Inspection on 06/07/07 for Vancouver Road, 23

This inspection was carried out on 6th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vancouver Road, 23 20/12/06

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 6th July 2007 12:00 Vancouver Road, 23 DS0000025649.V341660.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 Vancouver Road, 23 DS0000025649.V341660.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. Vancouver Road, 23 DS0000025649.V341660.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 vacant post Care Home 8 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Vancouver Road, 23 DS0000025649.V341660.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) 20th December 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 Residents 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. 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. To new residents have moved in to the home since the last inspection. Information about the service provided is made available to current and potential Residents in the homes Statement of Purpose and Residents Guide. The recent CSCI report is currently kept at the home. The manager agreed to continue to make this available to Residents 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 Residents are charged between £62 and £75- per week, which is included in these charges. These fees are the residents contribution to the costs of care, but the details of this cost still needs to be clarified to Residents within their contracts in simple English. Residents have to pay for other personal expenses such as hairdressing and personal shopping. The provider’s email address is: Vancouver@regard.co.uk Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 5 Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day in July 2007. 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 November 2007 and a new manager has now been appointed. Six residents gave their views about how the home is managed, and four residents planning files were examined. Three support staff and the Assistant Team Manager were interviewed and four staff files were examined to see recruitment and supervision 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 sixteen of the twenty requirements and recommendations made at the previous inspection had now been met. Generally Residents said they were very happy at this home, even though many of the staff are new. Some residents want to move out to more independent flats of their own, and even though this has not yet happened for them they said that they are being listened to by the manager. The atmosphere was relaxed and friendly. The manager and staff involved Residents 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. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 7 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. What has improved since the last inspection? What they could do better: Information about fees for Residents must be better explained in their contracts so that they fully understand what they are paying for and why they might be paying more than other Residents. Not all Residents have a full assessment of their needs given to them by Social Services. The home should help Residents to get full Care Assessments from Social Services for anyone who hasn’t got one. Having these will make sure that the home knows all of the support they should be providing. Care Plans for Residents must be reviewed at least every 6 months and other people important to the Resident’s care support need to be asked their opinions about what is needed. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 8 Risk assessments must be improved and reviewed regularly to better protect Residents. Some more staff need to be qualified so that Residents get the best care from well-trained staff. Staff need more training in some important areas such as mental health to help them to be more skilled in helping Residents. The home should try to give all people who complain a written explanation about what they have done and what was decided. The management should try to do a short list of policies that the Residents might want be asked about when they are being reviewed. 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. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents do have all the information to make a choice about where they live. The homes needs assessments are in place, and the home has been responsible in requesting information from social services when needed. Some information regarding charges and what is included needs to be updated in Residents contracts/statements of terms and conditions. EVIDENCE: There was a requirement at the last inspection in asking the home to update this Residents Guide to include fees to be paid, and what is included in the service provided. There is now a good updated Residents Guide, which include all relevant information. However the area covering fees state specific fees, rather than the range of fees, and it is recommended that a range of fees be included in this document when next being reviewed. (Refer to Recommendation YA1) Two new residents have moved into the homes as the last inspection. One of these spoke with me and said that she felt well supported by the home when deciding to move in. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 11 The Service User Guide and statement of purpose are well laid out and are detailed about the service provided. The home has a comprehensive care needs assessment system, which supports the care planning process. All of the four residents files examined showed that all a good assessment in place which are provided by the local authority, or the referring agency, or where there are gaps information provided by social services, the home has done its own assessment, and has request more information from social services. There was a recommendation made at the last inspection for the home to request full care assessments from social services, for the residents who did not have them in place. This is now done and examination of four residents files showed that there full list of information about each resident social and leisure interests is available to improve care planns for residents. Where there were gaps in information there are copies of letters that had been written to social services requesting for information to be provided. The manager said that he will now chase up the progress on these requests for three residents who dont have full information provided. (Refer to Recommendation YA2) There was a recommendation made at the last inspection for the home to ensure that the font size/type is increased in size to make all residents documentation readable. This has now been done. There was a recommendation at the last inspection for the home to include more information about social and leisure interests in care assessments. This has now been done and the manager has requested care assessments from three social workers. Since the new manager has come to the home he has introduced a process of meeting would all of the residents with the key worker to get to know them, and also to ensure that the key working system is picking up information from each resident about their interests and how to make sure that they get to do things that they like doing. The manager has now met with five out of the seven current residents. There is a welcome pack for new admissions to the home that is placed in a the residents room file, this includes a range of information about the all but explains residents responsibilities, and also how they were get support for care planning on getting the service they need. This is also explained through residents and key-worker meetings. There was a requirement at the last inspection for the home to assess residents wishes and abilities to take their own medication. The home has now carried out an assessment with all of the residents and there is a good the pictorial assessment for each residence on their file, which is signed by them and by the staff concerned. These look very comprehensive and understandable as pictures are used to help people find it difficult to read. