Inspection on 27/07/07 for Streatham Common South, 22

This inspection was carried out on 27th July 2007.

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

Other inspections for this house

Streatham Common South, 22 11/05/06

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 Streatham London SW16 3BU Lead Inspector Sonia McKay Unannounced Inspection 27th July 2007 09:00 Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Streatham Common South, 22 Address Streatham London SW16 3BU 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) 0208 765 0716 0208 764 2229 crownwise@yahoo.com 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.V340930.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2006 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 people currently using the service 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 people for independent living. Prospective residents are provided with an information pack about the home. 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.V340930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit began at 09.00 a.m. and was completed in nine hours. The inspection consisted of discussion with residents; staffs on duty, the registered provider and the area care director. There was a tour of the home premises and examination of records relating to care and staffing. The Commission required the registered manager complete a written assessment of the service provided (an Annual Quality Assurance Audit sometimes called an AQAA). Information supplied in this self-assessment is used to inform this report. The Commission also distributed written surveys to people involved in the service. Surveys were completed by: • One relative • One local authority placement and monitoring team • Four residents The Commission would like to thank all those who kindly contributed their time and views to this inspection. What the service does well: What has improved since the last inspection? Residents are being supported to learn how to cook and to take part in cooking some of their own meals. More staff have attained a vocational qualification in providing care. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 6 The area care director has completed an assessment of the staff training needs and a training and development plan are in place. This will ensure that staff have the right sort of training to meet the needs of the residents. 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. The summary of this inspection report can be made available in other formats on request. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 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 Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have adequate information about the services provided in the home and their individual needs and aspirations are assessed and recorded in a written plan. People have an opportunity to visit the home for a trial period before making a decision to move in. EVIDENCE: There are two documents that provide information about the service provided, a statement of purpose and a service users guide. The service users guide contains a summary of the information provided in the statement of purpose and additional information about the services provided, the home environment and the outcomes of resident satisfaction surveys. The ‘Service Users guide and associated individual contracts must provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (both personal care and food) and the payment arrangements (resident contribution/local authority contribution) must be stipulated. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 9 The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the resident. (See requirement 1) The registered home manager liaises with the placing authority and health teams when a prospective resident is referred. This involves visiting the person, meeting with psychiatric health professionals and reading any hospital assessments and reports available. Prospective residents are offered an opportunity to visit the service before moving in for a trial period. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The assessed and changing needs of people using the service are documented in written care plans that are reviewed and updated regularly. There is a need to ensure that people are able to make decisions for themselves and to better document any decisions that are made on their behalf. Although there is a risk assessment process in place, there is a need to further develop staff confidence in using risk assessment to enable residents to have a more independent lifestyle. EVIDENCE: The personal files for two residents were examined. Each resident has a written care plan, detailing the nature of support that they require from staff. These plans are reviewed regularly and updated as goals are achieved. Plans are discussed with each resident during key work sessions and residents sign the plans to signify their agreement. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 11 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. The registered provider is the state benefit appointee for all of the residents. Residents need some assistance with budgeting and managing their money that is held in safekeeping in the staff office. Examination of these records indicates that on some occasions the registered provider has shopped for items of clothing for three of the people. The level of involvement of each person in making decisions about these purchases is not clear. People should be making their own decisions about buying personal items and they should also be supported to choose these items for themselves. (See requirement 2) The previous key inspection noted that there was a need for a general risk assessment audit tool that enables staff to make assessments and develop programmes for increasing independence (for example, using kitchen equipment and self-medication). This enables rehabilitation. A random inspection carried out in November 2006 noted that such a tool had been developed and was being introduced. The registered provider has introduced new formats for the assessment of risk. Each person 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. Discussion with staff during this inspection indicates an understanding of the need to keep people safe by using a formal risk assessment approach. A care manager commented, “ There service could improve by placing more emphasis on recovery, outside activities and moving people towards independence”. The service has recently started to place more emphasis on supporting people to develop their independent living skills, and staff are keen to do this as safely as possible. Staff would benefit from some training in how risk assessment and multi disciplinary agreement can be used to enable people to take risks and further develop their independence. (See recommendation 1) There is information about local advocacy groups and the home manager has also contacted a local advocacy service for information about the services that are available in the area. