Inspection on 28/12/07 for Tennyson Road, 104

This inspection was carried out on 28th December 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tennyson Road, 104 19/11/08

Tennyson Road, 104 20/04/07

Tennyson Road, 104 27/11/06

Tennyson Road, 104 28/10/05

Tennyson Road, 104 17/06/05

Tennyson Road, 104 12/03/05

Tennyson Road, 104 14/09/04

Tennyson Road, 104 06/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Tennyson Road, 104 Luton LU1 3RP Lead Inspector Sally Snelson Unannounced Inspection 28th December 2007 13:35h Tennyson Road, 104 DS0000014977.V357206.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 Tennyson Road, 104 DS0000014977.V357206.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. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tennyson Road, 104 Address Luton LU1 3RP 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) 01582 418858 Mr Geoffrey Plane Miss Deborah Newman vacant post Care Home 8 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (8) of places Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2007 (Random inspection) Brief Description of the Service: 104 Tennyson Road is a care home, which is registered for a maximum of eight adults with mental health needs. The accommodation consists of a three-storey house with eight single bedrooms. The office is on the ground floor. It also has sleeping in facilities for staff (including en suite facilities). The lounge, dining room, and the kitchen are also located on the ground floor. The laundry room is located at the back of the house and accessed via the kitchen or from outside. There is a small parking space at the front and a garden at the back. The rear garden is secluded and has some shrubs, trees, flowerbeds, and a small patio area with a barbeque. The home is situated approximately one kilometre from the shopping centre of Luton. A bus stop is located within walking distance of the home. There is a regular bus service to the town centre. The fees for this home vary from £487.70 per week for residential placements, to £768.00 per week according to needs. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection of 104 Tennyson Road was a key inspection, was unannounced and took place from approximately 13.30 hrs on 28th December 2007. Sally Snelson and Louise Trainor regulation inspectors undertook the inspection. The last key inspection had taken place on the 20th April 2007. Then because a resident attempted suicide, a random inspection was undertaken in September 2007. The attempted suicide was reported under RIDDOR and the health and safety investigation remains ongoing. The newly appointed manager, Jane Bozier, was present throughout and feedback was given to her throughout the inspection. During the inspection the care of two people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, and staff were spoken to and their opinions sought. Information gathered at the random inspection of the home, which took place on 26th September 2007, is also included within this report. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. Prior to the inspection four service user questionnaires had been received, however these had all been completed on the resident’s behalf by the then registered manager. We prefer views to be sought more independently, for example from families or advocates if the resident is unable to complete the questionnaires themselves. The inspector would like to thank all those involved in the inspection for their input and support. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the registered manager and the acting manager had both resigned. As a result a new manager who is preparing to go through the registration process had been appointed. The manager appeared to have a clear vision for the home and was aware of the areas that needed urgent attention. Residents commented that they had spent the best Christmas at the home because the staff had been with them and spent time with them. We were aware during the inspection that staff were interacting more often with the residents and involving them in decisions about the home. The manager was gradually working through, reviewing and altering the documentation used by the home. She was also looking at the policies and procedures and updating these as necessary. Care plans had improved although there was still a need for more detail to be included in them. During the day there were now two staff on duty and the on-call system was more robust. Staff were preparing most of the meals from fresh produce and not using as many ready made frozen meals as they had in the past. It was also hoped that residents would become involved in meal preparation. Staff certificates had been removed from communal areas of the home giving the home a more homely feel. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 7 What they could do better: In the short time since the random inspection, the meeting with the proprietors and the new manager taking up her post the home has made a number of improvements. However there are still some areas that need attention and we need to see that the improvements made are sustained. The areas where improvements are needed are :• There must be a Statement of Purpose and Service Users Guide that includes all the required information to ensure that the residents are able to make an informed choice about where they live. • Service users must only be admitted following a full, documented, assessment of need undertaken by staff competent to do so. • All service users must have a signed contract, which protects them from being moved from one room to another. • Care plans must be kept under review and altered, as care needs change. As with care plans risk assessments must be kept under review and altered as needs change. • Procedures for the safe storage, administration and recording of medication must be adhered to, to ensure that residents receive the medications they are prescribed. • All residents must be made aware of how to make a complaint and the timescale within which to expect a response. • Staff must have training on the safeguarding of vulnerable adults that reflects the local policy. • Staff must have the skills necessary to meet service users individual needs, and there must be evidence that the staff have the most current training in specific areas that reflects good practice. • Staff files must include all the documents listed in schedule 2 of the National Minimum standards. • The home must ensure staff have regular, recorded supervision meetings. • To ensure that the home offers the residents the standard of care that they want, and deserve, a regular quality assurance system must be introduced. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 8 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. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 9 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 Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 10 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): 1,3,5 Quality in this outcome area is adequate. The proprietors and the manager had worked on all the admission paperwork to ensure that all new residents would have a thorough assessment from which an admission decision could be made. However because there had been no new referrals this could not be tested. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the random inspection three months previously, it was noted that, ‘the home had an old NCSC registration certificate displayed. The registration certificate allowed for eight service users, with a mental health condition, over the age of 65 years to be admitted to the home. At the time of the inspection there were six service users at the home, including one who was on a family holiday and another who had been admitted (the day before) to an assessment unit because of increased challenging behaviours. Of the six service users, only one was over 65 years old’. Since then we have reviewed the certificate and the proprietors have been sent a notice of the proposed new certificate to Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 11 agree. One resident no longer lives at the home and at the time of the inspection there were five people using the service. Following the random inspection the proprietors were invited to attend a meeting with us to ensure that they were aware of the seriousness of some of the issues from the random inspection. During this meeting they were made aware of the need for the Statement of Purpose to be more specific about the conditions that the staff team had the training and experience to care for, as the certificate would be less prescriptive. Some work had started on reviewing the Statement of Purpose and it was now more detailed. However still more needed to be done to ensure that the Statement of Purpose and the Service Users Guide included all the information required by Regulation 4 and 5 and schedule 1 of the National Minimum Standards and was in a format suitable for those living at the home. There had been no new residents admitted to the home since the last inspection, so it was not possible to assess standard 2 and ensure that the requirement made as part of the random inspection had been met. This requirement was also made as a result of a resident’s self harming behaviour that may have been prevented if the staff had all the available information about the resident at the point of admission. However admission procedures had been changed and the manager spoke of the importance of assessing a new resident and encouraging trial visits in the first instance. When we asked the manager about the admission criteria she was clear that the home was suitable for those with most types of mental health problems, but they needed to be fairly independent and not need more than 2 hours of support at night because of the staffing arrangements. See staffing section of this report. All residents were being issued with new tenancy agreements, which were to be signed by themselves, or a representative, and the management. One of the residents spoken to had agreed to give up her bedroom so that another service user, who had temporary mobility problems, could have a ground floor room for a while. Both residents had agreed this move, but there was no documentation to support it. A robust contract would not allow for this to happen without all those involved being issued with new contracts to ensure that people were not moved about without their consents. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 12 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. Care plans had been reviewed and many re-written in more detail. However staff agreed there was still a need for more improvement to ensure that the residents care needs were comprehensively recorded and could be provided by anyone reading the plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had worked with the staff to look at the care plans and how they were written. It had been identified that in the past not all care needs had been included in the plans, and that in many cases there was insufficient detail to ensure the standard of care required would be provided by someone who did not know the residents as well as many of the staff did. For example, statements such as ‘encourage communication’, did not describe how this was Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 13 to happen. The manager reported that she intended to discuss care plans and the associated risk assessments with the staff team at each team meeting and possibly at supervision sessions, to ensure that they were kept updated. We felt confident that once staff were familiar with the new system the care pans would be improved to a satisfactory standard. Once again, because new systems had been introduced, it was impossible to assess that the plans were being regularly reviewed and updated as necessary. Following the inspection and prior to a serious concerns meeting called by the safeguarding multi-disciplinary team on the 2nd January 2008, the manager reported that only the day before she had separated the risk assessments from the care plans to make both documents easier to use. At this meeting it was agreed that during this period of change the risk assessments