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 12 One resident has said that they would like to manage their own medication and the manager is now following up on this with this resident. I spoke with this resident who confirmed that this been done. There is a policy regarding new admissions which is used to help guide the process when people are moving in. There was a requirement at the last inspection of the home to update contracts for residents, to include fees to be paid, and to show the service to be provided. This is now been done and all of the residents have contracts with the home, which include fees, showing who pays the fees, and what they receive for the payment. Three residents contracts were examined and it was noted that residents are still being charged between £63 approximately and £78 approximately per week, which the manager clarified is for their contribution towards the service they receive. One resident pays £15 per week more than other residents, but this has not been fully explained in the contract he warned that all. This issue needs to be better clarified in residence contracts. (Refer to Repeated Requirement YA5, partially met) Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 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 Residents is handled in a confidential manner. EVIDENCE: There was a requirement made at the last inspection for the home to involve residents more in writing their care plan. The new manager has started in the process of individually meeting all of the residents, to review a range of important areas regarding the care they receive. He has now met with five out of the seven residents in the home, and this has resulted in new information going into the care plans at the request of the residents. Notes have been kept of these meetings and although this does not represent a complete review of care plans, such as involving family and other professionals, this process has helped to improve care plans the people in the home. Formal care reviews have not been happening six monthly and 12 monthly as discussed, and the Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 14 reason for this is a high turnover are staff, and a period of waiting for the appointment of a new manager. This requirement is partially met and is now repeated. (Refer to Repeated Requirement YA6) The organisation has that Person Centred Planning process in place for enabling residents to express their own needs, and have these to fully taken into account in the planning process. The home is in the process of completing these with all of the residents. There is training scheduled for all of the staff in how to support residents to be fully involved in this planning system, and this is seen as a good way forward in improving the planning system to this home. A full range of health and social interests are included in the planning system and these include friendships and relationships are people. All of the residents care plans were in formally reviewed in April 2007. Six of the residents who spoke to me said that they had been involved in these reviews. There was a requirement made the last inspection for the home to ensure that a formal agreement is reached which some residents, about management of their finances, as the home is currently responsible for this. There is now a signed agreement on each residents file showing that this agreement has been reached. These agreements are also written with the use of pictures, which help the residents to understand them better. There was a requirement made at the last inspection for the home to review all risk assessments, and to ensure that they are still relevant to each of the residents. These were reviewed for all the residents in April 2007. This requirement is now met. However the current risk assessments do not specify fully what the risk is. For example they say things like the risk is” out in the community” or “ while on the Stairs “. Descriptions such as these do not clarify what the risk actually is, and improvements need to be made to these assessments. The risk assessments need to be reviewed again to ensure that where necessary they are more specific as to what is meant by the risk, and given the nature of support provided in the home, these reviews should include relevant health care professionals. (Refer to Repeated Requirement YA9) Vancouver Road, 23 DS0000025649.V341660.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): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to take part in age/peer and culturally appropriate activities, They are part of their local community, and are supported to have relationships. Resident’s rights are respected, and good meals are provided. EVIDENCE: Residents are supported to go out in the local community to clubs, pubs and leisure facilities. Most Residents are very independent and they are able to go out regularly on a daily basis. More thought has been given to the planning and support for community activities. The home provides a friendly and supportive atmosphere for Residents, and staff communicate well and have good skills in motivating Residents to go out in the community, and take an active part in their local environment. Although money of the care staff are new to the home, they have gotten to know the residents well, and six residents said generally get on very well with the staff, Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 16 and are able to get the support they need to go out in the local area. Residents have access to a car provided by the home to go out on trips and two Residents spoke of having had gone on holiday last summer to Bognor Regis supported by staff using a car. The manager said that each of the residents care plans now include a plan for weekly activities, and he has discussed these with almost all of the residents in his meetings with them. These activities include: cooking, housework, health care appointments, and some daytime activities outside of the home. There is now involvement from the community challenging needs team, and part of the involvement includes improving ways of involving and motivating residents to participate in activities. There has been improvement in planning of activities and involving residents in doing this. All Residents are supported to maintain good links with their family and friends and there are no restrictions on having visitors. Three Residents said they regularly have family and friends visit and that staff make them feel very welcome. One Resident 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 Residents. Staff are very respectful of Residents and speak in a very friendly and inclusive manner. All Residents have a key to their bedrooms and the front door of the home. The Residents 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 Residents. Almost all of the residents spoken to said that the food provided by the home is good, that they are involved in shopping, and often involved in cooking to some degree. Food provided is healthy and nutritious and good records are kept of food eating. Vancouver Road, 23 DS0000025649.V341660.