Inspection on 18/12/06 for Sunnyhill Road 99

This inspection was carried out on 18th December 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnyhill Road 99 15/12/08

Sunnyhill Road 99 15/11/05

Sunnyhill Road 99 29/07/05

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 Sunnyhill Road 99 Sunny Hill Road 99 Sunny Hill Road London SW16 2UW Lead Inspector Ms Rehema Russell Unannounced Inspection 18th December 2006 10:30 Sunnyhill Road 99 DS0000062220.V316854.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 Sunnyhill Road 99 DS0000062220.V316854.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. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnyhill Road 99 Address Sunny Hill Road 99 Sunny Hill Road London SW16 2UW 0208 971 0060 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) Mr. C. Oakley, 229 Mitcham Lane, SW16 6PY Mr George Asante Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: 99 Sunnyhill is an ordinary terraced house in a residential area, with nearby on-street parking. It is located within five minutes walk of a main shopping centre which has full community facilities, including bus and rail transport. It is owned by a private company which specialises in mental health provision for males of African descent and which has two other homes in a nearby local area. The appearance of the home conforms to normalisation principles and there is nothing that would mark it out from any other house in the road. The ground floor has a lounge, one bedroom, toilet and shower, kitchen-diner and a very large rear garden. The first floor has the office, three bedrooms and a bathroom with toilet. The second floor has one bedroom and a bathroom with toilet. The home is not suitable for people with mobility problems. Prior to admission, prospective service users are given a brochure and verbal information about the home. On admission they are given the service user guide. A copy of the most recent inspection report is made available in the office for staff, service users and visitors. The weekly charge is £1,150 - £1, 250, and there are no additional charges. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 18th December 2006. At the time of the inspection there were four service users resident at the home, one of whom was in hospital, and one vacancy. The inspection was facilitated by the Registered Manager and the Proprietor. The inspector also spoke with a support worker and three service users, saw the communal rooms and two bedrooms, and looked at documentation and records. What the service does well: What has improved since the last inspection? What they could do better: There was one requirement arising from the previous report of November 2005 – for a formal annual service users’ survey to be carried out – but it was not implemented due to particular circumstances arising at the home. The requirement has therefore been repeated following this inspection, with an Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 6 extended timescale. There are no new requirements and only one recommendation arising from the current inspection. The recommendation is for the very occasionally used PRN medication to be printed up on the MAR (medical administration record) charts so that administration can be recorded on MAR sheets as well as in the daily reports. 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. Sunnyhill Road 99 DS0000062220.V316854.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 Sunnyhill Road 99 DS0000062220.V316854.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, 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about the home. A full assessment is undertaken on all new service users prior to admission to ensure that the home can meet their needs. Prospective service users are encouraged to make several visits to the home, to meet with staff and other service users, and to have a trial stay in order to make a decision about whether the home will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide were seen. They contain all of the information required by legislation, written in a clear and easily understood style. The Service User Guide includes the complaints procedure as well as the home’s policies on smoking, alcohol and drugs. Each service user has been given a copy of the Service User Guide and has signed and dated it to show that they have read and understood it. One service user showed his copy to the inspector in his room and said that he refers to it when necessary. In addition, the home has a brochure which is given to all prospective service users. Prospective service users and interested parties are therefore enabled to make a well informed decision about the home. The assessment process undertaken for the service user admitted to the home within the last few months was examined. Verbal and documentary evidence Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 9 showed a thorough referral procedure. The prospective service user had been visited by the registered manager and proprietor several times, all relevant and up to date information from medical, psychiatric and social professionals had been obtained, a full and thorough pre-admission assessment form had been filled out by the registered manager and a referral form from the social worker had been obtained. The home had facilitated the prospective service user to visit the home on three occasions, once accompanied by his social worker, at which he was shown his room and met with staff and service users. The proprietor also accompanied the prospective service user to a facility at which he would be undertaking activities, in order for him to assess whether it would be suitable. He then stayed at the home for a one week trial period, at the end of which the whole staff team discussed the experience and a decision on admittance was made. The service user confirmed to the inspector that he had been encouraged to look at other homes and possible placements before making his decision, so that he was aware of the range of options available and therefore made a positive choice for this home. Sunnyhill Road 99 DS0000062220.V316854.