Inspection on 27/02/07 for Sycamore, The

This inspection was carried out on 27th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore, The 23/02/09

Sycamore, The 23/11/05

Sycamore, The 26/07/05

Sycamore, The 17/03/05

Sycamore, The 16/06/04

Sycamore, The 09/02/04

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Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Sycamore, The 34 Lancaster Avenue West Norwood London SE27 9DZ Lead Inspector Sonia McKay Unannounced Inspection 27th February 2007 09:00 DS0000022767.V320957.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 DS0000022767.V320957.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. DS0000022767.V320957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore, The Address 34 Lancaster Avenue West Norwood London SE27 9DZ 020 8761 9064 and 020 8761 4909 020 8761 9064 corinne@mcdonald34.freeserve.co.uk 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) L`Arche Lambeth Ms Corinne McDonald Care Home 5 Category(ies) of Learning disability (0) registration, with number of places DS0000022767.V320957.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: The Sycamore is a residential home for five adults with a learning disability. It is one of five residential care homes in the locality that form the L’Arche Lambeth community. The aim of the community is to create communities that welcome people with learning disabilities. Fundamental principles of the community are that each person has a right to friendship, a spiritual life and to live in an environment that fosters personal growth. It is a large Victorian house with front and back gardens. It is located on a residential street close to shops and transport links. The team of assistants live in the home and are managed by a house leader. LArche also provides access to college courses, therapeutic daytime activities and skills workshops, such as candle making, gardening, stonework, packing and weaving. Service users are encouraged to participate in all aspects of community life. A copy of the most recent inspection report is available in the home on request and weekly placement fees start from £797.00 and increase depending on the amount of staff support that an individual needs. DS0000022767.V320957.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of The Sycamores was conducted in five hours. The inspection involved observing meal arrangements (breakfast), talking with four service users before they went out of the house to attend their daytime activities and discussion with staff and the home manager. Records relating to care provision, the physical environment and staff recruitment and supervision were examined, along with records of local authority placement reviews and team meetings. There was also a tour of the premises. What the service does well: What has improved since the last inspection? New furniture has been purchased for a communal lounge and a shower room has been refurbished. The carpets on the stairs and in the hallway have been replaced. One service user now has some pet goldfish. The home manager has completed her vocational studies and now has qualifications in care and management. Risks associated with access to hazardous cleaning products have been examined and steps have been taken to make the kitchen safer. DS0000022767.V320957.R01.S.doc Version 5.2 Page 6 The organisation is making a great effort to make sure that staff are good and that people with disabilities are safe when being cared for by staff. Quality assurance systems are developing, involve consultation with service users and assess outcomes for service users. 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. DS0000022767.V320957.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 DS0000022767.V320957.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, 3, 4 & 5. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users have adequate information to make an informed decision to move into The Sycamore. Additional information must be provided in accordance with recent changes in legislation about fee transparency. There is an extensive opportunity to ‘test drive’ the home. Individual needs and aspirations are assessed and met and each service user has a written and visually accessible contract stating the terms and conditions of occupancy. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users’ Guide’. Emphasis is placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. The statement of purpose has been revised to include up to date information about the current staff team. There is also a guide for people using the service. This contains a summary of the purpose of the home and a description of the services provided. The guide is user friendly and contains many colour pictures, making it more accessible to people who would find a text only document difficult. DS0000022767.V320957.R01.S.doc Version 5.2 Page 9 Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. (See requirement 1) L’Arche offers long-term placements only and has a lengthy placement process, which is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This provides the referred person with an opportunity to experience life in the home before making a positive choice to move in for a trial period. The most recently admitted service user to The Sycamores had visited the home on a number of occasions before making a decision to move in There has been a detailed six-week and six month placement review involving the core member and his family, social services and staff from the home and the LArche workshops. The views of existing core members are also taken into account during the placement process and trial period. L’Arche places emphasis on providing staff with communication support skills and provides staff with ‘sign-a-long ‘ training, and specialist training for communicating with adults with a learning disability. A database of photographs of all community members (core members and staff), significant locations and other useful objects is available to assist with this. Each service user has a contract of service and occupancy that is produced in an accessible format with pictures and symbols that is explained to service users if they are unable to understand the document themselves. Copies of these contracts are available in individual care files. DS0000022767.V320957.