Inspection on 14/12/04 for Townley Road, 2-3

Care Homes For Adults (18 ­ 65)Townley Road, 2-3Dulwich London SE22 8SWUnannounced Inspection14th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Townley Road, 2-3 Address Dulwich, London, SE22 8SW Email address Tel No: 020 8299 1841 Fax No: 020 8299 0820Name of registered provider(s)/company (if applicable) Hexagon Housing Association Name of registered manager (if applicable) Ms Norma Smellie Type of registration Care Home No. of places registered (if applicable) 10Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0) Registration number G020000033 Date first registered Date of latest registration certificate 29th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 25th June 2004 yes NO 11/03/04 If Yes refer to Part CTownley Road, 2-3Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th December 2004 10:00 am Mark StroudID Code118288Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionCatherine AlimiTownley Road, 2-3Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementTownley Road, 2-3Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Townley Road, 2-3. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Townley Road, 2-3Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Townley Road is a Care Home offering care, nursing and accommodation to ten service users with mental health needs. It aims to provide placements of two to three years to allow service users to move on to a range of other housing options. It is owned and run by Hexagon Housing Association. The home is located in North Dulwich, close to the train station, shops, banks, a post office and bus services. The home consists of a three storey residential building, bedrooms on the first and second floor. All bedrooms are single. There is no passenger lift. There is a garden to the rear.Townley Road, 2-3Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection took place over an afternoon in December 2004. The inspector spoke to three service users, who said they like living at the home. All of the Standards assessed were met of almost met. The quality of care is good. Choice of home (Standards 1-5) Both if the 2 Standards assessed were met The last report states that the manager had updated the homes statement of purpose and service users guide to include all of the required information. Good assessment information was found in place at this inspection. Service users have clear signed contracts with the home. Individual Needs and Choices (Standards 6-10) 2 of the 4 Standards assessed was met, and 2 were almost met All service users have Service User Plans in place, signed as agreed by service users. Evidence was found that staff know how to work with service users. Examples were also found of goals changing without clear explanation, including dates for discharge from the home. Service User Plans may not be accessible to service users, and as a result not help staff and service users as much as they could, to work together towards clear goals. The designated individual and one staff member said one service user was difficult to communicate with. Apart from reference in one assessment not to use certain words, no guidance regarding communication was found in their file, indicating for instance what works well and what doesnt, when to approach them, and evidence that agreement regarding these needs had been established with the service user. Both the designated individual and one staff member confirmed that the service user absconded to express their feelings, and that this placed them at risk. The home should evidence that the service user and staff are being supported to communicate effectively, and use this to develop support to other service users. The last report states that a cook supports rehab work at the home. However, restrictions regarding access to the kitchen are likely to undermine this work, and this must be reviewed to uphold the rights and meet the needs of individual service users. Lifestyle (Standards 11-17) The 1 Standard assessed was met Service users move freely around the home, and are supported well in the community. Responsibility for chores is clear, a rota used in the kitchen. The home has changed communal arrangements in consultation with service users, noting a reduction in smoking. Personal Healthcare and Support (Standards 18-21) Both of these 2 Standards were met Staff provide appropriate flexible personal care. If Service User Plans were more accessible, Townley Road, 2-3 Page 6 it would enable staff to work with service users more effectively. Key work arrangements are clear, the home covering the absence of key workers amongst a group of named workers, by prior agreement. The home prompts service users to request advocacy in assessments, and the Registered Manager has recently approached advocacy services to come and talk to service users about advocacy. The inspector found one service user who is unhappy about their Service User Plan where there was no advocacy involved, although a relative had active involvement. The last report confirms that service users had good access to healthcare facilities locally and high levels of support from the community team, as well as an excellent medication system. Concerns, Complaints and Protection (Standards 22-23) Neither of these 2 Standards were assessed The last report states the home had recently re written their policy on abuse and staff had undergone training in this area. Environment (Standards 24-30) The 1 Standard assessed was almost met The home was again found clean throughout and had good facilities for service users to access. The main lounge has been divided to provide a no smoking area at the front of the house. This room is very pleasant and comfortable, but not so well used by service users. Staffing (Standards 31-36) The 1 Standard assessed was met Staff are confident and clear about their roles and responsibilities. They were open during the inspection, identifying achievements at the home as well as shortfalls. There are sufficient numbers of diverse staff working at the home, supporting service users flexibly. Conduct and Management of the home (Standards 37-43) The 1 Standard assessed was met The manager is unchanged; the last report stating the manager is extremely competent and has managed the home since it first opened. No unmanaged risks were found at the home, fire equipment serviced.Townley Road, 2-3Page 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Townley Road, 2-3Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Registered Provider must ensure that Service User Plans support service users to make clear decisions by · · 1 13(4)(c) 15 YA18YA7Y A6 Presenting information in an appropriate format Including