Inspection on 20/12/06 for Vancouver Road, 23

This inspection was carried out on 20th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vancouver Road, 23 06/07/07

Vancouver Road, 23 23/01/06

Vancouver Road, 23 13/05/05

Vancouver Road, 23 22/11/04

Vancouver Road, 23 24/06/04

Vancouver Road, 23 06/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Vancouver Road, 23 Forest Hill London SE23 2AG Lead Inspector Sean Healy Unannounced Inspection 20th December 2006 10:00 DS0000025649.V307689.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 DS0000025649.V307689.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. DS0000025649.V307689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vancouver Road, 23 Address Forest Hill London SE23 2AG 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) 0208 6993762 0208 699 3762 vancouver@regard.co.uk The Regard Partnership Limited *** Post Vacant *** Care Home 8 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places DS0000025649.V307689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. eight residents, of whom four may have both a learning disability and a mental disorder (dual diagnosis) 23rd January 2006 Date of last inspection Brief Description of the Service: Vancouver Road provides a care home to a maximum of eight women and men with mild to moderate learning disabilities, who might also have other support needs. A maximum of four service users might also have a diagnosis of a mental disorder. The overall aim is that of providing a specialist service in a nurturing and stimulating environment, which would enable users to develop or achieve independent living skills within a community setting. The home states that staff have relevant experience in the field of learning disability and mental health, however better training for staff is needed in these areas. The provider is a company: The Regard Partnership Ltd. who provides other residential homes and supported living in England and Wales. The statement of purpose says that the two directors are qualified nurses with experience in learning disability and mental health. The day-to-day running of the home is delegated to a manager, who leads a team of staff. The premises are a semidetached house, with single bedrooms on three floors and a large garden. The home is not suitable for people who cannot manage stairs. The area is served by public transport, has a selection of shops and other civic amenities. At the time of this inspection there was one vacancy. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The recent CSCI report is currently kept at the home. The manager agreed to make this available to service users and explain it’s content to them. At 20th December 2006, the homes fees are set at £1,372.75 and £1,550.92 per week for accommodation and support. The majority of these costs are met by the referring social services authority, and includes food and some transport. A number of service users are charged between £62 and £75- per week, which is included in these charges, but the details of this cost needs to be clarified to service users within their contracts. Residents have to pay for other personal expenses such as hairdressing and personal shopping. The provider’s email address is: Vancouver@regard.co.uk DS0000025649.V307689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day in December 2006. The inspection was unannounced, and was facilitated by the Acting Manager and the Area Manager for the provider organisation. The Registered manager had left employment in the previous month and an experienced manager was now acting up while awaiting the appointment of a new manager. (The post was already advertised) The inspector spoke with three service users who were in the home, and examined three service users planning files. Three support staff were interviewed and three staff files were examined to see recruitment and training records. The inspection included examination of records and policies and procedures, and a tour of the building. There were also views provided by the local authorities adult protection team on the homes reporting and intervention regarding protection of vulnerable adults. The inspector found that six of the ten requirements and recommendations made at previous inspections had now been met. Generally service users said they were very happy at this home. The atmosphere was relaxed and friendly and staff involved service users and spoke with them regularly. What the service does well: There is a good and welcoming atmosphere in the home and good interaction between staff and service users. The staff help the service users in activities, and provide support for in house and community activities. Staff know service users well and communicate well with them always speaking in a friendly and respectful manner. The home is well decorated and maintained and service users rooms are well maintained and reflect their own choices and preference. The manager provides a sensitive and encouraging approach to managing the home, and tries hard to ensure that service users and staff are safe and secure in the home. Staff are experienced and most of the staff have gained an understanding of service users’ support needs over many years. Training is provided by the organisation, which includes good foundation training, and staff are well informed of the best ways to support service users. Visitors are welcomed and the home does not place restrictions on visiting times. The home provides good food and good health care support. The home is well maintained and is clean and safe. DS0000025649.V307689.