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 & 10. 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 assessed needs and goals are reflected in their individual plan. They are consulted on and participate in all aspects of home and community life and are able to maximise their independence through a framework of risk management. Information about service users is handled appropriately and confidentially. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set with the service user, home staff and staff from the workshops. L’Arche are developing service user accessible plans. Care plans are appropriate and detailed and considerable work has been carried out with service users to ensure that staff are able to understand each persons method of communication. Placing authorities have reviewed the care provided to all service users. The service user invites people of their choosing to the in-house annual review, DS0000022767.V320957.R01.S.doc Version 5.2 Page 11 this may be family members, home/workshop and senior staff and a LArche advocate. Staff work creatively with service users before an annual review to enable them to understand and contribute as much as possible to the process in ways of their individual choosing (video, photographs, spoken word, objects, music and drawings). The actual review meeting is held in a place that is comfortable to the service user (either at home or in a formal meeting room). The meeting aims to review the past year’s success and difficulties and the health of the service user, review goals and plan how new goals can be supported. Risks and independence are discussed and reviewed regularly. The home manager said that initial steps are being taken towards independent travel for one service user, by travel training, although these are long-term plans. A general risk assessment process is in place. The document covers topics and activities that each service user is likely to engage in and indicates the level of risk posed to the service user during each activity. In the event that an activity is deemed to present a higher degree of risk to their health and safety, a more detailed individual risk assessment is completed identifying the steps taken to minimise the risk. The home manager explained the need to take risks as part of developing a more independent lifestyle. L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a key worker. This is in place at The Sycamore. L’Arche uses a semi-independent advocacy system. This ensures that someone from outside the home who knows the service user and sees them often is involved. The services of fully independent advocates are obtained if major decisions need to be made. Service users are encouraged to participate in the day-to-day running of the home and in community planning. They can take part in weekly house meetings, ‘talking group’ meetings with the community director six times a year and community council elections. Service users are also involved in the assessment of new staff during their probationary period and in discerning internal applications for house and community leaders. Confidential written information about each service user is stored securely in lockable filing cabinets in the home managers office. DS0000022767.V320957.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 have opportunities for personal development. They are able to take part in a wide range of leisure activities, and therapeutic employment. Appropriate relationships with family and friends are encouraged and supported. Service users are encouraged to be responsible in their daily lives. Meals are healthy and attractively presented and mealtimes are relaxed. Staff interact well with service users. EVIDENCE: L’Arche is a faith-based community and offers active support to each service user to develop their faith and spiritual lives. Service users who choose not to attend religious activities of any particular denomination are offered alternative activities. All service users are offered opportunities to engage in art, music and nature. DS0000022767.V320957.R01.S.doc Version 5.2 Page 13 Each service user has a place in the L’Arche workshops (weaving, stone work, gardening and candle making). Two service users also visit the LArche retirement group. Some service users attend local college classes specifically for service users with a learning disability, developing skills for daily living, drama, music, art and sailing. One service user is attending mainstream classes. Service users said that they enjoyed their daytime work and activities. A wall planner with symbols and photographs is available for each service user; this serves as a reminder of what is going to happen each day. The proximity of the other L’Arche homes provides a close community. L’Arche Lambeth has been operating for almost thirty years and has developed good relationships with local individuals and organisations. There are plans for a celebration of the community to mark the thirtieth year. Service users have been consulted and have opted for a party, with a disco and a fish and chip supper. Some of the staff live at The Sycamore with the service users, with the intention of building a shared community and consistent engagement between the staff and the service users. Attention is paid to special celebration days and there are birthday parties and dinner parties with guests. All service users are offered a minimum two weeks holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interests. Holidays have included trips to France, America, Canterbury, and Ireland. One service user recently visited India and spoke happily about his trip. The home manager said that home staff supported the cultural needs of one service user by making Caribbean Gospel music available, exploring Caribbean recipes and visiting culturally appropriate hair salons, markets and restaurants in the area. One service user has