all identified needs and action agreed as described below regarding visual impairment, absconding, and food hygiene Setting clear long term, and short term goals which are reviewed as necessary to adjust sleeping patterns as described below Including clear discharge plans31.03.05··in consultation with other stakeholders as appropriate. The Registered Provider must ensure that restrictions regarding access to the kitchen are reviewed against individual Service User Plans, maximising service users independence and enabling service users to take responsible risks, are properly informed, and that their needs and action are recorded in the Service Users individual Plan as stated above. The Registered Provider must ensure that the hot water supply to the top floor bathroom meets the needs of service users.212(1)(a)(2) (3)YA731.03.05312(1)(a) 23(2)(j)YA2431.03.05Townley Road, 2-3Page 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Townley Road, 2-3 YES NO NO YES YES NO NO NO YES NO YES YES YES YES NO NO YES NO NO YES Page 10 Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) 3 0 0 NO NO YES YES X X 14/12/04 14:30 3The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Townley Road, 2-3Page 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 417.31 417.31 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Use of payphone, toiletries, magazines, hairdressing. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Three service user files were inspected. Each contained a Care Programme Approach (CPA) review, multi-disciplinary review assessment written up by a professional representing the purchasing authority. In addition, the home was seen to hold assessments from previous placements and hospital admissions. Evidence was not found regarding restricted access to the kitchen, in place on the day of inspection. This will be described further under Standard 7, where a Requirement is made.Townley Road, 2-3Page 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All three service user files inspected contained a contract, describing the room to be occupied, terms and conditions, and other arrangements appropriate to the setting. A copy is available and its location understood by service users, who were seen to have signed them.Townley Road, 2-3Page 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Three Service User Plans were inspected. These contained good basic details including next of kin, date of admission. Social workers and other professionals contact details were included in a `shared care booklet, where health contacts were recorded, in a form that could be readily understood by most service users with some support. The contents of the Service Users Plan was however difficult to assess, since information was held across a number of documents, including reviews and a separate multi-disciplinary meetings record. When the inspector tried to assess planning for one service user due to move placements, evidence could not be clearly established for the implementation of plans against all assessed needs, including those identified by the home in their own assessment, and those identified in Care Programme Approach (CPA) review records. The homes own discharge policy says a plan of action should be agreed clearly identifying who is responsible for doing what. A CPA form should be agreed and completed with resident and signed by all concerned. Evidence of this was not found. Needs associated with a visual impairment, described by the designated individual and one staff member, were not described in the Service Users Plan. On this evidence, the inspector assesses that service users would find it difficult to understand clearly the process of planning, and their role within it. Care Plans that were inspected were signed by the service user. One Service User Plan did not contain sufficient detail by which service users could sense they were achieving realistic goals, and setting new ones. One plan, which aimed to adjust the sleeping pattern of a service user, had a target time that was clearly not being met from the verbal account of the designated individual, with no evidence that transitional times towards this goal were set and achieved. Nevertheless, the designated individual gave a clear verbal account of work completed to date, and this must be recorded clearly in the plan.Townley Road, 2-3Page 14 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? The home currently state that a maximum stay of three years is offered towards increasing independence, service users ideally moving to settings where they would need to take more responsibility for meeting their own needs. The home demonstrates that it is keen to consult service users as a group, holding regular service user meetings. However, the inspector assessed that, regarding restricting access to the kitchen, the home needs to start from the development of individual plans, to focus on individual needs and rights, including · · Access to the main kitchen, which is currently restricted due to the homes food hygiene concerns, previously agreed at a meeting with the service user group Including in Service User Plans reasons for individual restrictions, such as risks from infection, and include needs and agreed action regarding food hygiene, such as trainingStandard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Three service users files were inspected. These contained up to date risk assessment regarding risks of financial abuse, aggression towards staff, non-compliance with medication, and lack of independent personal care. Before this inspection, a service user had absconded. The designated individual and one staff member said that the home identified signs that there was an increased risk of the service user absconding before the incident, and measures were clearly put in place to try to increase supervision of the service user. Clear agreement around protocols for this support between the home and the purchasing authority, which included the service user being followed in the community, need to be established and evidenced in the risk assessment. In practice, the home was seen to have responded promptly once the service user had absconded.Townley Road, 2-3Page 15 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Service user files were found safe and secure, and no personal information was found stored inappropriately.Townley Road, 2-3Page 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This Standard was not assessed during this inspection.