contained a mixture of up to date information and also historical information that could be safely archived. Service users would benefit if staff were able to locate salient information about current care needs with ease. (See recommendation 8). A lock had been fitted to the inside of a stairway door from the basement communal area up to the ground floor hallway. This lock presented a risk that a service may be able to lock themselves in the communal areas (the lock was of a type that would prevent staff access in an emergency). (See requirement 19). 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 2 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 2 3 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score 1 2 2 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 22 Streatham Common South Score x 2 2 3 Standard No 37 38 39 40 41 42 43 Score 2 x x 2 2 2 x G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 25 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 Regulation Requirement Timescale for action 24/06/05 YA3 & YA19 12, 13 & 14 2. YA5 12(5)(a) The registered person must develop an individual service users plan based on the care management assessment and care plan. This plan must be sufficiently detailed to provide staff with adequate information on specific risks and how they are to be minimised (the regularly recorded observations of one service user were not sufficiently advised or detailed and did identify clear triggers for action to be taken by staff). The subsequent plan must be advised and ratified by the appropriate health professionals and the placing authority involved in his care. 12/08/05 Individual written contracts or statements of terms and conditions within the home must include a copy of the service users plan, arrangements for reviewing that plan and details of any policy or rule that may limit personal freedom. Service users must have a copies of the contracts, which have been signed by the service users and the registered manager. Version 1.30 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Page 26 3. YA6 & YA11 14, 15(2)(a) 12 4. YA8 12 & 24 5. YA9 12 & 13 6. 7. YA19 & YA41 YA20 12 & 19 13(2) 8. YA23 12 9. YA26 23 & 16 The registered person must ensure that the homes internal individual care plan documents are reviewed regularly and are in line with Community Care Assessment part 2 (care Plans) when available. Previous requirement. Unmet timescale: 31/03/05 The registered person must develop increased opportunities for those service users who wish to, to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. Previous requirement. Unmet timescale: 28/01/05 The registered person must ensure that action is taken to minimise any identified risks and hazards, to avoid limiting the service users preferred activity or choice. Risk management strategies must be agreed with the service user and placing authorities. Previous requirement. Unmet timescale: 28/01/05 Records of each accident must be kept. The registered person must ensure that identification of service-users (photographs) and allergy information are added to the MAR chart folder. Previous requirement. Unmet timescale: 31/03/05 Arrangements in place for a service user returning to the home after hospital discharge must be revised to ensure that he is adequately protected. The registered person must ensure that an audit of furnishings in service users bedrooms is completed against 12/08/05 30/09/05 12/08/05 01/07/05 01/07/05 01/07/05 30/09/05 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 27 10. YA27, YA29, YA41 & YA42 12, 23 & 16 11. YA31 18 12. 13. YA32 & YA35 YA33 12 & 18 12 & 18 14. YA33 18 & 24 15. 16. YA35 YA35 18 18 17. YA37 10 & 18 the list in NMS 26.2. Items identified as being unavailable must be made available or a record kept of why an item was not supplied. Previous requirement. Unmet timescale: 25/02/05 The registered person must ensure that a check on the temperature of hot water in outlets throughout the premises is conducted on a regular basis (i.e. weekly). A record of the results of these checks must be maintained in the home. Previous requirement. Unmet timescale: 18/02/05 Job descriptions for all posts of employment in the home must be sent to the CSCI Southwark office. Staff must attend training in supporting the needs of someone with epilepsy. The registered person must ensure that staff have adequate time for a handover of information between shifts. This meeting must be identifiable on the staff duty rota. The registered person must specify the management administration time available to the home manager. Previous requirement. Unmet timescale: 31/03/05 Each member of staff must have an individual training needs assessment and training profile. 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. The registered person must ensure that the registered home manager is supported to 01/07/05 28/10/05 28/10/05 26/08/05 26/08/05 28/09/05 28/09/05 31/12/05 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 28 18. YA40 12 & 13 19. YA42 23 commence the appropriate care and management qualifications (NVQ level 4 in Care and the Registered Managers Award) by 2005. The registered person must ensure that policies and procedures appropriate to the setting are developed and reviewed on a regular basis. A list is available in Appendix 2 of the National Minimum Standards. Confirmation that all necessary policies and procedures are in place and have been reviewed must be sent to the CSCI Southwark office. The registered person must ensure that the lock on the door to the staircase leading to the basement communal areas is removed. 28/10/05 01/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered person should introduce a more effective method of recording keyworker/service user meetings. These records should be signed by the keyworker and the service user and should detail the progress made in achieving care plan objectives. The registered person should install an external television aerial to improve the poor picture quality of the basement communal lounge television and also the television. reception in service users bedrooms. The registered person should appoint a member of the staff team to the responsibility of maintaining up to date information about local college courses and classes and employment opportunities (some colleges and employment agencies also offer specific services and courses for adults with a diagnosed mental health need). Records of the outcomes of healthcare apppintments G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 29 2. YA14 3. YA12 4. YA19 22 Streatham Common South 5. 6. 7. YA24 YA28 YA33 & YA37 8. YA41 should be maintained in the individual file of the service user. The registered person should take advice on the implications for the home following the full implementation of the Disability Discrimination Act. Consideration should be given to making the communal lounge more comfortable and homely. The practice of requesting staff to attend the home when they are not on duty to have supervision meetings with the home manager should be reconsidered. Steps should be taken to facilitate these essential meetings to within paid hours of employment as is good practice. The home manager and deputy should re-organise the records kept in the staff office and consolidate some of the vast number of files to make them more accessible. This will ensure that up to date information is clearly available and older less important information safely archived. 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection 46 Loman Street London 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 22 Streatham Common South G52-G02 S22760 StreathamCommonSouth V228524 190505 Stage 4.doc Version 1.30 Page 31 - 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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