Inspection on 26/09/06 for Wheathill Road, 19

This inspection was carried out on 26th September 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wheathill Road, 19 16/11/07

Wheathill Road, 19 25/01/06

Wheathill Road, 19 01/09/05

Wheathill Road, 19 07/12/04

Wheathill Road, 19 04/05/04

Wheathill Road, 19 20/11/03

Wheathill Road, 19 01/09/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Wheathill Road, 19 19 Wheathill Road Penge London SE20 7XQ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 26th September 2006 09:00 Wheathill Road, 19 DS0000006907.V306678.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 Wheathill Road, 19 DS0000006907.V306678.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. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheathill Road, 19 Address 19 Wheathill Road Penge London SE20 7XQ 020 8659 7425 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) Community Options Limited *** Post Vacant *** Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category MD(E) for named service user only. 25/01/06 Date of last inspection Brief Description of the Service: The home is a large house located in a residential area of Penge. The facility is part of the Community Options group, which operates the home, whilst Hyde Housing owns the building. The home is for five residents who have long-term mental health problems. All residents in this home are on Enhanced Care Programme approach (CPA). The main purpose of the home is rehabilitation into the community, with residents developing the skills for more independent living. Residents are encouraged and supported to be independent in all activities of daily living. In addition integration into the local community and accessing local services including health provision is promoted. The home has its own staff team with a Manager and Deputy Manager heading it up. Senior management and personnel are provided through the head office of Community Options. On call support and advice are also available through the company seven days a week 24 hours a day. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by the inspector over a one day period. At the time of the inspection there were four residents in the home, one was on overnight leave. Two staff were on duty - the Deputy Manager and a support worker. A student nurse on placement was also due on duty although failed to attend. The inspector met with four residents, two briefly, the other two spent more time with the inspector. Eliciting information and engaging with some of the residents was difficult, particularly with this type of client. The inspector did however feel that the residents were satisfied with the level of support and facilities provided within the home. Two comment cards were received one from a resident, the other a health professional. The information provided within the comments, related that a good standard of care and support was provided with staff addressing issues appropriately. What the service does well: What has improved since the last inspection? The new care plan formats provide a framework from which to develop a care plan which is fully reflective of needs. Physical health problems also had risk assessments included to provide a more comprehensive picture of the issues and actions to be taken. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 7 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 Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 8 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): 2 The quality rating in this section is adequate. This is based an all of the information including the site visits. Information is provided to residents prior to admission although evidence of trial visits, visits by family members etc, is not always fully recorded. Residents are issued with contacts once admitted. EVIDENCE: The variation for the one resident living in the home, who is over 65 years, has been approved. The Statement of Purpose has been amended although details of one support worker were omitted. In view of the present Manager’s forthcoming retirement this will need to be further amended. The resident who had been most recently admitted met with the inspector, although he himself was unable to identify what the admission procedures had been or if he had visited prior to permanent placement. There have been no newly admitted residents to this home since the last inspection. The information of the most recent admission was inspected. This resident is on Enhanced Care Programme Approach. The information included an assessment interview however this was not dated or signed. Details of a “panel interview” were dated 3/06/05. There was a report from the Occupational Therapist dated 3/12/04. There was a CPA information sheet dated 13/12/04. Other information included a Crisis Plan and other information Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 9 from the Maudsley dated 10/2/04. The CPA care plan was dated 11 March 2003. There was no reference to what other information had been provided to the resident or his family or outcomes of any trial visits. Written confirmation of the home’s ability to meet all of the resident’s identified needs must be in place and provided to the resident. The inspector is aware that shortly after admission this resident was readmitted for a long period of time before returning to the home. This resident had suffered a significant relapse in his mental health condition, which required inpatient treatment. Robust assessment procedures must be undertaken to determine the suitability of prospective admissions to the home. This is particularly important when dealing with vulnerable and volatile residents because of the impact this may have on other residents and the dynamics on the home. In addition, community provision has less staff and immediate medical input, than inpatient services. Please see requirement 1. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 10 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): 6,7,9. The quality rating in this section is adequate. This is based an all of the information including the site visit. Care plans have undergone some improvement although more detail in the action to be taken is required. Reviews need to be addressed at appropriate intervals, with dates and signatures of staff and resident in place. EVIDENCE: Care plans and associated records are stored in the staff office. Two care plans were selected, including that of the resident whose assessment information had been inspected. The key worker to one of these residents was the Deputy Manager who demonstrated a good knowledge of his needs, support required and ongoing management. The staff member related to the inspector that the resident was significantly mentally impaired, including problems around thought disorder, orientation and paranoia, as well as issues with standards of personal hygiene all of which impacted on his engagement with rehabilitation activities. This resident has caused considerable management problems due to his mental health and more recently; he was missing from the home for a number of weeks. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 11 The care plan was inspected for this resident. It was evident that some improvements had been made to the care plan format; these now include separate sections for physical and mental health, as well as other identified problem areas. Additional sections in the documentation, address areas such as dietary problems, activities of daily living, family/social support and medication. In the first care plan, under physical health, issues identified included high sugar intake, high cholesterol, damaged teeth and one that simply said: “weight”. There was no further indication of the specific problems i.e. over weight/underweight. In addition there was no intervention in respect of this problem and the inspector was unable to find supporting weight charts or specialist advice relating to this. The other identified problem areas did have some interventions documented although these were limited in content. Throughout the documentation staff signatures were omitted as was that of the resident, however this may not have been possible with this gentleman. All of the problems had a review date set for six months. Supporting risk assessments were in place for fire, self-neglect individual missing persons information, orientation delusions and hallucinations. These had been generated between May and September 06, and again six month reviews were stated. The risk assessment in respect of smoking in his bedroom was limited however the general a fire risk assessment dated 2 April 2006 contained more information. The Community Options support plan detailed four problem areas, which had the resident’s and staff signature in place. There was a mental health assessment dated 25/09/06. The second care plan documentation included risk assessments with review dates in place, Community Options support plan, the CPA care plan, dated July 2004, and a list of identified needs. The majority of these had the resident’s and staff signatures in place. There was a summary relating to the progress made on the identified areas of need, dated February 2006 and August 2005. This resident suffers from epilepsy, which is unpredictable in it’s presentation. On the wall of the office there was guidelines on the immediate action to be taken. This needs to be included in her care plan, kept under review and tie in with her risk assessment. Management must ensure all staff including bank and agency staff are familiar with the guidance. It was noted that within the Regulation 26 report, reference to the content of care plans and risk assessments was highlighted for improvement. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 12 The second staff member, interviewed by the inspector, related a good knowledge of this resident’s needs, family networks and level of support she required. He was her key worker. The observed practice on the day was that staff demonstrated a consistent approach to residents, which is essential in this setting. In general some improvements had been made to the care/support plans, but specific information and more detail is required to fully and comprehensively address the residents needs. Up to date CPA reviews and care plans must be obtained and available. Identified problems must be reflective of the totality of the individuals needs. Outcomes and goals must be achievable. It is essential when caring for unpredictable mental health residents that all information is comprehensive in content reflective of needs and kept under regular review. Communication of information is essential with this type of resident, to accurately reflect the current situation, and ensure that action is taken in a timely manner by appropriate professionals. Please see requirement 2. Wheathill Road, 19 DS0000006907.V306678.