would benefit from being reviewed at least monthly. The manager reported that she was surprised at how much was done to the residents, without there being any documentation to support that the residents had made decisions. As a result the manager had already sourced bus passes for the residents so that they could travel if they wanted and access more opportunities. Staff were also involving residents in making decisions about the daily running of the home. One example was that menus had been discarded and some of the residents went with a staff member to do the food shopping, and then daily they decided, from what was available in the fridge and freezer, what they would have to eat. One resident explained that when they went shopping they could choose a treat for themselves. It was also apparent from speaking with the residents that they were making more informed choices about their lives, for example about how much they smoked or drunk. We were concerned that a monitor had been put into the bedroom of a resident without any documentation to support that she was in agreement with this invasion of her privacy. However the reasoning behind the decision was sound as she had recently returned from hospital and might need to speak to staff. As already stated there was a need to make risk assessment more user friendly and ensure that there were risk assessments in place for any risk to a resident associated with their lifestyle. Again, this was well under way and from talking with the manager we had confidence that she was aware of the importance and the need for these documents. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. Since the last inspection it was apparent that residents were being supported to develop socially, both inside and outside the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection it was apparent that the staff team were identifying ways in which to encourage residents to pursue interests and to be part of the local community. For some of the residents staff were taking this change in lifestyle very slowly and were only at the stage of talking to them about doing things, like leaving the home independently, or getting on a bus, while others were already planning holidays and having meals out with staff. The manager had arranged for a yoga teacher to come into the home to work with a resident who did not like leaving the home. The plan was to gradually develop a Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 15 relationship and maybe encourage the resident to eventually attend a class. We still believed that the staffing levels for the home did not take into account residents going out in the evenings if they needed support to do so. At the random inspection it was recorded that the staff had stayed in the office together and the residents had been by themselves in the rest of the home. This was a marked contrast to the staff/resident socialisation that was seen and heard at this inspection. As a result residents were happy to talk to us about their experiences of living in the home and were starting to discuss their aspirations. As already mentioned the manager had discarded the rolling menu plan, and was encouraging the residents to shop weekly and then make daily decisions about what they had to eat from the stocks available. Residents stated that they enjoyed this, and at times they did not all have the same thing. One of the residents had recently started helping staff prepare the meals. The manager was aware of the need to record what residents ate if there were any indications that they were not having a balanced diet, and keep a record of the meals provided. Tennyson Road, 104 DS0000014977.V357206.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 poor Despite an improvement in the way medication was recorded, stored and administered it remained impossible to reconcile the medications as some staff were still not following the procedure correctly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As at previous inspections it was noted that the home had good relationships with community health professionals. However, in the past it had been unclear when residents refused medications, or refused to attend medical appointments and how this was managed. The manager was aware that residents had not been followed up when they made what appeared to be poor uninformed decisions and she was working with individuals to look at their health and how they managed it. For example, one resident was being encouraged to reduce the amount of alcohol he drunk by being reminded about how he felt when he had taken excess. The manager had also discovered that Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 17 another resident who regularly refused medication, did so because she was not up and about at the time she was expected to be at the office to collect her morning tablets. As a result staff were now taking the medications to her bedroom and offering them to her and she was no longer refusing them. The manager reported that the staff rotas were built around any appointments that residents had with which they may need support. Residents confirmed that they could get up and go to bed when they wished and were free to come and go from the house, although it was expected that they would be in by 9pm as there was only a sleep-in staff member on duty. The manager was in the process of assessing the health needs of the residents and only carrying out those regular health checks considered necessary. For example, it may not be necessary for every resident to have a monthly weight check or blood pressure check. All of the Medication Administration (MAR) charts were looked at. There were discrepancies in each one as some medications that were not written as prn medications (to be given as necessary), had not been given if they were not needed, so there were blanks were the carers signatures should be. Talking to staff it was apparent that they believed the medication should be given as necessary and not regularly as documented. It was also noted that a resident was responsible for one of their medications but as this had not been recorded on the chart it looked as though it had never been given. When we discussed our findings with the manager she was shocked that there had been so many omissions despite the extra training she had given staff. We took the opportunity to remind her, that in the future, as the registered manager she would be responsible for what the staff did, or did not do, and that she needed to audit regularly to ensure compliance. Tennyson Road, 104 DS0000014977.V357206.