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information about fees for living at the home must be improved so that service users are fully informed about the charges made, and the level of support they should expect. For example some service users charges are higher because they need extra support but this is not clearly written down and explained to them. Some service users have to pay some money each week to the provider but it is not made clear to them what these charges are for. All service users who have been placed in the home by social services must have a full assessment of their needs given to them by social services. The home must help service users to ask for these. Having these will make sure that the home knows all of the support they should be providing. Care plans need to be written better so that service users can fully understand them, and be able to have their opinions included. All of the activities included in each service users care assessment must be included in a planned way in their care plans. Some service users said they are not sure what is in their care plans. Risk assessments must be improved and reviewed regularly to better protect service users. DS0000025649.V307689.R01.S.doc Version 5.2 Page 7 Where the home is responsible for service users benefits and bank accounts this must be agreed in writing by the service user or someone else who will protect their best interests. The home manages these benefits or accounts for some service users but there is no record of their agreement for this to happen. Some more staff need to be qualified, and the homes records on staff recruitment need improvements to show that service users are protected and kept safe. Staff need more training in some important areas such as mental health to help them to be more skilled in helping service users. Service users views need to be included in any development plans for the home, and they and staff should be offered the option of having their opinions included in the homes policy development. There should be a clearer system for checking that newly referred service users do not pose any risk to existing service users, before they move to the home. 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. DS0000025649.V307689.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 DS0000025649.V307689.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): Standards 1, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have all the information to make a choice about where they live. The homes needs assessments are in place but social services assessments are not routinely requested and are not in place for a number of service users. Some information regarding charges and what is included needs to be updated in service users contracts/statements of terms and conditions. EVIDENCE: The home has reviewed the Statement of Purpose and service users guide which looks to be very comprehensive. This guide provides information describing the services offered by the home, the qualifications of the registered provider, manager and staff and a summary of the purpose of the home. The Statement of Purpose was reviewed in November 2006 and shows the baseline fees as £1400 pounds per week but does not adequately describe what services are included. For example food, transport and accommodation are not described in the Statement of Purpose or service user guide, otherwise these documents are very well laid out with the good use of pictures as an aid to understanding. The home must include in the service users guide more detailed information about the services provided and the fees to be paid, and who would be responsible for paying these fees. (Refer to requirements YA1) DS0000025649.V307689.R01.S.doc Version 5.2 Page 10 The home carries out full assessment of need for all new service users before their admitted. Examination of three service users assessments showed that the home carries out it’s own detailed assessment of all services users care needs. These show a good level of information which helps to provide information for care plans. However none of the files examined showed evidence of a Social Services assessment on file, and it is important that the referral agent or Social Worker provides this information in order to ensure that all care needs are independently assessed. (Refer to requirements YA2) Assessments in some cases were written in very small font /type size making it very difficult to read. These assessments need to be written in a type size that is easily readable. (Refer to recommendations YA2) The homes assessments did not include service users wishes or abilities regarding self medication. It is likely to be the case that some service users can self medicate, but their views have not been asked by the home. The home needs to include all service users wishes and ability to self medicate in the assessment system and in the care plans. (Refer to requirements YA2 and YA20) Assessments show some information about service users social and leisure interests but in many cases the information is not very detailed. It is recommended that all service users assessments include better information about their social and leisure interests, and their views on which particular activities they would most like to pursue. (Refer to recommendations YA2) Each service user has a newly designed contract showing terms and conditions and the fees to be paid. These contracts also include what they will get in terms of support and guidance from staff. However these contracts do not include the following information; • • • • Accommodation to be provided, including the room and facilities. Food to be provided within the contract cost. Transport (the home provides some transport free of charge) Any additional charges, what these charges are for, and who should pay them. (some service users have an additional charge of between £62 and £75 a week which is not included in contracts) There should also be a clear separation of the amount Social Services will pay and the amount service users will pay. (Refer to requirements YA5) DS0000025649.V307689.R01.S.doc Version 5.2 Page 11 DS0000025649.V307689.