recently purchased some goldfish, and staff support her to look after her pets. Personal information held in individual care files contained detailed information about family and friends, their birthdays and family history. This enables staff to support service users to maintain and develop family relationships. Discussion with the home manager indicates a healthy attitude towards sexuality, and one young male service user is on the waiting list for a men’s discussion and education group. One service user is able to use a front door and bedroom door key. DS0000022767.V320957.R01.S.doc Version 5.2 Page 14 Observed interactions between the staff and the service users were respectful, natural and caring. The service users and assistants eat at a large dining table together in the communal kitchen. Breakfast was being served as the inspection began. Service users and staff interacted well. Each service user has the breakfast menu of their choice. Records of meals eaten examined indicate that a range of meals are served. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Each service user chooses and helps to prepare an evening meal each week to the best of their ability. DS0000022767.V320957.R01.S.doc Version 5.2 Page 15 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. Service users receive personal support in the way they prefer and require. Service users physical and emotional needs are met and the home manager is liaising effectively to improve pro-active healthcare and understanding of the individual treatment needs of individual service users. Staff must ensure that prescribed medication is administered as prescribed and records must be kept of all administration to avoid potentially dangerous mistakes and overdose. EVIDENCE: Service users are well dressed in clothes that are weather appropriate, in styles that reflect their personal choice, personality and the day ahead (for example, sensible clothing for gardening work). A staff team comprised of both men and women provides same gender personal care support. Female staff occasionally provide personal care support to one male service user. This has been discussed and agreed with the service user and professionals involved in his care. Personal care routines are clearly laid out in individual plans, detailing the level of support required with each task. DS0000022767.V320957.R01.S.doc Version 5.2 Page 16 The home manager is working with the local group practice and a hospital trust to improve healthcare for adults with a learning disability and communication needs. The potential outcomes for this work are: increased understanding of the healthcare needs of individual service users, better access to health services and developing tools to assess levels of distress that can be automatically communicated to nurses, doctors and consultants (for example, signs of anxiety or pain an individuals inability to wait patiently in hospital or surgery waiting rooms). Records of the health appointments attended by the service users indicate that the home maintains adequate records of healthcare. Support is provided for each service user to attend a range of appropriate healthcare appointments. Healthcare provided includes regular visits to the dentist, doctor, optician, audiologist and neurologist. There is also input from specialists from the community team for adults with a learning disability on referral. A member of the behaviour support team visited on the day of the inspection to discuss an assessment of one of the service users. Staff support service users to take their medication. The home manager has developed good procedures for the management of medication, especially monitoring of liquid stock. There is a range of written information about medication available including details of each person’s preference for taking their medication. • • • • • • • • • There are clear MAR charts with a photograph of each service user to aid identification There is clear and detailed information about each prescribed medication, why it is being used and any potential side effects There are clear medication procedures that are reviewed regularly There is a letter from the GP about what over the counter medicines each service user can have (to avoid contra-indications) There are clear guidelines for when staff should administer as required medication (PRN) There is detailed information about what symptoms to look out for and how individual service users may express pain or discomfort There is a system of stock checking that justifies stock available with stock administered or disposed of There is a staff signature list to identify who has administered a dose of medication There is a register of medication collected from the pharmacy and disposed of Staff are vigilant when checking medication collected from the pharmacy, recently identifying that an incorrect medication had been dispensed. Staff DS0000022767.V320957.R01.S.doc Version 5.2 Page 17 took appropriate action to ensure that the service user obtained the correct medication. However, a check of medication administration records shows that there are still occasional gaps in recording when a medication is administered. Although medical advice is taken about any implications of missed doses, it is essential that medication be administered as prescribed at all times and that a record is maintained of all medication administration to avoid overdose. (See previous requirement 2) DS0000022767.V320957.