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 adequate. To ensure that staff and residents are kept safe, residents must be aware of how to make a complaint and staff must be familiar with the safeguarding policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We had not received any complaints about the home since the last inspection and the manager reported that she was not aware of any. At the last key inspection it was recorded that staff were aware of the need to detail how any complaints were investigated. All four of the residents who returned a pre-inspection questionnaire stated that if they were unhappy they would talk to a member of the staff team but three of the four recorded that they were not aware of the correct procedure for making a complaint. At the random inspection it was noted that two days before the inspection one of the service users had been involved in an incident on a public bus, which put himself and members of the public at possible risk. This had not been reported via Regulation 37, although when we arrived at the inspection we were asked if a Regulation 37 referral was necessary, and one was completed. The incident had not been reported under the Safeguarding of Vulnerable Adults (SOVA) Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 19 and the staff believed it was not necessary. They were asked to check with the safeguarding co-ordinator that they were correct. The homes SOVA policy was not linked to the local policy and/or the Department of Health ‘No Secrets’ document. It had not been reviewed since 2005. Since then staff had appropriately reported incidents and the new manager was sourcing SOVA training for herself and the staff team. Tennyson Road, 104 DS0000014977.V357206.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): 24,30 Quality in this outcome area is adequate. Small alterations made to the home since the last inspection made it feel more homely and gave the residents an appropriate place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been a number of changes to the home, for example the lounge had been cleared of clutter, it had been painted and new curtains hung. One of the residents had been involved in the changes and was proud of the room referred to as (name of resident) room. The room had also been decorated for Christmas. As a result residents were spending more time in the lounge and had asked for it to become the smoking room instead of the dining room. The manager had suggested that there should be a 2-week trial period of this Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 21 suggestion over the Christmas period and then a final decision should be made at a residents meeting, planned for the 8th January 2008. One resident took us to his bedroom, which he had personalised to his own choice. The manager had some long term plans to improve the environment of the home. There are a number of areas that could be improved upon including, the size of the office, that also had to be used as the staff sleep-in room, and the poor distribution of bathing and showering facilities. Since the last inspection staff certificates had been removed from the hall walls and the home appeared cleaner. Tennyson Road, 104 DS0000014977.V357206.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): 32,34,35,36 Quality in this outcome area is adequate. The new manager was in a position to employ new staff that would have the same vision for the home that she did and consequently reduce some of the institutionalised practices that were seen at previous inspections. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team had changed almost completely since the last inspection. The manager reported that new staff would have the opportunity to complete a robust induction programme. The manager had worked in the past as a trainer and was keen to support staff to learn in which ever way was best for them. The manager and the deputy were sourcing the qualifications they needed for their new role and although some staff had nursing qualifications it must be remembered that they were not employed as nurses and need to undertaken social care training. The manager plans that staff will be asked to feed back from any staff training that they have attended. We discussed the importance of not only recording Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 23 what training staff had attended but also what training any member of staff needed to refresh or attend. Since the last inspection the staff files were have been moved and are now stored in a secure box. The manager was in the process of auditing every staff file and believed that there was something missing from most of them. We discussed the need to either secure the missing documents or record why this was not possible. The manager had ensured that all of the staff had a Criminal Record Bureau check on file. The level of staffing had been a major concern at the last inspection. The manager reported that there was now two staff on duty during the day until 7pm and then one from 7pm to 9pm when that member of staff became a sleep-in. As mentioned previously it is expected that younger adults may want to engage in evening activities and this staffing level would not be able to support this. We were also informed by the proprietor at the serious concerns meeting on 2nd January 2008, that it was not financially viable to have two staff on duty while there were only five residents in the home. However, in order to make it possible for a resident to come home from hospital in time for Christmas staff had done a period of waking nights. In addition to the staff rotas senior staff from 104 Tennyson Rd and the sister home The Beeches provided on call support. A new system was due to start in the New Year with each senior being responsible for one night a week. The manager had re-introduced staff supervision but to date it was not possible to be sure that staff would receive the required six supervision sessions a year. The manger had a structure for supervision sessions. Tennyson Road, 104 DS0000014977.V357206.