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): Standards 6, 7, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessed and changing needs are not fully reflected in all care plans and risk assessments need to be updated and understood by all staff. Information about service users is handled in a confidential manner. EVIDENCE: There was a requirement made at the last inspection for the home to ensure that service users are fully involved in writing their care plans. This was not met. (Refer to repeated requirement YA6) All service users have care plans in place and these reflect thought being given to the level of care and support needed. Service users in the home are relatively independent and have the ability to participate well in the care planning process. However there is no record for one service user of having had a full care review in previous twelve months, and the only recent review on file was a mental health review of May 2006. This service user had a care DS0000025649.V307689.R01.S.doc Version 5.2 Page 13 plan which reflects many of the assessed needs but shows little information in planning the social and leisure interests which were identified in the assessment. For example yoga, cooking and music appear in the assessment but are not included in the care plan at all. This service users care plan was also not signed by her, and the type size is too small to read easily. The file itself was badly organised and difficult for the service user to follow. The Manager agreed there was need to improve the care plan system to ensure the service users assessed needs are fully included in care plans, and their agreed by the service user. (Refer to requirement YA6) The staff are sensitive and supportive in helping service users to make decisions about their daily activities and choices in a range of areas within the home. Service users said that staff are very helpful and friendly and know them very well. Four of the current seven residents have their benefits managed by the organisation, and told inspector that they are happy to continue with this arrangement. However there is no signed agreement from these residents to authorise the home to do this. The home must ensure that this is formally agreed in writing with the service users, or someone on their behalf where they don’t feel comfortable in making this decision themselves. (Refer to requirement YA7) Some service users have their own bank accounts and cash cards, where the provider acts as their appointee for benefits, a fixed amount is lodged monthly by the provider for the service user to access independently the organisational appointees have been approved by the benefit agencies but currently do not provide statements to services users showing how these benefits are being spent. The provider should provide regular statements to service users for whom they manage bank accounts showing how their funds have been spent and current balances. (Refer to recommendations YA7) Some service users pay contribution between £65 and £75 weekly, but it not clearly stated on the service users contracts or any other agreement to be found on the service users files, what these payments are for (Refer to requirement made under section YA5 of this report) All service users files contain appropriate risk assessments. However some of the risk assessments were not appropriate, and not specific enough in describing what the actual risk was. For example one service users risk assessment mentioned using a kettle as a risk, but did not say in what way using the kettle was a risk, for example would she throw it, is she unsteady on her feet, does she have some sort of seizures which present the risk? The Manager said that this service user uses a kettle on a regular basis without any problem. There were also a number of overlapping risk assessments on this service users file regarding risk while travelling in the community, which can easily cause confusion regarding what actually is the risk. The home needs to DS0000025649.V307689.R01.S.doc Version 5.2 Page 14 review all service users risk assessments to ensure they are relevant to service users, clearly written and understandable, and regularly reviewed at least every six months. (Refer to requirements YA9) There was a requirement at the last inspection for the home to ensure that service users information is handled and stored securely. This was met and service users files are now kept in a locked cabinet in the lounge area. DS0000025649.V307689.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in age/peer and culturally appropriate activities, but need more help developing meaningful activities. They are part of their local community, and are supported to have relationships. Service users rights are respected, and good meals are provided. EVIDENCE: One of the three service users files examined showed that their care assessments said that their service users enjoyed yoga, cooking and music as preferred activities, however her weekly plan does not reflect all of these activities, and shows cooking and cleaning as activities on each Wednesday which were not done on the day of the inspection. There was no obvious prompting to support her do these activities and although she appeared very happy and there was good interaction with staff she was not engaged in activities in the home throughout the day. The Manager of the home agreed that activities need improvement to show that service users do not become DS0000025649.V307689.R01.S.doc Version 5.2 Page 16 bored or withdrawn. There is also a risk where some service users are not engaged in meaningful activities they may be placed at some risk when going out in the community unsupported. The home needs to ensure that activities both social leisure and educational are better planned and a system for prompting and supporting service users to participate is more consistently applied. (Refer to requirements YA12) Service users are supported to go out in the local community to clubs, pubs and leisure facilities. Most service users are very independent and their willing to go out regularly on a daily basis. There is some thought needed to be given to the planning and support for community activities. (Refer to standard YA12 above) The home provides a friendly and supportive atmosphere for service users, and staff communicate well and have good skills in motivating service users to go out in the community, and take an active part in their local environment. Service users have access to a car provided by the home to go out on trips and two service users spoke of having had gone on holiday last summer to Bogna Regis supported by staff using a car. All services users are supported to maintain good links with their family and friends and there are no restrictions on having visitors. Three service users said they regularly have family and friends visit and that staff make them feel very welcome. One service user also said that she can have friends stay over if she wishes by agreement with the homes manager. The home has a policy on having visitors which reflects the above comments of service users. Staff are very respectful of service users and speak in a very friendly and inclusive manner. All service users have a key to their bedrooms and the front door of the home. The service users said that staff give them their own mail to open themselves and that they can go anywhere in the home without restriction. The home provides a planned shopping and cooking system which includes service users. One service user said that she didn’t like having oven chips and would like more fresh fruit and vegetable. She told the Manager who responded very helpfully and said he would tell staff of her wishes. Food provided is healthy and nutritious and good records are kept of food eating. DS0000025649.V307689.