Inspection on 15/08/07 for Thicket Road

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thicket Road 15/12/09

Thicket Road 31/05/06

Thicket Road 03/01/06

Thicket Road 18/05/05

Thicket Road 19/10/04

Thicket Road 30/04/04

Thicket Road 21/12/03

Thicket Road 14/08/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Thicket Road 79 Thicket Road Penge London SE20 8DS Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 15th August and 29th 2007 09:30 Thicket Road DS0000006968.V339475.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 Thicket Road DS0000006968.V339475.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. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thicket Road Address 79 Thicket Road Penge London SE20 8DS 0208 776 9569 0208 776 9569 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) www.leonard-cheshire.org.uk Leonard Cheshire Ms Susan Cornish Care Home 7 Category(ies) of Learning disability (7), Physical disability (1) registration, with number of places Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: The home is a seven-bedded facility for those residents with a learning disability including one person with a physical disability. The residents in this home have challenging behaviour and need structured behaviour programmes with on-going support. Staff are provided throughout the 24-hour period with waking night staff. The home is a large detached house in a residential area of Penge. It is well served by public transport and close to local amenities. The home has undergone major refurbishment including a two-bedded extension on the lower ground floor. This has significantly improved the home for residents and staff. Policies, procedures and documentation are generated through Leonard Cheshire Foundation with amendments made locally. The fees in this home range between £1,200 and £1969.83 weekly. Once received the report will be made available in a pictorial format, as other documents have already prepared in this format. Staff will spend time going through the elements of the report with residents and facilitate a level of understanding as far as their abilities allow. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a two day period. During the first site visit the inspection was facilitated by the Deputy Manager. The inspector spent time observing day to day routines and the practice within the home. Staff on duty were interviewed by the inspector, including those who were key workers to the residents involved in case tracking. Engagement with residents by the inspector, was limited due to communication barriers, however there were many signs amongst the resident group of well being. The atmosphere in the home was relaxed and residents were observed to be involved in individual activities where choice and independence were promoted. The inspector case tracked resident’s care plans and supporting documentation to cross referenced the observed practice and monitor compliance with individual support plans. The inspector sampled records and documentation relating to quality assurance, staff recruitment and training as well as health and safety service records. The inspector was able to confirm that many areas of the home had improved, which impacted positively on the lives of residents and staff working in the home. What the service does well: The home manages some of the most challenging residents in this community setting. Residents in this home have complex needs including physical, mental and leaning disability issues. Choice, privacy and dignity are all paramount within the residents care. The service has retained a core group of senior staff who have provided consistency to the home and stability particularly in some of the difficult periods the home has experienced. Staff have been receptive to comments and feedback provided, and acted upon these to enhance the quality of care. Leonard Cheshire as an organisation have also been supportive to the home and staff confirmed this to be the case. The home has developed good working relationships with the specialist and multi disciplinary teams who provide ongoing support and advise to the home staff. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home has a good foundation from which to work however this must be maintained and where appropriate enhanced. One example is in respect of staff training whilst this has improved more needs to be done in relation to mental health both in terms of practice and the knowledge base. Within the logbooks which detail the individual progression records more detail should be included to fully represent the resident’s day. The management should try to fill the staff vacancy to ensure consistency of resident’s care and strengthen the staff team. Efforts to enhance existing communication tools should be continued to obtain maximise benefit for the resident population. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 7 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. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 8 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 Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome are good. This judgement has been made using available evidence including a visit to this service. Residents are subject to comprehensive assessment procedures, which, with this type of resident is essential to maintain a therapeutic environment in the home for all residents. Staff have amended and adapted pre assessment information to maximise residents understanding of the services provided. EVIDENCE: At the time of the two site visits there were six residents in the home. The home has had one vacancy for almost a year and although efforts have been made to fill this to date this has not been successful. There is discussion within Leonard Cheshire regarding this, and whether to operate the home as a six bedded facility only. The assessment procedures into the home, can take a considerable time to complete to confirm the residents suitability. It s essential with such a client group that prospective residents are subject to robust assessments and lengthy introduction periods to reduce potential disruption both to the new admission and the existing residents. There have been no new residents admitted to the service for two years therefore current assessment procedures were discussed although not evidenced. In previous inspections these has been evidence of assessment by Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 10 the staff in Thicket Road, multidisciplinary input, trial visits and introductory periods. The Manager outlined