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): 37,39,40,42 Quality in this outcome area is adequate. The manager appeared to have a clear vision for the home, which would improve the outcome for the residents who lived there and the staff who worked there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had only been in post about six weeks at the time of the inspection and at her own admission had a lot of work to do to get the home to the standard she wanted. The staff on duty were all happy with the changes she had made and believed she was intent on improving the lives of the residents. She was looking into the right courses to gain the necessary Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 25 management qualifications. She was a registered mental health nurse with a previous history in health and social care teaching and so had the necessary care qualifications. She intended to submit an application to become the registered manager in the near future. The manager had introduced weekly staff meetings, which were also being used as training sessions. For example the manager had put together a medication presentation for staff, and together the staff team had discussed an audit system. Residents meetings had also been introduced and the next one was advertised for 8.1.07 at 1pm in the dining room. At the random inspection we were given copies of quality questionnaires that had been completed in Autumn 2006 by families and relatives and in February 2007 by the people who lived at 104 Tennyson Rd. On the whole families rated the home as satisfactory and the residents as good. Both groups rated activities as poor. The proprietor responded to this by informing everyone of the cut backs to day care services. To inform the annual development plan the manager needed to repeat and expand these questionnaires. The home had a policies and procedures file, but many of the policies had not been specifically written for the home and had not been updated and reviewed. The manager planned to look at a number of policies at each staff meeting and after discussing the content with the staff team expected the staff to sign to say they had read them and agreed to work with them. There was nothing to suggest that since the appointment of the new manager there were robust systems in place to check all the health and safety equipment in the home. Tennyson Road, 104 DS0000014977.V357206.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 X 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 3 x 2 X 2 3 x Tennyson Road, 104 DS0000014977.V357206.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 4,5,and schedule 1 Requirement Timescale for action 01/04/08 2 YA2 14(a) There must be a Statement of Purpose and Service Users Guide that includes all the required information and ensures that the residents are able to make an informed choice about where to live. 01/04/08 Service users must only be admitted following a full, documented, assessment of need undertaken by staff competent to do so. This requirement was made as a result of the random inspection on 26.9.07 and could not be assessed as no new service users had been admitted. It was therefore extended. All service users must have a signed contract which protects them from being moved from one room to another. Care plans must be kept under review and altered, as care needs change. This requirement was made as a result of the random inspection and because care DS0000014977.V357206.R01.S.doc 3 YA5 5 (c) 01/04/08 4 YA6 12,15 01/04/08 Tennyson Road, 104 Version 5.2 Page 28 5 YA9 12 6 YA20 13(2) 7 YA22 22 8. YA23 12 & 13 plans had only been rewritten since the new manager had been employed it was not possible to assess that they were being updated and reviewed regularly. As with care plans risk assessments must be kept under review and altered as needs change. Procedures for the safe storage, administration and recording of medication must be adhered to ensure that residents receive the medications they are prescribed. All residents must be made aware of how to make a complaint and the timescale within which to expect a response. Staff must have training on the safeguarding of vulnerable adults that reflects the local policy. Staff must have the skills necessary to meet service users individual needs, There must be evidence that the staff have the most current training in specific areas that reflects good practice. This has been extended from 15/12/07 to allow for the new staff team that have been employed Staff files must include all the documents listed in schedule 2 of the National Minimum standards. The home must ensure staffs have regular, recorded supervision meetings This has been extended from 15/12/07. DS0000014977.V357206.R01.S.doc 01/04/08 01/04/08 01/04/08 01/04/08 9 YA32 YA35 12 (4)(b) 01/04/08 10 YA34 19 Schedule2 18 (2) 01/04/08 11 YA36 01/04/08 Tennyson Road, 104 Version 5.2 Page 29 12 YA39 24 To ensure that the home offers the residents the standard of care that they want, and deserve, a regular quality assurance system must be introduced. 01/04/08 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. 3 4 Refer to Standard YA7 YA19 YA24 YA40 Good Practice Recommendations There should be documentation to support any systems which could invade a residents privacy. Consideration should be given to offering the residents the opportunity to pursue evening activities. The home should continue to work to a refurbishment improvement plan. The manager should ensure that all the policies and procedures are reviewed. Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Tennyson Road, 104 DS0000014977.V357206.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!