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Respectful and sensitive support is provided for service users regarding personal care, and emotional needs. Service users are not fully supported to retain administration of their medication. EVIDENCE: All services users are independent in their personal care and no specialist equipment is needed. Personal care support is limited to only prompting occasionally and staff do not provide support in bathrooms or toilet areas. Times for going to bed, getting up and meals are flexible for each service user, and three service users confirmed this. All service users’ files examined showed health care needs are well managed with good input from a range of health care professionals. Service users are aware of their health care support needs and all confirmed that they had been registered with a GP and regularly attend a dentist. Some service users have mental health support needs and where appropriate have a community psychiatric nurse involved in their care planning. DS0000025649.V307689.R01.S.doc Version 5.2 Page 18 The home has a written medication policy that is clear and up to date. The Boots Pharmacy blister pack is used to administer medication. Records are well maintained with minimal omissions recorded. The Lewisham pct pharmacist visited on 17 November 2006 and did a full inspection of the management, storage and administration of medication. This report showed administration to be satisfactory and recommendations were made regarding completing details on the head of the medication sheets more clearly and asking the pharmacist to print labels for MAR sheets, and for individual boxes to be labelled. The home has taken steps to meet these requirements. None of the service users have been assessed regarding their ability to self medicate, although service users generally have a good level of independence in other areas of their lives. The home must ensure that all service users have this assessment and there are clear notes made about their wishes and abilities on assessments and care plans. (Refer to requirement under Standard 1 of this report.) DS0000025649.V307689.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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users feel their views are listened to and acted on, and they are adequately protected from abuse and neglect. EVIDENCE: There was a requirement at the previous inspection for the home to ensure that the complaints system includes the date when complaints were closed and whether the complainant was satisfied with the outcome. This requirement is met. The manager now records all complaints in a complaints book, which includes details of the date of receipt of complaint, the nature of the complaint, and the outcome, including the date. This book is being kept in a locked cabinet to ensure confidentiality. Complaints are discussed regularly between the home’s manager and the area manager. There were eight complaints since the previous inspection and all were from service users. Some of the issues concerned water temperature checks not being done in service users’ bedrooms (upheld), toilet door being locked (not upheld), one service user said she had been hit by another service user and this was dealt with by the social worker concerned. It was noted that not all the service users had received a written outcome for their complaint and it is recommended that this should happen. (Refer to recommendation YA22.) The home has a written adult protection policy which is in line with the local authority’s adult protection policy. This was last reviewed in May 2006. There was one adult protection issue reported by the home to the local adult protection team. There had been some concern expressed during the process DS0000025649.V307689.R01.S.doc Version 5.2 Page 20 of investigating this that the home had not received adequate assessment information regarding one service user, to enable them to make an informed decision about whether the home was appropriate. This resulted in more than one service user being placed at serious risk. The home’s management strongly asserted that they had not received important assessments regarding risk. The referring professionals were unable to provide evidence to show that this information had been given to the provider. This issue was appropriately reported to the adult protection team and the outcome has not been finalised as yet. However the service users who were at risk have now been safeguarded as the other service user has since moved. It is strongly recommended that the home and provider include specific questions regarding the nature of a range of risk areas in their admissions system, and have these signed off by the referring agencies before admission. (Refer to recommendation YA23.) DS0000025649.V307689.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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable and safe and is kept very clean and well maintained. EVIDENCE: The home’s premises are suitable for the purposes of providing a service for the people who live there. The ground floor is wheelchair accessible and all of the service users are fully mobile. The home is a good size, well lit, and well decorated, and is maintained to a high level of cleanliness and hygiene. All health and safety issues are well managed with the exception of risk assessments which need to be improved. (Refer to Standard 9 requirements.) Each service user has their own room and there are two bathrooms, one separate toilet and shower room, and an additional toilet shared amongst eight service users. The home is central to local buses and shops and is in a quiet residential road. DS0000025649.V307689.