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 12 Consultation with residents during 2006 indicated that some wished to have more involvement in the running of the home. The registered provider has developed a brief plan for how this will be achieved. This is good practice. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are able to continue with the lifestyle of their choosing and most maintain social links without staff support. Some of the ways of running the home are rather institutional and there should be greater emphasis on supporting residents to widen their social networks and community links so that they can increase their independence. EVIDENCE: People currently living in the service can maintain their relationships and friendships themselves, either by visits or by telephone calls. Family and friends are welcomed, and with the residents agreement can also be involved in meetings and activities. Residents choose whom they see and when and can see visitors in the privacy of their bedrooms. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 14 A range of ‘in-house’ recreational activities is available. There is a pool table and board games available in the communal lounge and there is a sometimes a vehicle available to take staff and residents out during the daytime and evening. There is a television and radio in the communal lounge. On the day the inspection one resident was shopping at a local supermarket. One resident has recently signed up for a computer course at a local college, and, as recommended in the previous inspection report, there is information about local colleges and courses available in a communal lounge. There are no plans for the registered provider to provide residents with annual holidays away from the home. (See recommendation 4) The opportunities for social activities are generally limited to group activities arranged in a larger home, owned by the same registered provider, close by. Many residents of these homes have lived in the homes for a long time and a social network has developed. There are daytrips, movie nights and parties for special occasions, such as birthdays. Whilst there is value in such activity, feedback from placing authority care managers involved in the care of some of the residents indicates that the service is viewed to be rather institutional. Comments received include, “ There isn’t enough opportunity for clients to develop social networks outside of the house or to develop vocational activities outside the house. Clients are paid to jobs in the house ” and “ There is not enough access to community activities as there is much more emphasis on clients going out in the mini-bus’, and “ There is not enough opportunity for clients to shop and cook”. (See recommendation 3) The registered provider also offers some work to residents living in the home. There is no information about external employment opportunities and specialist supported employment resources. Staff should know about these resources so that they can inform, assist and encourage residents. (See recommendation 2) Times for getting up and going to bed are not fixed. Residents are given a key to the front door and to their own bedroom and all bedrooms and bathrooms can be locked from the inside (staff have a master key to gain access in an emergency). Records are kept of all main meals served in the home. Meals are served in the communal dining room at reasonably set times, although residents wishing to have a meal later can do so. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 15 A reasonably varied range of meals is provided, including culturally appropriate meal options and healthy options. People have access to a hot and cold drinks and snacks at all times. There is a small fridge, microwave and drinks preparation area in the communal lounge. The majority of the food provisions are purchased in bulk and 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 people can make themselves a snack or request staff support them to prepare one. The home has introduced a healthy eating plan and low fat/low cholesterol meal options are now available. Residents are now taking a more active role in meal preparation and on the day of the inspection two residents were preparing their own lunches with support from a member of staff. Staff on duty prepare the main evening meal and the residents take turns to assist. Residents contribute ideas to menu planning during house meetings. One resident prefers not to eat any meals in the home; instead she is given her food allowance to buy food of her choice. Although each resident has an individual daily programme of household activity and community participation, there is a need for staff to continue to support and encourage increased participation in the areas of menu planning, budgeting, cooking and shopping. This will enable residents to develop their independent living skills and confidence. (See recommendation 5) Staff on duty where uncertain as to whether the names of current residents have been added to the electoral role. This should be done to ensure that residents have he opportunity to vote in elections if they wish. (See recommendation 6) The registered manager indicates that financial restraints have prevented the service from improving as much as he would have liked this year. This may be a factor in the ability of the service to provide additional staffing to support residents in community based activities and skills development. Feedback from current residents, some of who were assisted by staff to complete the surveys that the Commission sent out, is generally positive. Residents confirmed that staff listen and they are able to do as they wish generally. One said that he would consult staff though. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and healthcare needs are addressed. Staff must be more careful when administering medication to ensure that accurate records are kept. EVIDENCE: Residents need different types of support to manage their personal and self care. If a resident needs assistance with washing and bathing, this is identified in a written care plan. The range of support currently provided ranges from monitoring and verbal advice to actual assistance with bathing. There are both men and women in the staff team so residents can state a preference for this type of personal assistance if they wish. A key-working system is in place, with each member of the staff team having additional responsibilities for working with a particular resident and assisting them with their plans and appointments. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 17 The records of health-care appointments attended by two residents indicates that residents access an appropriate range of health care in keeping with their individual health needs. If a resident 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 resident to ensure that they are making an informed decision. All residents are registered with a local GP practice and two residents were attending routine medication reviews with the Doctor on the day of the inspection. A member of staff supported both residents to attend the reviews and update care records on return. 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. The registered manager has completed a risk assessment in regard to residents taking control of their own medication. This is good practice. None of the residents are currently fully managing their own medication. All medication is stored in a lockable steel cabinet in the staff office. A refrigerated cabinet is available to store insulin for one resident. There are medication procedures in place and all staff have signed a sample signature list to make it clear who has administered any medication. Staff have been trained in safe administration of medication. Medication administration records are pre-printed by the supplying pharmacist and justified stock checks are carried out regularly by the home manager. Each record has a clear colour photograph of the resident it is for and information about the possible side effects of each medication they are prescribed. The supplying pharmacist conducts regular inspections and files reports with the home making any recommendations for change. The most recent report of January 2007 indicates a need for regular return of excess stock. This had been done. Examination of these administration records indicates that there are some gaps in recording when a medication has been administered. It is not clear whether doses were missed or staff failed to sign the record. (See requirement 3) One resident is regularly unavailable or out of the house when medication is due to be taken. Staff have made an entry on the chart but there is no plan as to how this can/will be addressed. (See requirement 4) Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents feel as though their views are listened to and acted upon and they are protected from abuse, neglect and self-harm. 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. A recommendation to introduce loose-leaf complaints forms for residents has been implemented. This better ensures the confidentiality of the complaints record by preventing peoples reading the details of any previous complaints made in a hard-backed book. Surveys completed by residents prior to this inspection indicate that they know how to make a complaint and that staff listen to them when they do. Discussion with the registered provider and area manager indicates that there have been a number of complaints from staff and one from a placing authority. The registered person must make sure that a record is kept of these complaints and the actions taken to address them. The registered provider has agreed to send details of these complaints to the Commission by the 3rd August 2007. (See requirement 5) Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 19 The questionnaire completed by the registered care manager indicates that there have been no complaints made by residents since the last inspection visit. 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 resident is at high risk of self-neglect. Home staff are working with mental health professionals to develop strategies to increase her safety. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 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 clean, comfortable and safe environment although frequent problems with the hot water and heating system must be resolved quickly. Use of a shared bedroom should be phased out and advice must be taken on how the home can meet changes in legislation about smoking in communal areas. EVIDENCE: The home is well decorated, furnished and clean. There are five single bedrooms and one double bedroom, currently occupied by one resident. (See recommendation 7) There are an adequate number of bathrooms and toilets, with appropriate privacy locks and thermostatically controlled hot water temperature controls to prevent scalding. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 21 There is a communal lounge, dining room and laundry area in the basement of the home. 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. Residents who smoke are asked to do so in the communal lounge. This is not in accordance with recent changes in legislation in regards to smoking in public areas. (See recommendation 8) There have been frequent interruptions to heating and hot water in recent months. Discussions with the registered provider did not clarify whether the current system is in need of repair or replacement. Residents must have access to heating and hot water at all times. (See requirement 6) Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staff training and development plans are in place although staff induction is not being co-ordinated properly. There is insufficient evidence of a thorough recruitment process and this does not adequately protect vulnerable residents. 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 residents. There is a core team of nine staff. A neighbouring home provides additional staff cover when needed. This provides residents with continuity and familiarity. There are two to three staff on duty during the day and one member of staff is on duty at night. Two members of staff also provide support for activities in the community (one driver/support worker and one support worker), although these staff are shared with two other homes. The manager and director of care provide out of hours on-call emergency cover and advice. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 23 Six members of staff have achieved a vocational qualification in care and two team members are currently undertaking the award. This is good progress in developing a qualified staff team. 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. A set of recruitment records for a new member of staff were examined. The records do not contain the required second reference or proof of address. The photograph is inadequate and the enhanced criminal records check, although recent, was not taken up by the registered provider. These types of checks are not transferable and must be done by the registered provider for all new staff. There is also no record of the selection interview and the induction training record is only partly completed. (See requirements 7 & 8) A training and development plan for 2006-2007 is in place and is based on a training needs analysis of the current staff team. There is also progress in delivering the planned training. Training recently provided includes: • • • • • • • • • Safe handling of medication Health and safety Moving and handling Infection control Drug and alcohol issues Diabetes POVA (The Protection of Vulnerable adults) Introduction to mental health Care planning 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. There are also team meetings, the minutes of which indicate that meetings are held quarterly. Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a need to clarify senior line management so that the home is well run. The registered manager must continue to update his knowledge and attain a vocational qualification. The health, safety and welfare of residents are promoted by regular environmental safety checks. EVIDENCE: The registered home manager is currently undertaking the Registered Managers Award. To ensure up to date knowledge, the manager must also complete a vocational qualification in care at level 4. (See requirement 9) There is some level of confusion as to senior line management within the service, with both the registered provider/owner and the director of care giving Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 25 the registered manager conflicting direction and both undertaking visits in accordance with Regulation 26 (the monthly visits that registered providers are bound to undertake to check on the quality of the service being provided). The copies of the reports filed in the home and given to the registered manager are brief and do not identify some of the issues that the registered provider said she has identified on her visits to the home. This does not provide the manager with clear direction or feedback about the service. This must be resolved. (See requirement 10 & recommendation 9) The registered provider has a development plan for 2006-2007 in place. The plan reviews the achievements of the past year and sets targets for this year. Targets include: • Resident 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 residents. The results of the surveys are published and made available to residents. The views of other stakeholders (for example health professionals, families and advocates) in regard to how the home is achieving goals for residents are being sought. 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. Systems and checks to ensure environmental health and safety are in place. Action has been taken to meet the requirements of a food hygiene inspection visit carried out in 2006, as required in the previous inspection report. Records of incidents and accidents are kept appropriately and social workers, mental health professionals and the Commission 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.V340930.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Streatham Common South, 22 DS0000022760.V340930.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The registered person must ensure that people are fully involved in making decisions about spending their own money. The registered persons must ensure that there are no gaps in the recording of when a medication is administered. The registered person must take action to ensure that medication is administered as prescribed. If a medication is repeatedly not administered because the resident is not available this must be reviewed with the GP. The registered person must keep a record of all complaints made by residents, representatives or relatives or by any person working at the care home about the operation of the care home and of the action taken by the registered person in respect of any such complaint. The registered person must DS0000022760.V340930.R01.S.doc Timescale for action 30/11/07 2. YA7 20 12 31/08/07 3. YA20 17 31/08/07 4. YA20 12 13 31/08/07 5. YA22 17(2) Sch 4(11) 31/08/07 6. YA24 23 31/08/07 Page 28 Streatham Common South, 22 Version 5.2 7. YA34 19 8. YA35 18 9. YA37 10(3) ensure that there are adequate supplies of hot water and a functional central heating system. The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The registered provider must ensure that there is evidence of all checks required by regulation including: • Proof of identity • Proof of address • Two references • Evidence that the person is physically and mentally fit to undertake proposed duties • A recent colour photograph The registered person must ensure that there is a staff training and development programme which meets the ‘Skills for Care’ training targets in terms of staff induction training. The registered person must ensure that the registered manager undertakes an NVQ at level 4 or an equivalent qualification. The timescale of 31/07/07 for meeting this previous requirement is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by- 31/08/07 31/08/07 28/09/07 10. YA39 26 The registered person must establish and maintain a system for monthly unannounced visits to the home. These visits must be thorough enough to ascertain DS0000022760.V340930.R01.S.doc 31/08/07 Streatham Common South, 22 Version 5.2 Page 29 an opinion of the standard of care being provided. Reports on the outcomes of these visits must be filed with the registered manager and the Commission. 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 YA12 Good Practice Recommendations The registered persons should provide staff training in using risk assessment as a tool to enable greater independence for residents. The registered person should make sure that staff know about the opportunities for employment and for training towards employment that are available in the area so that they can encourage residents to explore these options. The registered persons should consider how the day-today operation of the service could be revised to encourage to better support people to develop their independent living skills and community-based networks. The registered persons should provide residents on longterm 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 people who share the same interests. The registered persons should ensure that people are supported and actively encouraged to develop their independent living skills, for example, shopping, cooking and budgeting. The registered persons should update the electoral role so that residents can vote in elections if they wish. The registered person should ensure that only residents who expressly wish to share a bedroom are accommodated in a double bedroom. The registered person must seek advice as to how the service can accommodate recent changes in legislation on smoking in public areas. The registered person should clarify senior line management so that the registered manager is clear about what instructions to follow. DS0000022760.V340930.R01.S.doc Version 5.2 Page 30 3 YA13 YA17 4. YA14 5. YA11 6. 7. 8. 9. YA16 YA25 YA28 YA37 Streatham Common South, 22 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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