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): 12,13,15,16,17 The quality rating in this section is good. This is based an all of the information including the site visit. Residents have choice and flexibility in their daily lives. Involvement with the local community is promoted. EVIDENCE: Activities within the community are encouraged and engagement with local services implicit with ongoing rehabilitation. Activities of daily living within the home are in place to promote a level of functioning for more independent living. Residents are of different abilities and have varying degrees of mental impairment. Routines and allocated task are reflective of this, however with some residents it can be very difficult to engage in and therapeutic activity. Risk assessments are in place to address issues such individual missing persons, to allow residents flexibility to go out for varying lengths of time. Each resident has an allocated housework task in the home, which they are supported to do. In addition, residents shop for their own food, clothes and any other item they may need. Residents are supported to take care of their own bedrooms. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 14 Visiting is open. At the time of the inspection one resident was on overnight leave from the home. This is something that she does regularly. In addition residents access services such as the MIND day centre, gardening clubs and have days out with staff from the home. One resident described her leisure activities as going out for coffee, baking cakes, and going shopping, all of which she enjoyed. She felt that there was flexibility and choice in her day including rising and retiring times, meals etc. Wheathill Road, 19 DS0000006907.V306678.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): 18,19,20. The quality rating in this section is adequate. This is based an all of the information including the site visit. Personal care is provided in the manner preferred by residents. Up-to-date and comprehensive information is not always included in the resident’s documentation either in respect of physical health care or that provided under the CPA arrangements. Medications are stored, recorded and generally managed satisfactorily. EVIDENCE: Residents within this home need support and encouragement with personal care, which can sometimes be difficult as they may be resistive to this. Staff are faced with difficult choices in the event that residents levels of hygiene become unacceptable. Clear guidance on such situations must be in place to address the individuals needs and behaviours. Health care is recorded in the diary and in the daily records. The entries relating to physical health care appointments, was limited without information on outcomes of appointments, follow up or conclusion. After care, for mental health residents, under the Care Programme Approach (CPA), has specific timeframes for reviews. It is at these reviews that problem areas are discussed and evaluated with members of the multi disciplinary team and the residents themselves. CPA has it’s own care plans and recording Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 16 formats. The information seen on the day of the inspection, relating to the CPA information is referred to under the section “ Individual needs and Choices”. Medications are securely stored in a cabinet in the first floor office. This was inspected and found to be tidy with no overstocking evident. A weekly check on medications is undertaken by staff in the home. The BNF reference manual was available for staff to access. All residents in this home are on some medication. One resident is selfmedicating. In relation to this, her Psychiatrist had written to confirm her suitability, however this was dated 2001.The assessment of her ability to self medicate was dated 16/05/05 and was due for a six month review, which had not been conducted. This is now overdue. On the medication administration charts, residents’ photographs were in place and records were generally well completed. One chart had the residents allergies not completed. The received and returned medications were recorded on a separate sheet. Those medications that are administered “as required”, were recorded The list of medications, which can be administered as homely remedies, was dated December 2004. Homely remedies, if applied generically throughout the home, must be updated as residents and their needs change. Alternatively, as in this home where the homely remedies are for named individuals, then this should be kept under review as residents conditions may change. An annual review is recommended. Please see requirement 3 and 4. Please see recommendation 1. Wheathill Road, 19 DS0000006907.V306678.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): 22,23 The quality rating in this section is good This is based an all of the information including the site visit. Information regarding complaints is provided to residents and includes external avenues. Staff demonstrated a good knowledge of adult protection, whistle blowing and dealing with complaints. EVIDENCE: The complaints information was on display in the hall and available in the policies an procedures. The information included external avenues and the details of the CSCI. Also in the policies and procedures manuals was guidance on whistle blowing and abuse. In addition information on how to raise concerns and complaints is found in the Service User Guide. The CSCI have received no complaints regarding this service since the last inspection. Any concern or complaint that a resident makes, then the information relating to this is retained in their individual file. The home has not developed a complaints log for monitoring these events. The complaint’s log should detail the actual concerns, give a statement of the action taken and the out comes. Investigation details and/or interview notes should be securely retained. The complaints log should specify if the complainant is satisfied with the outcome or not. The complaints log should be retained on site and easily accessible for staff to make entries. The residents with whom the inspector met, stated they would go to staff or in some cases other members of the multi disciplinary team or Head Office staff. Non of the residents felt intimidated when making complaints or concerns known. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 18 The inspector met with the two staff who were on duty during the inspection, one a newly appointed support worker the other the Deputy Manager. Both demonstrated a good knowledge of the adult protection and whistle-blowing procedures. Both stated that they would report any event including abuse, and they felt that the company would be supportive in any situation. In addition they both had a good knowledge of whistle blowing and dealing with complaints. Please see recommendation 2. Wheathill Road, 19 DS0000006907.V306678.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): 24,30 The quality rating in this section is adequate. This is based an all of the information including the site visit. There was evidence of wear and tear in some areas, and parts of the home require attention to maintain it to a satisfactory standard. EVIDENCE: The home is a domestic style house in a residential area of Penge. It has easy access in to the town centre, which is well served by many buses. The home is located over three floors, with communal areas on the ground floor and bedrooms throughout. The staff office, which is also the staff sleep in room, is on the middle floor. There is a designated smoking room adjacent to the kitchen and all other areas are non smoking. The smoking areas had evidence of wear and tear with burn holes to the carpet and were very smoky. Metal ashtrays were available. Access to the garden is via this area. The garden was pleasant. The ground floor lounge was also suffering wear and tear with staining to the sofas and carpet apparent. The ceiling was also in need of redecoration. The kitchen was clean and tidy although a unit door was missing, as was the swing bin lid. The flooring also required attention. This had been identified in Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 20 the Environmental Health report dated 2 May 2006. All other areas of the kitchen were satisfactory. The laundry area was tidy and all equipment in working order. Two bedrooms were inspected and in stark contrast to one another. The first was personalised clean and tidy, whilst the second was in a poor state. This bedroom belonged to the residents who had been part of the case tracking exercise and the most recent admission. The room was stark with bare walls, burn holes in the carpet and generally in an untidy state. Staff advised the inspector that this resident was difficult to engage with and had not wanted to personalise his room so far. Staff were themselves maintaining his bedroom. Hot water temperatures were satisfactory and window restrictors in place. One resident has a personal alarm in her bedroom due to her medical condition. All areas of a registered care home must be maintained to a reasonable standard of health safety and hygiene. In the event that residents are, for whatever reason, unable to do this for themselves, staff must ensure this is actioned. Please see requirement 5. Wheathill Road, 19 DS0000006907.V306678.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): 32,35. The quality rating in this section is adequate. This is based on all of the information including the site visit. Staff are provided in sufficient numbers to address the support residents need. Induction and ongoing training provide an effective knowledge base for staff to be competent in the work that they undertake. EVIDENCE: The staff off duty rota indicated that there are two staff during the day time period and one staff sleeping in overnight. The home employs four support staff one Deputy Manager and one Manager. The two Managers work shifts and are included in the numbers. Staff recruitment files are retained at the Head Office, these will be inspected 7 November 2006. On previous inspections these have been found to be to a good standard . The support worker with whom the inspector met had worked with Community Options on a bank basis before applying for a permanent position. He had, prior to this, completed a degree in Health and Social Care and had worked with learning disability residents previously. He confirmed that he had received a five-day induction through the Head Office. This had covered topics on health and safety, residents’ needs and aspects relating to working in a community setting. Other training topics had Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 22 included medication proficiency, mental health awareness and stress management. Within his training file there were no certificates to confirm the training provided or his induction certificate. The file did however contain certificates from staff who had left including the previous manager The training file for the Deputy Manager was inspected. He himself stated he had received a lot of training. He confirmed that he had completed the NVQ level 3 and RMA. The training certificates in the file included topics on challenging behaviour, mental health, drug awareness and dealing with benefits. Supervision was said to be conducted by the Manager although notes arising from these sessions were lacking. In the file there was one record of supervision for the Deputy Manger dated February 2006 and one for the support staff member dated 1/9/06. Other records of supervision were without staff or supervisee signature. Staff appraisal records could not be located. Please see recommendation 3. Wheathill Road, 19 DS0000006907.V306678.