the admission procedures as follows: There would be an initial contact made either directly to the home or through the multi disciplinary team. An information pack would be sent out including the Statement of Purpose and Visitor’s and Resident’s guides. These documents have been produced in pictorial formats to assist with communication and understanding of the home and it’s services. Once the information had been received then an appointment would be made for the next of kin and where possible, the resident themselves to view the home. Information from the multi disciplinary team and the Care Manager’s assessment would be requested. A team meeting would be convened to relay the information regarding the possible new admission, to staff. The resident, next of kin and Care Manager would be invited for an initial discussion wher any areas of concern could be discussed. Funding approval would be obtained. Introductory visits, including overnight stays to the home would be organised and these would vary in number depending on the resident. These visits would serve as an opportunity for residents to meet with their key worker, staff and other residents. If all areas were satisfactory a letter confirming placement would be sent. Contracts, terms and conditions would be issued. Once an admission date has been agreed then the transport arrangements would be confirmed. The resident would be registered with the GP and contact made with the specialist services at Bassett’s centre. The key worker would start the initial care plan documentation using the assessments information and that gained through trial visits. There would be a three month trial period included. In the two resident’s files inspected there was documentation relating to terms and conditions and the tenancy agreement signed by the Care Manager. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 11 Thicket Road DS0000006968.V339475.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has individual guidelines, which detail the care to be provided, and how staff are to provide it. The care plans are specific to the individual’s identified needs and draw upon the experience of the multi disciplinary team to provide a comprehensive record of support and identified risks. The care plans and supporting guidance provide a good tool on which to base the care and support for the individual resident. EVIDENCE: The inspector selected two care plans for inspection. The care plans contained a photograph of the resident, next of kin information and details of multidisciplinary contacts including the GP and Social Worker. Within the first file, there was information of a review that had been undertaken at the Day Centre to monitor progress on the individual’s programme of activities. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 13 Each resident has individual guidelines outlining the specific way their care is to be delivered. These guidelines are detailed and reflective of resident’s abilities and disabilities. The first care plan included an individual emergency statement, medication procedure, missing persons, a gender care statement and procedure, bathing procedure and dietary information. Some of the guidelines had been created in pictorial formats to aid residents understanding. These individual guidelines were regularly reviewed and all had been addressed within the last two months. Some entries had first names of the staff member, and not all records had full signatures. Full signatures and dates should be used on all records There was a detailed summary outlining potential risks drawn up by Lorne Taylor a member of the specialist learning disability service. This document included trigger factors and staff interactions to reduce risk. Other information in the residents file included monthly progress reports and information on relapse indicators. There was a summary of the Social Services review conducted June 2006. One resident had a behaviour-monitoring chart in use. Logbooks record the daily events of individual residents. Some of these entries were limited in content and did not provide relevant or comprehensive information on the residents. This needs to be addressed. In the second care plan, again there were comprehensive instructions on how to provide care covering personal care, sunburn, allergies, going out, and an individual financial statement. There was detailed instructions on the medication management and administration of drugs. This resident also had a weekly activities programme. The progression records in the logbook were again in place and dated although some of these could have provided more information. Risk assessments were in place for individual missing persons, personal emergency plans as well as homely remedies and specific medication guidelines. Records are safely stored in the staff office located on the ground floor. Please see requirement 1. Please see recommendation 1. Thicket Road DS0000006968.V339475.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and enabled to partake of opportunities provided in the local community to enhance their quality of life including those for leisure, work and health care. Visiting and family contact is facilitated with open visiting times and residents are supported for home leave periods. EVIDENCE: During the two site visits the staff were supporting residents with their individual programmes including leisure and social activities. On the first visit the inspector spent a lot of time observing practice on both floors, noting the interactions between staff and residents, as well as residents with one another. It was evident that the residents were more relaxed and the home itself felt calmer. Staff were seen to accompany residents out and engage with them in activities. Some residents in this home attend local day centres for varied Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 15 social and leisure activities. Other activities include going to the pub to have a meal, a dance class, day trips to beach resorts, museums and galleries. Whilst in the home residents are supported to be involved in meaningful activities enhancing or developing existing skills. One example of this was a resident with a staff member preparing lunch. Residents are involved in menu planning with staff support. The individual resident’s specific dietary needs are detailed in the support plan. The menu is varied and healthy eating is encouraged, although this sometimes is not the resident’s choice. Specific dishes including ethnic and vegetarian options are included to encourage residents to try different foods and eat a varied diet. In one care plan viewed this resident had been a volunteer in the past and had attended one of the local day centres. A report detailing the progress made was on file. The home has established links with organisations that offer employment initiatives. There is a park close by and residents use this, although none are able to go out of the home unescorted. The home has it’s own transport and taxis are also used as a mode of transport. Residents in the home do have freedom passes, which allows free travel on public transport. In early September, two resident and three staff are due to do go on holiday to Bultlins. Staff are paid whilst accompanying residents on holiday. The remainder of the residents will have other trips arranged. Residents have their own notice board. The residents have their own meeting, which is chaired by an external facilitator, who is a member of the resident support team. Thicket Road DS0000006968.V339475.