Inspection on 20/10/06 for Wadeville Hostel

This inspection was carried out on 20th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wadeville Hostel 17/08/07

Wadeville Hostel 27/02/06

Wadeville Hostel 06/09/05

Wadeville Hostel 10/02/05

Wadeville Hostel 31/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Wadeville Hostel 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND Lead Inspector Maria Kinson Key Unannounced Inspection 20th October 2006 12:20 Wadeville Hostel DS0000037846.V303552.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 Wadeville Hostel DS0000037846.V303552.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. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wadeville Hostel Address 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND 01322 342998 01322 440663 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) MCCH Society Limited Ms Georgina Waters Care Home 13 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (4) of places Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: In December 2002 this home varied its registration and changes were made to the configuration of the home. The home is now registered for thirteen service users with a learning disability, two of whom may be over 65 years of age. The registered provision provides 24-hour support with a sleep in arrangement and waking night support. The house is split into two parts, six service users live in 2b and seven service users live in 2a. Each house has its own kitchen/dining room, lounge, bedrooms, toilet and bathing facilities. The garden is a shared area for both sets of service users and is also shared with other people in the surrounding supported living accommodation. Daytime opportunities are provided through the day services previously operated by Bexley Council but now managed by MCCH Society Ltd. The Community Learning Disability Team provide specialist health and social input. The commission was not able to obtain information about the fees charged by this home. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over three days. When the inspector arrived in the home on 20/10/06 there was one bank staff member on duty and all of the service users were attending day services. A partial tour of the home was undertaken and two sets of care records were assessed. On day two of the inspection (26/10/06) the inspector examined health and safety records, assessed the management of medication in both flats and spoke with a visitor. The inspector returned to the home at 5pm on 27/10/06 to meet some of the service users. The inspector was only able to obtain limited feedback about the service, as the pre inspection questionnaire was not returned to the commission. What the service does well: This home provides good support for service users. Service users said that they liked living in the home and felt safe. Relatives said that staff kept them informed about important matters and were satisfied with the overall standard of care. The home has a stable team of staff who were familiar with service users needs and preferences and promote a family orientated, happy home. Service users assist with the running of the home by helping to keep the building clean and tidy, preparing meals and snacks and maintaining the garden. All of these activities help to increase service users self esteem and independence. The home was clean and tidy throughout. All of the communal areas were comfortably furnished and felt homely and welcoming. Service users bedrooms were arranged to suit their needs and contained lots of personal effects such as photographs, certificates, medals and items relating to their interests and hobbies. The food provided in the home was varied and nutritious. Menus were developed to suit service users tastes and specialist needs. Staff provided discreet support at mealtimes. Service users received support to access to educational classes and most service users were assisted to pursue their personal interests and hobbies. Staff must ensure that all service users are supported to undertake meaningful and fulfilling activities in the home and community. Service users were offered the opportunity to spend more time in the home and community with staff but often chose to continue to attend the day centre with their friends. Service users were supported to attend health care appointments and meetings. Some service users were not able to tell staff when they felt unwell. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 6 Because the home has a stable team of staff that were familiar with service users needs, staff were often able to identify changes in behaviour or mood that suggested service users were unwell. What has improved since the last inspection? What they could do better: This home provides a consistently good standard of support for service users but fails to meet a number of standards due to poor record keeping. The Registered Provider, Manager and senior staff must take action to address the issues outlined below. The home had developed a Service User Guide but information about fees were not included in this document. The arrangements for admitting new service users into the home were good overall but the manager and staff must ensure that adequate information about service users needs is obtained from the placing authority. Staff must ensure that all service users have an up to date care plan and risk assessment. Medication was mostly satisfactory but staff were not recording medicines received in the home from service users relatives and facilities for storing controlled drugs were unsuitable. Staff had a good understanding about adult protection issues but the procedure for safeguarding service users money was not always followed. Records maintained about staff recruitment checks were incomplete in parts. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 7 Staff training was variable. Some staff had not undertaken any training during the past year. The home was maintained to a satisfactory standard but both of the carpets in the lounges were worn and one was threadbare in parts. The home must ensure that health and safety issues are identified and addressed promptly. At the time of this inspection the fire alarm had not been tested for two months, there was no evidence that any fire drills had taken place in the past nine months and staff had not received a fire safety training update during the past year. The gas safety inspection was overdue and accident forms were not completed for all of the accidents that had occurred in the home. The rooms containing the hot water tanks were unlocked. 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. Wadeville Hostel DS0000037846.V303552.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 Wadeville Hostel DS0000037846.V303552.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users received information about the home but this did not include details of fees and charges. Prospective service users were supported to visit the home and meet staff and other service users before they moved in. The information obtained from the placing authority about prospective service users needs was variable. EVIDENCE: The manager confirmed that new service users were given a copy of the Service User Guide. This document did not include information about the terms and conditions of occupancy or fees. See requirement 1. The manager had received contracts for all of the service users but information about fees was not included and the contacts were not agreed or signed by the service user or their representative. The manager said she would be meeting service users and their representatives to explain the contract. See recommendation 1. The records for two new service users were examined. One service user was admitted as an emergency admission and the other service user was a planned admission. Staff had received a joint assessment form and summary of care needs for the service user admitted as an emergency admission. The service Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 10 user whose admission to the home was planned attended several meetings with staff to discuss the suitability of the placement, their needs, views and wishes. A referral form was completed by the placing authority and forwarded to the home. The assessment form was partially completed. Staff did not receive information about the service users social needs. See recommendation 2. The manager of the service had confirmed in writing to the service user that the home was able to meet their needs. Staff said that new service users were given an opportunity to spend time in the home, view vacant rooms and get to know the other service users and staff before making a decision to move in. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff did not always have access to up to date information about the action they should take to protect service users from harm or to meet their needs. Service users were able to actively participate in the day to day running of the home and received support from staff to make informed choices and decisions about all aspects of their life. EVIDENCE: The care records for two service users were examined. One service user was admitted in January 2006. The service user had a care plan dated 20/02/06 and staff had completed a pen portrait, which provided a summary of the dayto-day support the service user required. Guidelines were provided for staff about how to respond when the service user refused medication but this information was not accessible to all members of staff. Staff had assessed potential hazards and developed strategies to minimise or manage risk, prior to the service user going on holiday. The other service user was admitted to the home in August 2006 but did not have a pen portrait, communication passport, care plan or any risk Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 12 assessments. This service user had a history of epilepsy and had fallen twice since admission. The service user required significant input from staff to maintain their hygiene needs and to avoid conflict with other service users. Staff did not feel that the service user was suitably placed in the home and discussions were taking place to find a more suitable placement for the service user. See requirement 2 and recommendation 4. Discussions with service users and staff and examination of records showed that service users were able to play an active role in the running of the home. Service users helped staff to maintain the garden, prepare, cook and serve meals, purchase food, wash and iron their clothing, change their bed clothes and clean, vacuum and dust various parts of the home. Service users were asked to suggest ideas for activities and holidays and to tell staff if they required assistance to purchase personal items during a house meeting in February 2006. Some of the holiday destinations put forward by service users were used. There was no record of service user meetings taking place since this time. The manager should ensure that house meetings take place regularly. See recommendation 3. The manager said she wanted to increase service user involvement in other aspects of the running of the home. To assist with this staff were exploring the possibility of purchasing a computer and specialist touch screen programme for service users to use in the home. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Opportunities for pursuing personal interests and hobbies were mostly good but some service users did not receive sufficient support to meet their social needs. Service users were supported to maintain contact with their friends and family. The choice and variety of food provided in the home was good. EVIDENCE: Staff maintained a record of activities in service users diaries. Records were examined for two service users, for a one- month period prior to the date of the inspection. Records indicated that one of the service users had attended church services and a day centre, had a manicure, watched films and listened to music. There was no evidence that the other service user was supported to take part in any activities in the home or community but they did attend a day centre. See requirement 3. All of the service users living in the home were supported to take an annual holiday or to have a long weekend break during the summer period. One of Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 14 the service users that enjoyed drawing and writing was assisted to purchase various items to pursue her hobby. Service users were encouraged to attend social events such as clubs and parties and some service users had seen shows at the local theatre. Relatives were able to visit the home at anytime and some of the service users spent time with their family during weekends or holidays. The inspector spoke with one visitor during the inspection and obtained written feedback from one relative. Relatives were satisfied with the standard of care provided in the home, said they were kept informed about important matters and were made to feel welcome when visiting their relative. One relative said that the manager and all of the staff working in the home were “wonderful” and her relative was “well looked after” and “happy” living in the home. When service users returned from the day centre they were greeted by staff and offered a hot drink. Depending on their personal preferences they then spent time in their room or in the lounge or dining room discussing the day’s events with staff and other service users. There were no restrictions about how and where service users spent their time in the home and staff ensured that service users privacy was maintained where possible. Some service users chose to lock their room. There were good supplies of fresh fruit and vegetables in the home. All of the service users ate their meals in the dining room. Meals were prepared and served by staff and service users and looked appetising. The menus were developed by staff and service users and included a variety of different dishes and foods. Most of the service users had their main meal at the day centre during the week, so the evening meal was a hot light snack and a dessert. If service users did not like the food listed on the menu an alternative was provided. Staff provided support for service users during mealtimes by cutting up food, protecting service users clothing and encouraging service users to eat where necessary. All of the service users that the inspector spoke with said they “liked” the food served in the home but a number of service users advised the inspector that their favourite meal was the Sunday roast. One of the service users prepared hot drinks for staff and service users and was supported to make and decorate cakes for afternoon tea. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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. Staff supported service users to identify and address health issues. The management of medication was mostly good but some aspects of record keeping and the storage facilities for some drugs did not comply with regulations. EVIDENCE: Service users said that staff supported them to attend appointments and meetings. Staff maintained a record of visits to the GP surgery, hospital appointments and blood tests. Advice or guidance provided by other professionals was recorded. Service users were able to attend and contribute to meetings about their care, health and future and were supported where possible to make decisions for themselves. Relatives, advocates and staff were also consulted with the service users permission or if the service user was not able to make decisions for themselves. The arrangements for managing medicines were assessed on both of the units. Records of medicines received into the home from the local pharmacist were good but some medicines in 2b were bought into the home by a relative and were not recorded. Up to date records were maintained for medicines sent for disposal and records of administration were good. The medicines in 2a had Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 16 been moved to a different part of the home, as the kitchen was too warm for the storage of medicines. Drugs requiring special storage were stored in a locked cash tin in a locked filing cabinet. The previous recommendation to ensure that controlled drugs were stored appropiately had not been addressed. This issue was discussed with the pharmacy inspector who advised that the home must obtain a suitable cupboard if they are using controlled drugs regularly. See requirement 4. In the period since the last inspection one of the service users had died. The unexpected death of the service user had a significant impact on service users and staff. Some of the staff and service users attended the funeral and photographs of the service user were displayed in the home. The service users relatives continue to visit the home. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home had a comprehensive complaints and adult protection procedure in place for responding to complaints or allegations of abuse. The home did not have adequate systems in place to safeguard service users personal money. EVIDENCE: The home had a comprehensive complaints procedure, which included a timescale for responding to concerns and contact details for the commission. The home had not received any complaints since the last inspection. The commission are not aware of any complaints relating to this service. The manager of the home advised the inspector that the company’s adult protection procedure had not changed. One allegation was investigated under the local authority safeguarding adult procedure, but was not substantiated. Staff had a good understanding of adult protection matters and had received training about abuse. The home had received a new information poster “Knowing Your Rights”. The manager said that a copy would be displayed in the home or passed to service users. The personal money records for two service users were checked. Money was stored securely and records were maintained for all money received in the home or paid out. The record sheet included a photocopied staff signature for each entry. This practice does not provide adequate protection for service users money. Staff must sign entries on the form as they are made. The procedure followed by staff also included retaining receipts for purchases made on service users behalf or for money paid out for services such as hairdressing Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 18 and chiropody. One receipt for £13.98 for a birthday gift and one receipt for chiropody treatment could not be located. The manager said she carried out random checks on the money records but there was no written evidence of this. See requirement 5. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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 was maintained to a satisfactory standard but some carpets were worn and stained. All parts of the home were clean, tidy and odour free. EVIDENCE: Some redecoration was in progress in the corridor and stairway in 2b. The manager of the home was not informed about the proposed start date for this work and did not know what work was planned. This meant that service users could not be told about the work and prepared. When the decorators arrived they said they had been sent to redecorate a part of the home that the manager and staff did not consider to be a priority. The manager had to contact the maintenance department to discuss this issue. Staff were not issued with a work schedule so had no way of knowing if all of the agreed work had been carried out. See recommendation 5. The home was maintained to a satisfactory standard and all parts of the home felt homely, welcoming and comfortable. The carpets in the lounges were stained and there was an area on the carpet in 2a that was almost totally Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 20 threadbare. This issue was raised in previous reports but was not addressed. See requirement 6. A high standard of hygiene was maintained throughout the home. All of the communal areas and bedrooms visited were clean, tidy and odour free. Soap and hand towels were provided in some of the bathrooms and toilets. Staff should ensure that these facilities are checked and replenished regularly. Great care was taken when washing, ironing and storing service users clothing. Some of the service users told the inspector about the new shower room on the ground floor in 2a. A new ‘walk in’ shower and chair had been fitted and the flooring was replaced. Service users were very pleased with the new facilities and said the shower chair was “comfortable” and everything was “so much easier now”. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. 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. This home has a stable team of staff that provide good continuity of care for service users. Staff recruitment procedures were thorough but records maintained in the home did not always provide adequate evidence of this. Permanent staff had access to relevant training but the numbers of staff undertaking training was poor. EVIDENCE: This home has a stable team of staff. Staff had established good working relationships with service users and their families. The manager said that four care staff had attained a NVQ qualification in care and two staff were currently undertaking this training. The home continues to work towards meeting the standard set by the Department of Health for 50 of care staff to achieve a vocational qualification in care. The commission had agreed that staff records could be held centrally and a form outlining all of the information and checks that had been undertaken for staff would be kept in the home for inspection. Two staff recruitment forms were examined. The agreed form was in use but parts of the form were blank. It was not clear whether the staff members had completed an application form, Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 22 whether two written references had been obtained or if they attended an interview. See requirement 7. A provider relationship manager from the commission was undertaking additional checks at the company’s head office twice a year. The most recent audit was undertaken in June 2006 when all of the files examined were found to comply with regulations. The inspector discussed the arrangements for attending training sessions with a temporary (bank) member of staff. The staff member had little experience of working with people with a learning disability prior to her appointment. Despite requesting training the staff member had not received any induction or health and safety training. The staff member said she had experienced difficulties communicating with some service users and often had to rely on permanent staff for advice. Five staff training records were examined. Three members of staff had not undertaken any training during the past year and two members of staff had attended one training session on epilepsy or abuse during this period. The home received a copy of the training programme which listed all of sessions that were planned and staff were encouraged to attend. The manager and senior staff should address poor uptake of training with staff during supervision. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The support and care provided for service users was good but the manager and senior staff must take action to improve the standard of record keeping and to ensure that health and safety issues are identified and addressed promptly. Quality assurance work was improving but the arrangements did not include obtaining feedback from service users relatives and other professionals. EVIDENCE: The previous regulatory authority had assessed the manager to be a suitably experienced person to manage a care home. The manager said that she had completed the Registered Managers Award and was a NVQ assessor. A copy of the certificates in respect of these qualifications should be sent to the commission. Staff said that the manager was approachable and helpful. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 24 At the time of this inspection the manager of the home was supporting another care home on a part time basis. The commission were not made aware of this arrangement. See recommendation 7. There was evidence of quality assurance work taking place but there were no systems in place for obtaining feedback from service users relatives or representatives. The manager had not carried out any audits except for a ‘walking route’ check to identify urgent health and safety issues. Senior staff from the company had carried out a medication and health and safety audit in recent months. Staff were not aware of the findings from the medication audit but the health and safety audit indicated that a significant amount of work was required to comply with the company’s health and safety policy. It was not clear who was responsible for monitoring progress with this work. See requirement 8. A random check of health and safety and fire safety checks was undertaken. A new boiler and fire alarm system had been fitted since the last inspection. Staff said they had not been able to test the fire alarm for the past two months, as they did not have access to the code. The manager said that action was being taken to address this issue. The last fire drill had taken place in January 2006; it was not clear from the records what time of day the drill took place or how staff responded. There was no evidence that staff had received fire safety training during the past year. Records relating to portable electrical appliances, water chlorination, the mains electricity installation, fire extinguishers and the emergency lighting were examined. These records were found to be satisfactory but the gas safety inspection was overdue. The room containing the hot water tank in both flats was unlocked. The tanks felt very hot when touched. The manager must assess the risk of injury to service users and take action to maintain service users safety. See requirement 9. The records for two accidents were assessed. The circumstances surrounding one accident was recorded on an accident form and in the service users care notes. There was a brief reference to the second accident in the service users care notes but the accident form could not be found. See requirement 10. Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 25 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 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 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. 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 05/03/07 2. YA6 15 3. YA14 16 4. YA20 13 The Registered Person must ensure that the Service Users Guide includes the following information-: the terms and conditions of occupancy including the amount and method of payment of fees and a standard form of contract. A copy of the revised Service Users Guide must be forwarded to the Commission within 28 days of any changes being made. (The previous timescales of 01/02/05, 01/06/05 and 01/04/06 were not met) The Registered Person must 05/02/07 ensure that every service user has a support plan, which is reviewed and updated regularly. (The previous timescale of 21/04/06 was not met) The Registered Person must 05/03/07 ensure that all service users have regular opportunities to engage in recreational and social activities. The Registered Person must 05/02/07 ensure that • A record is maintained for all medicines received in DS0000037846.V303552.R01.S.doc Version 5.2 Wadeville Hostel Page 27 5. YA23 13 6. 7. YA24 YA34 23 19 8. YA39 24 9. YA42 13 10. YA42 17 the home • That Schedule 3 drugs are stored appropriately The Registered Person must ensure that there are adequate systems in place to safeguard service users personal money. The Registered Person must replace the carpets in the lounge in 2a and 2b in 2007. The Registered Person must ensure that the agreed form for recording recruitment checks is completed in full for all members of staff. The Registered Person must establish a system for reviewing and improving the quality of care provided in the home. This must include consultation with service users and their representatives. (The previous timescale of 19/05/06 was not met) The Registered Person must: • Assess potential risks to service users (in respect of access to the rooms containing the hot water tanks) • Ensure that gas safety inspections are carried out annually (confirmation that this inspection has now taken place must be sent to the commission) • Ensure that staff receive regular fire safety training updates • Ensure that regular fire drills are carried out • Carry out regular fire alarm tests The Registered Person must ensure that staff complete an accident form for all accidents that occur in the home. 05/02/07 31/12/07 05/02/07 05/03/07 05/02/07 05/02/07 Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 28 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 YA2 Good Practice Recommendations The Registered Provider should not admit new service users into the home until the placing authority has provided the home with a copy of the service users care needs assessment. The assesment should be completed in full. The Registered Person should ensure that contracts: • Include information about the fees charged • Are agreed and signed by the service user or their representative The Registered Manager should ensure that service user meetings take place regularly. The Registered Person should ensure that a risk assessment is carried out for all service users. Risk assessments and guidelines should be accessible to all members of staff. The Registered Provider should ensure that the manager of the service: • Receives adequate notice about any work that is due to take place in the home • Receives a job specification for any work that is planned so that he/she can comment on the plans if necessary, make adequate preparations for service users welfare and check that the agreed work has taken place The Registered Person should ensure that: • Staff training needs are discussed and agreed during supervision and appraisal • All staff receive induction training to TOPSS standard The Registered Manager should not be responsible for more than one registered establishment. 2. YA5 3. 4. YA8 YA9 5. YA24 6. YA35 7. YA37 Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 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 Wadeville Hostel DS0000037846.V303552.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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