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent and experienced but some staff need to work towards appropriate qualifications. Recruitment and employment records are in place but some improvements are needed to meet the standard required. EVIDENCE: The home has a good induction process in place which is now classroom based for at least three days at commencement of employment. However, some staff records showed that there may sometimes be a gap between an employee’s start date and the induction start date. Four of the ten support staff have achieved NVQ level 2/3 and two staff who have passed their probation have not yet had their schedule for attending a NVQ level course agreed. The home needs to ensure that a minimum of 50 of care staff achieve level 2 or 3. (Refer to requirement YA32.) Otherwise staff demonstrated a good knowledge of service users’ needs and have good experience in providing care in the area of mental health and learning disability. Staff communicate well with service users in an open and friendly manner. DS0000025649.V307689.R01.S.doc Version 5.2 Page 23 There was a recommendation at the previous inspection that all staff complete a full employment history as part of the recruitment process. This has now been done. Recruitment and employment records are now held centrally at the office and they are inspected by a CSCI PRM. The home’s manager is fully involved in the recruitment process and on the day of the inspection was engaged in staff interviews. Standard questions are used for interviews and the manager of the home checks references before passing these to the central office. There are occasions when staff have started work without having a full CRB clearance but have had a POVA first clearance. One staff file showed the start date the 12 June 2006, but the CRB arrived on 5 July 2006. The manager made assurances that when this happens staff never work alone with service users, but it is strongly recommended that this practice be avoided in order to fully protect service users. (Refer recommendation YA34.) In order for the home to keep a record of staff recruitment and employment at the home, a staff recruitment and pro forma document has been produced by personnel to be maintained at the home. This should allow staff recruitment procedures to be fully checked when inspected. However, this document is not fully adequate to achieve this, and needs improvement in the following areas: Information on the individual staff and experience and training needs to be included • A copy of POVA first document showing the start date and the date of the POVA first needs to be included • A photograph of the staff member needs to be included • Identification for staff within the first few days of employment must also be included This document must be kept at the home from the outset of employment. (Refer to requirement YA34.) There was a requirement at last inspection that the home ensure that all staff receive the required statutory training. This is met. The home has a good induction and training process in place which has been improved from the use of videos and books, facilitated by an outside trainer at the home, to a fuller classroom based induction covering health and safety, fire safety, food hygiene, moving and handling, medication, abuse and basic first aid. The induction course is completed over three days. There is a staff training and development plan in place for individual staff but the schedule does not include the following important information which is particularly relevant to this home: • Mental health training • Challenging behaviour training • Person centred planning The home must ensure that this training is included in the training package for all staff. (Refer to requirement YA35.) • DS0000025649.V307689.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been changes in the homes management but the running of the home has not been adversely affected by these changes. Service users views on quality of care are sought but are not included in the homes development plans, or in the homes policy development. Health, safety and welfare of staff and service users are promoted and protected. EVIDENCE: Currently the Registered Manager’s post for the home is vacant, the Manager having left within the previous month. There is an acting Manager in the post whose experienced and showed a good knowledge of service users’ support needs. This Manager is also qualified to NVQ Level 4, and the Registered Manager’s post has been advertised. The home’s Manager is incharge of the recruitment and induction of staff and also responsible for their day-to-day supervision, rota writing and budget management. There is an organisational DS0000025649.V307689.R01.S.doc Version 5.2 Page 25 management structure which is robust and provides good supervision for the home’s Manager. Their were two Requirements made at the last inspection regarding quality assurance. The first of these asked at the home have an effective system for gathering the views of the service users and their families about how the home is run. This was met. The organisation has a quality assurance director and four quality assurance managers, one of whom is allocation responsibility for overall quality assurance for the home. This Manager carries out Regulation 26 visits each month and there is a written report available at the home. There are also six-monthly audits carried out addressing the majority of Care Standards Regulations, and an Action plan is produced to make the necessary changes. The last of these audits was done on 25th August 2006 and looks to be very comprehensive. There were also monthly residents’ house meetings conducted and facilitated by staff. Monthly key worker meetings happens consistently and records are kept, and the organisation conducts service users surveys at least annually. However, there was a Requirement at last inspection that the home put in place a development plan based on the information gathered in order to plan improvement for the coming year. This has not yet been done and the requirement is now repeated. (Refer to repeated Requirement YA 39) There was a recommendation at least inspection that the home should consider using a recognised quality assurance system. This is now being met as discussed above. The home has a full complement of written policies and procedures which meet the standards required. There was a Requirement at last inspection that the registered Individual must ensure that staff and service users are involved in policy development. This has not yet been done and the Requirement is repeated. (Refer to repeated Requirement YA40) Health and Safety within the home is well managed. The home has an adequate health and safety policy which includes risk assessment, fire safety, food hygiene, moving and handling, and all of these are included in the staff induction and training programme. Fire equipment checks are being done on a weekly basis and the home has certificates for electrical and gas appliances which are up to date. Kitchen and bathroom areas are maintained to a high level of cleanliness and safety. DS0000025649.V307689.