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care in this home is well provided for, with specialist multi disciplinary support included in the ongoing and overall care provided. All other healthcare is accessed where possible, through the local provision, to encourage integration and normality into the resident’s lives. Residents can be confident that all of their healthcare needs will be addressed either by staff in the home or through the healthcare provision. EVIDENCE: All residents have single bedroom with a wash hand basin. Toilets and bathrooms of different types and styles and are located throughout the building One bathroom had a manual handling aid. Specific plans are in place to address resident’s hygiene and personal care In both those individual files viewed there was good information in respect of multi disciplinary team support. Multi disciplinary information was in place from the Psychiatrist, GP and from the Bassett’s Centre. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 17 Each resident is subject to an annual medication review .The GP deals with the management of the medical conditions whilst Dr Winterholder deals with the learning disability side of resident’s heath. Two residents go out to a local optician’s, whilst two are seen by the visiting service. All residents are seen at the Bassett’s centre for dental checkups. Hearing appointments are dealt with through GP referral. There was documentation evidencing health care input regularly. The home has devised a pictorial information brochure detailing hospital procedures. In addition it is piloting Pictorial Health Action plans, for one resident, which has been recommended from Southwark Social Services Residents have individual records in place including seizure monitoring and behaviour monitoring charts, when applicable. The Management in the home check to ensure residents are receiving regular health care however a simple matrix would make this an easier task than checking the documentation. The Manager advised the inspector this had already been identified for action. In the second care plan, this resident had been referred for music therapy and an assessment summary was available. There was evidence of a referral to the wheelchair service as well as one to the speech and language department. The home has a death and dying policy and individual arrangements would be recorded which are usually the next of kin’s instructions. More work is underway with residents to address this subject. Regulation 37 reports are forwarded to the CSCI and these have remarkably reduced in the last 12 months. Regulation 37 reports are audited for any heath and safety issues. Information from the multi disciplinary team indicated that incidents relating to challenging behaviour were low in this home. The medications systems were inspected. Currently there are no residents who self medicate. The medication is supplied through Boots. The medication file had clear photographs of residents and the file was well organised. There was a medication procedure in place, which included guidance on refused medications. Each resident had an individual homely remedies signed by the GP. This contained information on maximum dose and the reason for administration of that specific medications. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 18 Each resident has specific guidelines for their medication administration, as it is important this is addressed properly. All medications in use have information about their uses, side effects and therapeutic range. This is good practice. Those medications used “ as required “ are recorded separately. On the medication charts themselves there was evidence of medications signed in to the home and signatures for administration of medications. Allergies were recorded. The medications returned are recorded in to a book and stamped by the receiving pharmacist. There was no overstocking noted. The drugs fridge contained antibiotic syrup, which was dated on opening. There were no Controlled Drugs in use. Medications are checked by the shift leaders daily. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on how to raise a concern or complaint is available and as far as possible efforts have been made to maximise understanding of this information for residents benefit. Complaints are addressed within stated timeframes and information on external avenues for referral are included in the information. Staff have policies and procedures available for complaints, adult protection and whistle blowing, all staff had an understanding of these and how they should be implemented and actioned, which affords protection to residents. EVIDENCE: The CSCI has received no complaints about this service since the last key inspection. The home has its own complaints policy that details timeframes and external avenues for referral if dissatisfied. The complaints procedure was seen to be available in a pictorial format and can be made available in other languages. The home operates with a standard complaint/compliments record form. This is retained in the home and at Leonard Cheshire head office. The last recorded complaint in the complaints file was dated 23/10/06. The form outlined the complaint, supporting letters and correspondence were also available. The form should be amended to clearly detail if the complainant is satisfied with the outcome as currently this is only indicated in the final letter. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 20 Complaints are monitored by head office and any emerging themes would be investigated. The home has a specific whistle blowing policy, which is made available to all staff. Complaint policies and whistle blowing policies are reiterated through supervision sessions with the staff. Statistics on whistle blowing are audited quarterly. Staff with whom the inspector met had a working knowledge of abuse and all knew that it must be reported. Staff were aware of the term whistle blowing and again understood what action to take. All staff receive training in POVA and POCA. It is essential that staff are regularly updated in these topics to ensure that their knowledge is current and the correct procedures are followed. The home must ensue that the local, updated adult protection interagency guidelines are available One resident has no next of kin although her Care Manager is her appointed advocate. Advocacy services are available through local advocacy projects and through the organisation. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides comfortable and domestic style accommodation, which is well maintained. This home has significantly improved over the last year and this benefits residents and staff working in the home. Specific adaptations of bathrooms are in place for identified residents, however these are in keeping with the domestic style of the home. EVIDENCE: On both of the site visits the home was clean tidy and mainly odour free. The home had significantly improved in the communal areas and individual bedrooms. The ground floor corridors had had tongue and groove wood applied and this had really improved this area, which suffers wear and tear. The lounge was homely and pleasant, and although a new carpet is proposed for this area, the current one was to a reasonable standard. New sofas had been purchased for both the ground floor and the lower ground floor. A new nurse call system had been installed. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 22 The kitchen had benefited from a new cooker and dishwasher. The machinery in the laundry has been changed to a hire company as it provides a better service for repair. The washer has a hot wash facility for soiled items. The bedrooms inspected were clean and tidy, although one had an odour of urine, which was due to his incontinence. Bedrooms were personalised and despite some heavy wear, tear and damage were homelike and comfortable. Pictorial aids were in use for areas such as bathrooms. Two bathrooms are fitted with vandal proof fittings, which have been approved by the organisation and assessed under health and safety risk assessments. These have been made to look quite domestic they do not seem out of place in the home and are suitable for their function. The home does not employ a cleaner as in the past this was found to be a disruption to the residents. Current cleaning is reliant upon staff with residents input as part of their programme. Residents, as far as they are able, maintain their own bedrooms and the communal areas. This is an area, which should be kept under review, as residents needs change. Staff undertake regular heath and safety checks on the environment including hot water testing. The garden are has been revamped to make it easier for residents to access. More work is planned in this area to provide a low maintenance area, which would have bird feeders and allow for games to take place. The week commencing 15 September is when the office is due for repainting and the garden to be addressed. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents care. Staff are trained in mandatory topics and those specific to learning disability. Supervision systems provide staff with support and guidance when working with the residents in the home. All of these factors produce a well trained and supported staff team who can provide residents with good care. EVIDENCE: The home operates with a shift leader on every shift. Management cover is provided throughout the working day by the three Managers, on call support is also in place. Three staff files were selected for inspection including a new recruit. The staff files had in place confirmation of thie identity including photographs, copies of passports and birth certificates. The files contained application forms, two references, confirmation of the appointment, probation period, terms and conditions. An interview record was completed and this included standard questions. The job description, staff Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 24 information and medical questionnaire were also included in the personnel files. The inspector noted that the medical questionnaire and the two references were in sealed envelopes. On checking one of the envelopes it contained two references both signed and one with an official stamp. Confirmation of the CRB and POVA clearance was in the form of e- mail correspondence from a senior personnel officer at Leonard Cheshire head office, to the home. The e- mail included the CRB number, the date it was obtained and whether it was satisfactory. The CRB itself was not on file. This arrangement is in place for all Leonard Cheshire homes as a security measure. The Manager herself must be satisfied that the person is safe and suitable to work in the home confirmed by references, CRB clearance and interview skills. The inspector was advised that this system of Head Office undertaking all recruitment, is about to change, and the Home Managers will be more instrumental in this process. It is recommended that all staff have their CRB renewed every three years. All staff are issued with an induction pack, which covers general issues as well as those pertaining to the resident group. Supervision records were in place, indicating sessions are conducted regularly with the signature of the supervisee and supervisor. There is a supervision policy and guidelines in place for conducting supervision. All new staff receive weekly supervision during their probation period, as this is a very difficult time for both employee and residents. Staff sickness and absence is monitored. All of the files had training certificates detailing attendance to statutory topics and those relating to residents. The home has a training matrix in place, which identified what training staff have completed and that which is needed. All staff with whom the inspector met, stated that in their opinion the home and the management had improved. The reasons that they gave were the increased training, the consistent management team and the support from other members of the multi disciplinary team. Staff felt that the regular supervision was beneficial and provided a forum for discussion and problem solving. One