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): 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 feel their views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has a good complaints policy. There is text version and a more accessible version with photographs and symbols for service users who may not be able to understand a ‘text only’ document. A complaints poster is displayed on the notice board in the communal kitchen and has colour photographs of people who can assist with a complaint, including the CSCI. Regular weekly house meetings provide service users with an opportunity to raise their concerns. Each weekly meeting provides an opportunity to raise and discuss any complaints or concerns. Two complaints have been recorded in the home’s record of complaints made since the last inspection visit. A visitor complained that there were no biscuits and a member of staff had complained about noise disturbance from a toilet ventilation system. Both complaints had been responded to appropriately and the actions and outcomes recorded. A record of visitors to the home is available and is being used appropriately. DS0000022767.V320957.R01.S.doc Version 5.2 Page 19 Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. Staff were observed to manage instances of minor challenging behaviour calmly and appropriately. The relationships and interactions between service users are also closely monitored by the home manager. Service users receive support from staff to manage their personal finances. Cash is locked away and records and receipts are kept of each expenditure. DS0000022767.V320957.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, 25, 26, 27, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. EVIDENCE: The large home is suitable for its purpose, comfortably furnished, homely and clean. The large rear garden and back veranda provide adequate outdoor space. The homes location offers good access to local amenities, public transport and services. All bedrooms are single occupancy and attractively furnished to the preference of the individual accommodated. Plans are underway for one service user to decorate his own bedroom with staff support. There are two communal lounges that are comfortable and well furnished. DS0000022767.V320957.R01.S.doc Version 5.2 Page 21 New furniture has been purchased for one lounge. Bathrooms and toilets are sufficient in number and well situated close to bedrooms and communal areas. The first floor shower room floor has been refurbished, as required in the previous inspection report. This is an improvement although mould is reappearing on the walls and ceiling. The home manager said that this had been referred for investigation. The hall and stair carpet has been replaced, as required in the previous inspection report. A noisy ventilation system in a ground floor toilet has been replaced. The home is clean and pleasant smelling and hand-washing advice and facilities are readily available. There are regular ‘in house’ environmental safety checks, and a record is maintained. Fire authorities inspected the premises on the 15th May 2006 and confirmed that fire safety arrangements are satisfactory. DS0000022767.V320957.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, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have clearly defined roles and responsibilities and a training programme provides mandatory and specialist training to meet the specific needs of the service users. The provider has recognised that national minimum standards relating to vocational care qualifications for staff are not met, possibly because of high staff turnover and the recruitment routes used, and is taking action. Although the system is not in accordance with best practice, recruitment procedures have been further developed to ensure that service users are adequately supported and protected. Staff are well supported and supervised. EVIDENCE: L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. Staff are paid a small wage/expenses for a 48-hour a week commitment to the home and L’Arche community. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a DS0000022767.V320957.R01.S.doc Version 5.2 Page 23 combination of ‘in-house training’, mandatory training and training provided by the local specialist learning disabilities team. NVQ training is provided for staff that are able to commit to more than two years. Working visa constraints prevent some staff from staying in the UK for more than a year, so few have achieved this. The status of the assistants means that they do not normally have NVQ qualifications when they arrive and the director of L’Arche has conceded that it will be hard for the organisation to meet the national minimum standard for staff qualification. To address this, some posts are now set aside for staff who can offer a longer commitment. It is hoped that this strategy will reduce high staff turnover at the Sycamore and increase the availability of staff with a vocational qualification. (See previous requirement 3) On the day of the inspection one service user was looking forward to seeing an ex-assistant who was visiting to have dinner with everybody that evening. There is a team training and development plan and records of training undertaken by individual staff are well kept. As new assistants (staff) arrive on a regular basis this training programme is ongoing. Records are kept of who is working each day in the home and staffing levels are adequate. There is a minimum of three assistants on duty during the day and two on duty but asleep at night. Agency staff are not used. Assistants from other LArche homes provide sickness cover if necessary. During the previous inspection a requirement was made in regard to ensuring that staff have had adequate checks before commencing work in the home. Evidence of checks made on staff examined during this inspection indicate adequate checks had been carried out and the requirement is therefore met. The recruitment co-ordinator continues to make progress in auditing staff records and developing recruitment procedures. L’Arche is in a challenging position in this respect, as staff are often recruited from overseas and cannot therefore complete a CRB check until they arrive in the UK. As some staff are destined to ‘live-in’ this presents a risk to service users, as staff have not been fully checked before they arrive in the home. L’Arche is working hard to reduce this risk and has developed a range of polices, procedures and risk assessments to ensure that staff undertake the checks immediately on arrival to the UK. Additional reference checks, DS0000022767.V320957.R01.S.doc Version 5.2 Page 24 overseas police checks and translation of documents are completed before arrival. Clear responsibilities have been developed for the home manager and other staff to ensure that new staff are appropriately supervised during the period of time when only POVA first clearance is in place. This includes risk assessment and reduced responsibilities in providing care and support to service users, for example, not providing personal care or going out alone with any service user. The home manager is trained in supervision and supervises each member of staff on a regular basis. New staff are supervised frequently until they are established and familiar with the home and the service users. Supervision records examined show that meetings are held regularly and a member of staff confirmed that he has regular meetings with the manager. There are regular team meetings and minutes of the discussions and decisions made are available. DS0000022767.V320957.