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 good. This judgement has been made using available evidence including a visit to this service. Respectful and sensitive support is provided for Residents regarding personal care, health and emotional needs. Residents are supported to retain administration of their medication and medication is well managed. EVIDENCE: As was the case at the last inspection, all Residents 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 Resident, and six Residents confirmed this. All Residents’ files examined showed health care needs are well managed with good input from a range of health care professionals. Residents 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 Residents have mental health support needs and where appropriate have a community psychiatric nurse involved in their care planning. There is support provided by Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 18 psychology and psychiatry and challenging needs practitioners, especially in the area of communications and motivation. Residents files showed improvement in the use of pictures to help residents understand documentation if they were unable to read, and in the use of better weekly activity plans. There was not enough involvement of these health care professionals evident the review of care plans and risk assessments. (Refer to Standards 6 and 9 of this report) As at the last inspection 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. I examined the storage of medication, and administration records with the senior support worker, and records of medication kept and medication given are consistently good and well managed. The made at the last inspection for the home to ensure that all residents wishes regarding being able to self medication be reviewed with each resident, so that should any resident wish to, and be able to look after and take their own medication, they would be supported to do so. This has now been done and all residents files examined showed a written agreement has been drawn up with each resident. This process has resulted in one resident being identified as wanting to learn how to look after their on medication. The manager has said he will follow up on this in line with the homes medication policy. Vancouver Road, 23 DS0000025649.V341660.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 Residents feel their views are listened to and acted on, and that they are adequately protected from abuse and neglect. EVIDENCE: There have been 18 complaints made in the last 12 months. 12 of these were made since last inspection. The majority of these complaints have been from residents and have been mainly concerning loud noise from other residents. Card all of these have been fully investigated, and the home has involved psychology and the challenging needs practitioner, in working to improve the noise levels. This has resulted in a substantial reduction in noise at nighttime. There were two complaints about staff behaviour, which were fully investigated under the homes Adult Protection policy. Referred to Standard 23. Overall the home maintains a good and clear record of complaints made, and has taken appropriate action in dealing with these complaints. As at last inspection 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 Repeated Recommendation YA22.) There have been two adult protection issues reported since last inspection, and both of these were referred to the Lewisham Adult Protection Team. One of these resulted in the dismissal of a member of staff of verbal abuse and threatening behaviour. This was appropriately referred to the Adult Protection Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 20 team in Lewisham, and the home is in the process of referring this person to the POVA register. This second adult protection issue concerns the service user and a member of staff, and this is ongoing, and is being appropriately handled by the homes management. Vancouver Road, 23 DS0000025649.V341660.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): 24,25,26,27 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 Resident 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. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 22 The manager keeps a list of repairs requested, which include dates and times of repairs reported and repairs carried out. Four residents rooms were looked at, and these were seen to be very well maintained, clean, and decorated according to the wishes of the resident. There are plans afoot to residents to have new carpet fitted, and bought of the said that they are very were happy with having been asked about the colour and type of carpet they would like. There are plans in place to develop a sensory garden, with one resident leading this with the support of the Princes Trust, with whom the home developed a working relationship. This resident told me that she is very happy to be doing this job, and is very excited about the work. She said that she would speak with all the other residents about what they want in the garden. The office is somewhat cramped and difficult to work in a more than two people are in it. There is potential to extend this room without too much cost of a disruption. Bought the manager and the area manager agreed to look into the possibilities of doing this, as it would greatly benefit staff and residents when using the office space. (Refer to Recommendation YA24) Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staff generally receive appropriate training but not all relevant training is made available to them. EVIDENCE: The home has a good induction process in place which is now classroom based for at least three days at commencement of employment. All of the staff interviewed said that they had been inducted according to a formal schedule, and staff files examined showed this to be the case. There was a requirement made at the last inspection for the home to ensure that at least 50 of the care staff were qualified to NVQ level 2/3. This has been partially met and is still within the timescale. Three of the care and staff currently in post have NVQ level 2/3, however at least six staff should be qualified to this level. The manager has submitted an application for three more staff to start on this course soon. (Refer to Repeated Requirement YA32) Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 24 Staff demonstrated a good knowledge of Residents needs and have good experience in providing care in the area of Learning Disability. Staff were seen to communicate well with Residents in an open and friendly manner. At the last inspection a requirement was made for the home to ensure that the system from maintaining staff recruitment and employment information is complete, and that this information is maintained at the home. This requirement is now met. Recruitment and employment records are held centrally at the office and they are inspected by a CSCI provider Relationship Manager. The home’s manager is fully involved in the recruitment process. Standard questions are used for interviews and the manager of the home checks references before passing these to the central office. 