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, 8, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have individual care plans which reflect their assessed and changing needs and personal goals. Service users are encouraged and supported to make decisions about their lives and are supported to take assessed and monitored risks as part of an independent lifestyle. EVIDENCE: Three care plans were seen. All contained goals which were tailored to the individual and generated from the care programme approach document, and in the case of the most recently admitted service user, from the pre-assessment information. All care plans are devised with the input of the service user, key worker and care manager and signed by all three. One service user demonstrated to the inspector that he knew the contents of his care plan. For all new service users, the registered manager is the initial key worker and so the care plan of the most recently admitted service user was signed by himself and the registered manager only. Care plan files contained daily reports written by staff which give a very detailed picture of the service user’s moods, Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 11 activities, and any other relevant information. Care plans are evaluated monthly and altered or updated as relevant. All care plans, action plans, daily reports and monthly evaluations were dated and signed. The aim of the home is for service users to attain independence and to this end there are very few rules and regulations, and service users are encouraged and supported to make as many independent choices and decisions about their daily lives as possible. This was evident from speaking with service users and staff, and observation on the day of inspection. Several examples were given of how staff handle situations where service users’ decisions need to be modified or overruled in a sensitive way, taking appropriate professional advice as necessary. For example, if a service user refuses to undertake any structured activities staff will reiterate the objectives of the home – rehabilitation – and encourage and support the service user to undertake activities at his own pace. For example, they will be encouraged to attend a day/drop in centre for a certain number of days per week but will be able to freely choose the number of hours they attend each day. Service users’ choices rarely need to be overridden but if this is the case, then any such decision is fully discussed with the service user and recorded in the daily report. The manager has obtained a copy of the local MIND directory so that service users can seek independent advocacy support should they wish it. Two service users spoken with confirmed that they were completely independent in regard to their finances, handling all of their financial affairs themselves. Risk assessments were seen in care files and were comprehensive and thorough. A full range of risk categories are assessed, including aggression/violence, exploitation, risks to children and young adults, self-harm and severe self-neglect. Factors suggesting risk are detailed, a statement of anticipated risk is made and an action plan formulated. Risk assessments are reviewed 3 monthly, or sooner if appropriate. As previously mentioned, as the most qualified and experienced practitioner, the registered manager always undertakes the assessment of potential service users, including risk assessment, and is the key worker for the initial period of the new service users’ placement. In this way, risk can be carefully monitored during the period when the service user is new and relatively unknown to the home. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to develop social, spiritual, emotional and independent living skills, to find and keep appropriate jobs and to participate in the local community. Appropriate personal and family relationships are supported and residents are provided with a healthy diet of their choice. EVIDENCE: The home provides service users with a range of opportunities to maintain and develop social, emotional, communication and independent living skills. One service user regularly attends the church of his choice, undertakes paid employment and attends a project where he is able to socialise and play indoor games. Another is undertaking work experience twice a week, attends two drop-in centres, visits friends, goes out for meals and visits the cinema. A third service user attends a drop-in centre and a day centre where he undertakes art and craft and other activities. All service users undertake daily Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 13 living skills such as cooking, cleaning their rooms, laundry, shopping and managing finances, with support from staff if necessary. Service users are able to access all community facilities, such as shops, libraries, cinema, cafes and restaurants, which are all available locally, and can choose to do this individually, or with each other or staff as part of the planned activities at the home. Service users confirmed that appropriate personal and family relationships are supported, one service user feeling comfortable enough to bring personal friends to the home, another intending to visit and stay with family at Christmas. Staff and residents confirmed that routines are flexible, with residents choosing waking, sleeping and meal times according to their timetable during the week and their individual choice at weekends. On the day of