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users were seen to move between their bedrooms and communal areas at will, several of the service users going into the community independently. The tenancy agreements record service users right to a key, and their responsibilities for its safekeeping. Restrictions are currently in place, the kitchen closed at regular times, described further under Standard 7. There is a rota displayed in the kitchen for service users to share in some house keeping tasks, useful to building their independence. New arrangements have recently been made to smoking areas, a section of the larger lounge now used for smoking. The last unannounced visit by the organisation to the home recorded that service users are smoking less as a result. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? None of the service users were seen to require support to move around the home, confirmed by the designated individual. The inspector was not aware of, and did not see any personal care provided outside of bedrooms, or other private areas. One Service User Plan included support for a service user to adjust their routine to access activities in the day. A staff member identified one service user experiencing difficulty reading printed documents, due to a visual impairment. No evidence was found in the Service Users Plan that the home was providing specific support regarding visual impairment, for instance by using larger print, or assessing the use of appliances in the kitchen. The Registered Manager described the system of key work to the inspector, and staff were able to clearly name service users they key work. Multi-disciplinary meetings were minuted at the home with action, held on a regular basis under a Care Programme Approach (CPA). Standard forms prompt service users to ask for advocacy. No evidence of referrals or other work regarding advocacy was found in the three service user plans inspected. The Registered Manager said that advocacy is difficult to access, but that she has requested an advocate to speak to service users about services. The Registered Manager said that service users have good family support, and gave examples of this.Townley Road, 2-3Page 20 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This Standard was not assessed during this inspection. Standard met? XX 0Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Signed medication consent forms were found in the three service use files inspected. All other aspects of this Standard were met at the last inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X Standard met? 0Key findings/Evidence This Standard was not assessed during this inspection.Townley Road, 2-3Page 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES0 Standard met? 0Key findings/Evidence This Standard was not assessed during this inspection.Townley Road, 2-3Page 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The organisations unannounced inspection of the home in August noted a change in communal arrangements for smokers, only the rear half of the lounge a smoking area now. This was seen to lead to a comfortable smoke free area at the front of the house, new sofas seating eight people, television, and generally warm in appearance. The rear half of the room, now separated with floor to ceiling shutters was cold on one inspection, a service user seen resting over the radiator, while a further inspection found the room to be suitably heated. The Registered Manager clarified that this was likely to be due to a service user opening a door before the first inspection. The majority of service users were seen to use a further communal area described as the quiet area. During the inspection, the front area was seen to be used only briefly by two service users, otherwise service users using the rear smoking area of the lounge, or in most cases using the smaller quiet room, where there is a television. The bath water to the top floor bathroom ran slowly, one service user saying they found their baths cold as a result.Townley Road, 2-3Page 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This Standard was not assessed during this inspection. YES NO NO 10 0 0 0 Standard met? 0 8 20 0 0 0Townley Road, 2-3Page 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This Standard was not assessed during this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? The August 04 monthly unannounced visit by the provider described one staff member as having a `positive, inclusive approach. This was reflected through the staff group on the day of inspection. One staff member was careful to check the inspectors identity as he arrived, and staff were generally found to be clear about their roles and responsibilities. The designated individual said that four staff work each shift Monday to Saturday, three staff on Sunday, in addition to Manager and deputy. Staffing levels on the day of inspection provided one to one support to service users in and out of the home, as well as effective planning of the evening meal, and staff time socialising with service users as a group. There was a male staff member on duty during the inspection, and the staff team appeared to the inspector to be diverse in terms of culture and ethnicity.Townley Road, 2-3Page 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This Standard was not assessed during this inspection.0Townley Road, 2-3Page 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This Standard was not assessed during this inspection. YES 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Townley Road, 2-3Page 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This Standard was not assessed during this inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This Standard was not assessed during this inspection.Townley Road, 2-3Page 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Fire extinguishers were recorded as checked 26/09/04. No unmanaged risks were noted during this inspection, and the last inspection noted no concerns.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This Standard was not assessed during this inspection.Townley Road, 2-3Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateSignature Signature SignatureTownley Road, 2-3Page 34 Public reports It should be noted that all CSCI inspection reports are public documents.Townley Road, 2-3Page 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14th December 2004 and any factual inaccuracies: We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request. Please limit your comments to one side of A4 if possibleTownley Road, 2-3Page 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here Townley Road, 2-3Page 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Townley Road, 2-3Page 38 Townley Road, 2-3 / 14th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000007000.V200219.R01© This report may only be used in its entirety. 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