area, which was of concern, was the use of agency and the number of hours that they covered. This was discussed with the Manager and she confirmed that agency staff were used because of staff vacancies however these were regular staff that had been working in Thicket Road for some time. Currently the home has one full time vacancy. The Manager stated that prior to any new staff starting information would be received from the agency including confirmation of identity, CRB, work permit status, and references. Induction Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 25 would be over a period of one month with the essential points provided on the first day. The home only recruits staff from one agency who they have used regularly for some time. Some of the agency staff have been working in the home for over a year. The staff with whom the inspector met confirmed training in LDAF, NVQ, statutory topics and those related to residents. Staff confirmed that training was facilitated, with time off and full pay. Staff were asked about the residents for whom they were key workers and they demonstrated a good knowledge of the individuals. Six staff have completed NVQ training. Almost all staff have done induction and foundation LDAF training .All staff have been updated in SKIPP training and nine staff have completed a first aid course, three have done the four day certificate. All staff have done basic food hygiene and manual handling. All shift leaders have been trained in supervision. The Manager felt that two areas, which would improve the staffing, would be interviews and pre interview visits to take place at Thicket Road and residents to sit on the panel. In addition she identified that more training was required in specific mental health issues, which is being addressed. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 26 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team provide strong consistent leadership to the home supported by senior personnel through Leonard Cheshire. Quality assurance measures are in place incorporating the views of residents, staff and visitors to enable improvement in the service. Health and safety measures provide a safe home for residents to live in and staff to work in. EVIDENCE: Susan Cornish has been the Registered Manager of this service for four years having worked in the home prior to this. She has completed her RMA and is Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 27 currently doing her NVQ 4 qualification. She has two deputies who assist her in the day to day management of the home, and on every shift there is a senior support worked who co-ordinates the work as the shift leader. She is supported by senior management through the Leonard Cheshire organisation. Regulation 26 reports were available and generally were of a good standard. Some of the visits had been conducted outside of normal office hours, which is good practice. This allows an assessment of the service at times when the managers are not on site. Saturday and Sunday visits should be included in the schedule. The service conducts an annual self assessment review of the service. Senior Leonard Cheshire personnel conduct an annual service audit, whereby the service is audited for a week and a report details findings, recommendations and improvements. Residents meetings are held every 2/3 months, which are externally facilitated, and a pizza supper provided. Leonard Cheshire conducts an annual relatives survey. Comments contained in the survey are noted and action taken where possible. Staff meetings are twice monthly; minutes are recorded and circulated to all staff. There is an open agenda for staff to input into. Meeting for the volunteers are held every two months and minutes were seen. The inspector checked two residents monies and these were found to be correct. Receipts were in place to itemise expenditure and records were retained in the resident individual finance book. Daily checks are made on finances and any discrepancies investigated. There was some large amounts of money on site, which was for the residents holiday. The home has a staff member trained in risk assessment who has completed four days training. There is a nominated health and safety officer who has completed two days training in this field. Health and safety audits are conducted frequently and a monthly report on the findings are sent to the head office. Health and safety covers both the inside of the building and the external grounds. Records for health and safety audits were seen .The home always has a first aid trained member of staff on duty. The two first aid boxes checked were filled with appropriate items. The inspector checked a selection of service certificates and found these to be in order current and relevant. The legionella certificate was in the process of being addressed through the Housing Association. Hot water temperatures are checked twice daily. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 28 The home has one bath chair and no other equipment. This was due for service and confirmation of this was available. The home has introduced an updated fire procedure, which the organisation’s heath and safety officer has agreed. There was a fire risk assessment in place dated 6/6/07 conducted by Charles Webster, who is the home’s deputy Manager. Fire training had taken place approximately monthly for all staff including those on night duty, although staff need to sign for all training received .The LFEPA had visited 3 November 2006.Weekly fire alarm testing, monthly emergency lighting and fire equipment checks are undertaken and recorded. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 29 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 3 X 3 X 3 X X 3 X Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 30 No 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 YA6 Standard Regulation 15 Requirement The Registered Manager should ensure that all information relating to residents is comprehensive in content and relevant to ensure communication in effective. Timescale for action 31/12/07 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. YA6 Refer to Standard Good Practice Recommendations The Registered Manager should ensure that all records are signed with full signatures and dated correctly including daily log books risk assessments and care plans. Thicket Road DS0000006968.V339475.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thicket Road DS0000006968.V339475.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. 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!