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 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 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 3 X DS0000025649.V307689.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement Timescale for action 30/04/07 2 YA2 14 3 YA2 YA20 12.1,2,3 4 YA5 5 The Registered Provider and Manager must ensure that the service users’ guide contains more detailed information about the services provided, the fees to be paid and who is responsible for paying these fees. The Registered Provider and 31/03/07 Manager must ensure that all service users have a full assessment of needs provided by the referral agency or social worker. The Registered Provider must demonstrate that they have requested this information for all service users who do not currently have a Social Services assessment. The Registered Provider and 31/03/07 Manager must ensure that all service users’ wishes and abilities to self medicate are included in the service user’s care assessments. The Registered Provider and 30/04/07 Manager must ensure that service users’ contracts/terms and conditions include all of the information described in this report under Standard 5. DS0000025649.V307689.R01.S.doc Version 5.2 Page 28 5 YA6 15 6 YA6 15 7 YA7 20 8 YA9 13.4 9 YA12 15 10 YA32 18.1 c 11 YA34 19.1 & 4 The Registered Manager must ensure that service users are fully involved in writing their care plans and that they are written in the most effective language possible to make sure all service users understand and agree with them. This was a requirement at the previous inspection, timescale 31/05/06, not met. Failure to comply with this requirement may result in enforcement action. The Registered Provider and Manager must ensure that all service users’ care plans include assessed social and leisure activities as described in this report YA6. The Registered Provider and Manager must ensure that current arrangements for the home to manage a number of service users’ benefits on their behalf are formally agreed in writing with these service users or their representatives. The Registered Provider and Manager must review all service users’ risk assessments to ensure they are relevant, clearly written and reviewed at least every six months. The Registered Provider and Manager must ensure that there is a good system for planning for service users’ social and educational needs, and that service users are consistently supported to participate in these activities as discussed in this report YA12. The Registered Provider and Manager must ensure that a minimum of 50 of care staff are qualified to NVQ level 2/3. The Registered Provider and DS0000025649.V307689.R01.S.doc 30/04/07 30/04/07 30/04/07 31/05/07 30/04/07 30/09/07 30/04/07 Page 29 Version 5.2 12 YA35 18.1 c 13 YA39 24 14 YA40 24 Manager must ensure that the system for maintaining recruitment and employment information for staff at the home is complete and meets all of the needs of this requirement YA34 as discussed in this report.. The Registered Provider and Manager must ensure that the home’s training prospectus and induction procedure includes sufficient training in the areas of mental health, challenging behaviour and planning as discussed in this report YA35. The Registered Individuals must ensure that an annual development plan is in place that shows how the service aims to improve over the coming year based on the views of service users, their families and other stakeholders. This was a requirement at the previous inspection, timescale 31/07/06, not met. Timescale now revised. Failure to comply with this requirement may result in enforcement action. The Registered Individuals must ensure that a system is devised that ensures staff are fully involved in policy development and service users are offered the opportunity to be involved in policy development where relevant. This was a requirement at the previous inspection, timescale 31/07/06, not met. Timescale now revised. 30/04/07 31/03/07 30/04/07 DS0000025649.V307689.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA2 Good Practice Recommendations The Registered Provider and Manager should consider rewriting some care assessments where the font size is too small to read. The Registered Provider and Manager should ensure that all service users’ assessments include more detailed information about their social and leisure interests, and their views on which particular activities they would most like to pursue. The Registered Provider and Manager should provide regular statements to service users for whom they manage bank accounts, showing how their funds have been spent and current balances The Registered Provider and Manager should consider providing all complainants with a written outcome to their complaint as discussed in this report. It is strongly recommended that the Registered Provider ensures that specific questions regarding the nature of risk for service users referred is included in the assessment process and that these have been signed off formally by the referring agencies before admission. It is strongly recommended that the home does not commence employment for staff who have not had a satisfactory enhanced CRB disclosure check received by the provider. 3 YA7 4 5 YA22 YA23 6 YA34 DS0000025649.V307689.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent 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 DS0000025649.V307689.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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