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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. The home is well run and the registered manager is experienced and qualified. There is evidence of ongoing service development and positive feedback about management style. Quality assurance systems are developing and are based on outcomes for service users, although the registered provider has continued to fail to conduct regular inspections of the service and provide reports in accordance with regulation. Adequate systems for ensuing that health and safety are maintained are in place. EVIDENCE: The registered home manager has been in post for almost six years and has completed an NVQ level 4 in Care and Registered Managers Award. DS0000022767.V320957.R01.S.doc Version 5.2 Page 26 The manager has an in depth knowledge of the Sycamore service users and displays good leadership and commitment to her role. She is taking a positive approach to improving and developing the service provided and in encouraging the creative thinking of the staff team. This has resulted in well thought out written information about each service user, often written with full involvement of the service user. A member of staff spoke positively about the manager, saying that she is approachable, supportive and understanding. The L’Arche community has an annual development plan for quality assurance in place and consults with service users on a regular basis. The registered manager completed a quality check in February 2007 and is due to complete the annual quality assurance monitoring audit report in March 2007. Quality surveys have been sent out, but the home manager said that few have been returned. A requirement was made in the previous inspection report, as the home has not been visited on a monthly basis by a representative of the responsible person as required by Regulation 26 of The Care Homes Regulations 2001. This requirement is not met. Records available suggest that these visits have only been conducted three times in the last twelve months. The registered person must ensure that provider inspections of the service are carried out on a monthly basis. (See previous requirement 4). A requirement was also made about the risks of storing dishwasher tablets under the sink, as there is a risk of accidental poisoning. A risk assessment was carried out and appropriate measures to reduce the risk are now in place. • • • • • • • • The Gas Boiler annual safety certificate is available and is dated 15/08/06. Mains electrical circuitry had been safety tested on 22/09/06. The test certificate was noted to cover a five-year period from that date. Small electrical appliances had been safety tested on 11/12/06. The range cooker was serviced on 15/02/07. Fire authorities inspected the premises on 15/05/06. Regular checks are conducted on fire detection and emergency equipment. Fire evacuation drills are conducted with the required frequency. Environmental and fire risk assessments are conducted annually. Accidents and incidents are recorded and reported appropriately. DS0000022767.V320957.R01.S.doc Version 5.2 Page 27 ‘In house’ Health and safety responsibilities are nominated to a member of the team and a record of the environmental checks undertaken maintained. A fire risk assessment, fire notices and a building floor plan are available. Fridge and freezer temperatures are checked daily. A record is kept of all visitors to the home. Environmental health inspectors inspected the food handling arrangements on 25/01/07. The report of the inspection confirmed that food hygiene standards are being maintained. There is a photographic guide to good hand washing that service users can refer to when washing their hands at the kitchen hand-wash basin. DS0000022767.V320957.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 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 2 X 3 4 2 X X 3 X DS0000022767.V320957.R01.S.doc Version 5.2 Page 29 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement Timescale for action 30/06/07 2. YA20 13(2) 12(1) The registered person must revise the service users guide in accordance with recent changes in legislation. 30/04/07 The registered persons must ensure that service users do not miss doses of prescribed medication. The previous timescale of 31/12/05 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by The registered person must ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. Although some staff still do not have the required qualifications in some cases, a strategy has been DS0000022767.V320957.R01.S.doc 3. YA32 18(1)(a) 31/07/07 Version 5.2 Page 30 4. YA39 26 developed and progress will be monitored. The registered person must ensure that monitoring visits conducted on behalf of the registered provider, as required by Regulation 26, occur at least on a monthly basis, are unannounced and result in a written report that is supplied to the home manager and the CSCI Southwark office. The previous timescale of 30/04/06 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000022767.V320957.R01.S.doc Version 5.2 Page 31 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 DS0000022767.V320957.R01.S.doc Version 5.2 Page 32 - 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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