inspection service users were observed to freely choose where to spend their time, to access snacks and drinks whenever they chose, to be given their post to open privately, and to have keys to their rooms. The home supports and encourages service users to have an annual holiday, but although one service user chose to go away for 5 days last year, this summer none of the service users was interested in taking a holiday. Service users told the inspector that they were able to eat what and when they liked. Two service users cook their own meals and one, who is unable to cook safely for himself due to limited vision and cooking skills, has a meal that is cooked with the full assistance of staff or voluntarily by another service user. He is encouraged to carry out simple tasks independently, such as making tea and toast, and staff ensure that they are present if he wishes to undertake more complicated tasks so that they can provide support and encouragement. The home continues to employ a female domestic staff who visits the home for 2 days each week, undertaking some communal cleaning and providing culturally appropriate meals. All three service users confirmed that they were happy with the meals at the home and confirmed that they are able to choose the food provided. They also confirmed that if there was any food they wished to eat that was not available at the home then they would be given the money to go out and buy it. On the day of the inspection all three service users were eating out at a drop-in centre that was providing a Christmas meal and party. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate personal support is provided and service users’ physical, mental and emotional healthcare needs are met. Medication is stored, administered and recorded safely and service users are supported to self-medicate as appropriate. EVIDENCE: Service users do not need physical assistance with personal care but prompting is given as necessary and staff demonstrated that they do this in a way that maintains dignity and respect. This was also observed on the day of inspection, and confirmed by service users who said that staff “treat us respectfully” and “help us by talking and support, and with any problems”. Staff spoken with demonstrated a good knowledge of individual service users’ needs, preferences and characteristics, and how to encourage and support them in a way that is sensitive to their personalities. All service users were well groomed and dressed, with clothing and appearance that reflected their ages, individuality and choices. Documentation evidenced that service users are supported to access the full range of healthcare professionals and facilities as necessary, such as occupational therapist, consultant psychiatrist, general practitioner, Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 15 psychologist, dentist and optician. The daily reports of the service user who was recently admitted to hospital were seen and demonstrated that his mental health had been closely monitored and recorded by the manager, and that all relevant professionals, such as the consultant psychiatrist, had been consulted. The manager had managed to prevent a mental health section being necessary by convincing the service user to enter hospital voluntarily, and was now closely liaising with the hospital and the service user’s next of kin in order to achieve the best outcome for the service user, including his safe return to the home. The storage, administration and recording of medication was checked and found to be in good order. There is one service user who has a prescribed occasional (PRN) medication, that is only taken about once every few months. Staff are currently recording this in the daily notes, so that all staff are aware when the medication is taken and that the information forms part of the monitoring of the service user’s mental health, which is good practice. However, it is recommended that the home requests the pharmacist to include this medication on the medication administration records (MAR charts) each month, so that the occasionally given dose is also recorded on the MAR charts. See Recommendation 1. Staff have undertaken external training in the administration of medication and the manager is a registered nurse. Since the inspection of 15th November 2005, one service user has progressed to the stage where he is now able to self-medicate, which indicates a good improvement in his mental health and his rehabilitation skills. He keeps his medication in his own room, in a lockable metal cabinet, and takes the medication in front of staff, who then sign the medication recording chart. As good practice, the decision for self-medication was a multi-disciplinary decision discussed during the Care Programme Approach meetings with the community psychiatric nurse, social worker, consultant psychiatrist and registered manager. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know that their views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has a clear complaints procedure which is published in the statement of purpose and the service users’ guide. The home has a complaints book but has received no formal complaints to date. Staff are fully aware of the complaints procedure and how to support service users to access it. Service users are also aware of the complaints procedure but all three independently told the inspector that if they had a problem they would speak directly to a member of staff or the manager or proprietor, and were confident that it would be resolved. The registered manager has a thorough knowledge of Protection of Vulnerable Adult procedures and all staff have abuse training as part of the induction programme at the home. In addition, all staff have recently undertaken external abuse training, including POVA training. A support worker spoken with was fully aware of the many different types of abuse, of what to do if abuse was suspected and the procedures that would be followed should abuse be alleged. Staff also demonstrated a thorough understanding of possible physical and verbal abuse by service users and what practices and procedures should be followed. All staff have been trained in de-escalation techniques. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment, which provides sufficient privacy and promotes an independent lifestyle. Service users’ bedrooms suit their needs and lifestyles and promote their independence. Shared spaces complement and supplement service users’ individual rooms, and the home is clean and hygienic throughout. EVIDENCE: The home’s premises are suitable for its stated purpose and fully blends in with the residential area in which it is located. There are five single bedrooms, all above double bedroom size and therefore exceeding minimum size standards, and there is a lounge and a kitchen diner, both of which are large enough for five residents and staff to sit comfortably. The home has been decorated, fitted and furnished to a high standard throughout. Service users bedrooms have been personalised according to their individual tastes and preferences. All are lockable and all have double beds and good Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 18 quality bed linen. Two service users’ bedrooms were seen, a third having been seen at the previous inspection. Both bedrooms were well furnished and fitted and both reflected the very different characteristics and preferences of the occupants. One service user has made his room into a beautiful “retreat” by the use of linens and materials he has chosen himself and the arrangement of the furniture and his music equipment. The room was meticulously clean and tidy. A second service user bedroom was completely different – well furnished, fitted and personalised but fairly untidy, reflecting the behavioural characteristics of the service user. This was further evidence of the flexibility of the support provided by the home, which is tailored to individual service user’s needs and choices. There are three bathrooms in the home, one on each floor, so that service users have a choice of which to use. The bathrooms on the first and second floors have baths and shower facilities, and the facility on the ground floor is a shower room with toilet. As there are only five service user places at the home, the number of bathrooms exceeds minimum standards. The lounge has been provided with a television, Sky receiver, radio and books, and service users also have their own televisions/audio equipment in their rooms. As stated above, there is a kitchen/dining room on the ground floor, which is of suitable size to accommodate five service users. Each service user has their own lockable cupboard in the kitchen/diner for use as they become independent in regard to catering. The home was found to be of a high standard of hygiene and cleanliness throughout. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff, and an effective staff team that reflects their gender and cultural composition. There are suitable recruitment, training and support procedures to ensure the home has a staff team that is able to meet residents’ individual and joint needs. EVIDENCE: Staff are not employed at the home unless they have prior knowledge and experience in mental health and also have NVQ Level 2 or an equivalent qualification. The manager also ensures that staff have suitable personalities and characteristics for the work they are to undertake, such as reliability, humour, tact, trustworthiness and a suitable temperament. Two of the three current support workers have NVQ Level 3 and the third support worker is just finishing NVQ Level 2. The home has therefore exceeded the 2005 NVQ Level 2 training target. The support worker spoken with had worked for the organisation for five years. He demonstrated a good understanding of the particular mental health issues, behavioural characteristics and needs of the service users at the home. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 20 Minutes were seen of 2-3 monthly staff meetings and rotas showed that the ratio of care staff to service users is determined by the assessed needs of service users. For example there are usually two staff on duty for day shifts but when it is known that all service users will be out of the house at drop in centres or other activities all day, then there may be one support worker on duty for that period. There is always one waking staff at night. The staff turnover rate at the home is very low, and no agency staff are used, thereby ensuring continuity of care. The home employs only black male management and support staff, in keeping with the stated aims and objectives of the home. Staff therefore reflect the cultural and gender composition of service users. The proprietor, registered manager and support worker were observed to have open, friendly and positive relationships with service users. Service users told the inspector that they felt that staff were approachable, supportive and treated them well. There had been no recruitment of new staff since the inspection of 15th November 2005, at which all recruitment records were found to be in good order with all of the required information present and correct. At the previous inspection staff confirmed that they had been given initial induction training, which covered all relevant basic areas, and had only worked on shift with a more experienced member of staff for their first 3-4 weeks. Training and development is valued by the proprietor and manager and subsequent to induction training, staff follow a comprehensive training programme. This includes