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 allows staff recruitment procedures to be fully checked when inspected. Examination of four staff files, and of this pro forma system, showed that complete records are now being maintained at the central office, and information about to recruitment of all staff employed in is kept at the home as required. As was the case at the last inspection 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 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 The home must ensure that this training is included in the training package for all staff. (Refer to Repeated Requirement YA35.) There is training scheduled for all of the staff in how to support residents to be fully involved in Person Centred Planning, and this is seen as a good way forward in improving the planning system for this home. This staff training records showed that all of the staff are up-to-date in all of the statutory required training. With the exception of the training identified above the home provides very good training for its staff. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42 Quality in this outcome area is good 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. Resident’s views on quality of care are now being sought and are being included in the homes development plans, and in the homes policy development. Health, safety and welfare of staff and service users are promoted and protected. EVIDENCE: A new manager for the home has been appointed who is experienced in the field of Learning Disabilities and Mental Health support. He holds an Honours Degree in Psychology, and has specific experience in working with autism. He has completed training in infection control calmer diabetes, dementia, Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 26 supervision calmer epilepsy, and control of infection. Although he has only been at the home for a few months, he has already developed a good working knowledge of the needs of the residents, and has a good working relationship with all of the staff. The residents said that he is easy to talk to, and is always available at the home. The manager has signed up front NVQ for training course and is in the process of applying to CSCI from registration. There is no reason to believe other than that these commitments will be fulfilled. There was a requirement made at the last inspection for the home to introduce an Annual Development Plan based on resident’s views. This is now largely met. The manager has routinely met with five out of the seven residents to seek their views on how the home is run, and about specific ideas with regard to their care planning. Residents meetings have been introduced, and these take place every two weeks, and one of these took place today during the inspection. Clearly minutes are kept, with action notes, and these meetings are sometimes attended by other senior managers within the organisation. The manager has now started to incorporate views and ideas from residents into the homes action plan. There was a requirement at the last inspection for the home to devise a system is staff and residents to be involved in policy development. This requirement is now met. The staff are now offered the opportunity to be involved and make comments on key policies before they are finalised. The staff interviewed said that this happens at team meetings and during supervision. Residents to will be offered this opportunity at residents meetings. It is recommended that the home devise a shortlist of policies, which residents would be interested in commenting on, and ensure that these are discussed at residents meetings when they are being reviewed. (Refer to Recommendation 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. Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 27 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 3 2 3 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 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 28 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 YA5 Regulation 5 Requirement The Registered Provider and Manager must ensure that Residents’ contracts/terms and conditions include all of the information described in this report under Standard 5. This was a requirement at the previous inspection, timescale 30/04/07, partially met. Timescale revised. Failure to comply with this requirement may result in enforcement action. The Registered Manager must ensure that Residents are fully involved in writing their care plans and that they are written in the most effective language possible to make sure all Residents understand and agree with them. This was a requirement at the previous inspection, timescale 31/05/06, and 30/04/07 partially met. Timescale revised. Failure to comply with this requirement may result in enforcement action. Timescale for action 30/09/07 2 YA6 15 31/10/07 Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 29 3. YA9 13.4 The Registered Provider and Manager must review all Residents’ risk assessments to ensure they are relevant, clearly written and reviewed at least every six months. This was a requirement at the previous inspection, timescale 31/05/07, partially met. Timescale revised. Failure to comply with this requirement may result in enforcement action. The Registered Provider and Manager must ensure that a minimum of 50 of care staff are qualified to NVQ level 2/3. This was a requirement at the previous inspection, timescale 30/09/07, and still ongoing 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. This was a requirement at the previous inspection, timescale 30/04/07, partially met. Timescale revised. 31/10/07 4 YA32 18.1 c 30/09/07 5 YA35 18.1 c 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations The Registered Provider should include the range of fees DS0000025649.V341660.R01.S.doc Version 5.2 Page 30 Vancouver Road, 23 2 3 4 5 YA2 YA22 YA24 YA40 charged to Residents in the Service Users Guide The Registered Provider should contact the relevant social services for complete care assessments for three residents The Registered Provider and Manager should consider providing all complainants with a written outcome to their complaint as discussed in this report. The Registered Provider should consider extending the office space to better facilitate staff and residents needs. The Registered Provider and Manager should consider devising a shortlist of relevant policies which Residents could be involved in reviewing as discussed in this report Vancouver Road, 23 DS0000025649.V341660.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vancouver Road, 23 DS0000025649.V341660.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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