support to attain NVQ Level 3 via the proprietor paying the fees and the manager ensuring that the rota gives them time to study. The proprietor and manager encourage staff to attain NVQ Level 3 rather than Level 2 as Level 3 has several mental health components. Staff confirmed that further training is given each year, and this year the support worker spoken with had updated his health & safety, food hygiene and abuse training, and had also been trained in breakaway techniques. In addition the manager trains staff on a daily basis by explaining the diagnoses and conditions attributed to service users, and further supports staff by regular, minuted staff meetings. Staff also confirmed that they are given formal supervision every 2-3 months, at which they discuss care practice, keyworker issues and training needs, and which are minuted and signed with a copy given to them. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and the ethos, leadership and management at the home. Service users’ views are regularly sought and acted upon to inform the self-monitoring, review and development by the home, although a formal service users’ survey has not yet been carried out. Working practices promote and protect the health, safety and welfare of service users. EVIDENCE: The Registered Manager is suitably qualified, competent and experienced to run the home. He is a registered general nurse and a first level registered mental health nurse and has several years’ experience of managing registered homes for the client group. He has City & Guilds qualifications in management and is currently investigating undertaking the Registered Manager’s Award, as is recommended in the National Minimum Standards. In was evident from speaking with the manager that he has a comprehensive understanding of Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 22 mental health issues and managing people, and a good insight into the mental health and individual characteristics of each service user. The atmosphere at the home was open, friendly and inclusive and it was evident that both service users and staff found the manager and proprietor approachable. All three service users spoken with said that they would find it easy to approach the manager if they had any problems or complaints, or simply wanted to discuss something. Staff said they find the manager very supportive, that he teaches them and makes the team work well, that he is quick to spot any mistakes and will correct them in a supportive way, and that he always ensures that the service users are being well cared for and that the home is running smoothly. Staff said that they felt able to contribute to client care and development at the home via information exchanged at handovers, supervision and staff meetings, where their concerns and suggestions are listened to and acted upon. Service users’ views are sought on a continuous basis at the home. The manager is at the home on a daily basis, and as the home is small, he is in continuous communication with service users and staff. The proprietor visits the home at least once each week, speaking to service users, staff and the manager at each visit. He also completes monthly Regulation 26 reports. Community meetings take place monthly in the form of two meetings. The first meeting is attended by service users and staff and the second meeting follows immediately and is attended by staff only. At the first meeting service users express any problems, concerns or needs and at the second meeting the manager and staff discuss how the issues raised can be developed or resolved. In these ways the proprietor and manager continually seek the views of service users in order to inform the self-monitoring, review and development of the home. The home has not yet developed an annual formal service users’ survey and so has not yet summarised and published service users’ views. A requirement was made at the inspection of November 2005 for an annual service users’ survey to be conducted by 31st December 2005, when the home would have been opened for one year. However, at that period the home had only three service users, one of whom was unwell, and so it was not possible to carry out an effective survey. Once the home has at least four service users available to take part, it should be possible to carry out an effective survey and so the timetable for this requirement has been extended. See Requirement 1. A variety of documentation relating to health and safety and safe working practices were seen and found to be in good order. These included: staff training in fire, first aid, food hygiene and infection control; COSHH materials stored safely and locked away; boiler/central heating servicing; recording of water temperatures; visitors book; complaints book; regular fire drills and call point testing; recording of accidents and incidents; medication records; safety procedures posted; and emergency lighting tests. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 4 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 3 X Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 4 (1) (c) Requirement The Registered Person must devise and implement an annual formal service users survey. Previous timescale of 31/12/05 not met for acceptable reasons. The timescale for this requirement has therefore been extended. Timescale for action 30/06/07 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 YA20 Good Practice Recommendations The Registered Person should ensure that any PRN medication is entered monthly on MAR charts, even if the medication is not used for several months at a time. Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI Sunnyhill Road 99 DS0000062220.V316854.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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