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): 37,39,42 The quality rating in this section is adequate. This is based an all of the information including the site visit. The Management of this home had undergone many changes in the last few years with another change due imminently. Quality assurance measure are in place to reflect the views of staff and residents. Health and safety issues are addressed although some items are in need of updating including staff training. EVIDENCE: The current Manager is a trained nurse in the field of Psychiatry and has worked with Community Options for some time in several of their projects. He is due to retire the end of October 2006 and a new Manager is to be appointed. He has not completed to CSCI process to become the Registered Manager for this facility. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 24 The Deputy Manager has completed the NVQ 3 and Registered Managers Award. He is undertaking the Diploma in Mental Health through a distancelearning package. The residents and staff with whom the inspector met confirmed that the management, both within the home and those at Head Office, were supportive, helpful and that you could go to them with any issue. Community Options do provide forums for residents to have an active role in the management of the homes and the organisation in general. In house residents meetings are held; minutes of these were seen and had been conducted four times since May 06. There is a Community Options newsletter, which is on general circulation to all of the homes. Staff and residents are invited to input into this. Residents are invited to sit on interview panels although no one from this facility is doing so. Residents are also invited to participate in the Annual General Meeting and participate in many of the other committees that Community Options facilitate including the “Client Care Group”. Staff participate in an annual staff survey and the results of this are published and circulated. Staff meetings are held and the minutes of these were seen. The minutes of the staff meetings dated 19/09/06, did detail some residents issues, this would perhaps be better addressed at a separate forum. Reports from Regulation 26 visits were available for 20 September 2006, 31 July 2006, 6 June 2006 and 24 April 2006. These must be conducted monthly unannounced. Records relating to heath and safety including service certificates were inspected. The company has a health and safety committee, although from the minutes this had not been operational since July 2005. The fire records were inspected. Weekly fire alarm testing and emergency lighting records were up to date. Fire drills had been conducted with staff and residents participating, September, May and January 2006. First names were in place without full signatures. Fire maintenance is conducted quarterly on a contract basis. Portable appliance testing had been conducted July 2006. The five-year electrical inspection dated March 2004 was unsatisfactory. The action taken to rectify this needs to be confirmed in the response to the CSCI. Following the inspection, the electrical certificate was forwarded to the office on the 16 October 2006. The annual gas certificate was current. Hot water temperatures are tested monthly. The water chlorination certificate was dated November 2003 this needs to be addressed. Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 25 Training in respect of first aid was addressed with three staff having attended since 2004. Training on health and safety in the workplace was attended by two staff one in 2005 and one in 2004.Manual handling training / risk assessing needs updating for some staff. Two of the resident’s financial records were inspected and found to be satisfactory; one was without the residents signature. Staff check these routinely twice monthly. Please see requirement 6. Wheathill Road, 19 DS0000006907.V306678.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 X 2 2 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 x 3 X x 2 x Wheathill Road, 19 DS0000006907.V306678.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 YA2 Regulation 14 Requirement Timescale for action 28/12/06 2. YA6 15 The Manager must ensure that all assessment procedures are concluded and evidenced prior to any admission taking place. Evidence of information provided to the residents and their family should be recorded. Confirmation of the home’s ability to meet all of the resident’s identified needs must be in place. The Manager must ensure that 28/12/06 all care plans are fully reflective of needs, with robust interventions detailed. Risk assessments and all supporting documentation must be available, current and kept under review. Previous timeframe for action 30/09/05. This is now outstanding. The Manager must ensure that 28/12/06 all health care interventions are recorded and comprehensive in content . The Manager must ensure that 28/12/06 procedures relating to selfadministration are followed including timeframes for reviews. 3 YA19 13 4 YA20 13 Wheathill Road, 19 DS0000006907.V306678.R01.S.doc Version 5.2 Page 28 5 YA24 23 6 YA42 23 The Manager must ensure that all parts of the home are maintained to a satisfactory standard including communal areas and individual bedrooms. The Manager must ensure that all aspects of health and safety are addressed including staff training, servicing of items and on going monitoring and renewal. 30/03/07 28/12/06 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 YA20 YA22 Good Practice Recommendations The Manager should ensure that policies and procedures including those for medications, are annually reviewed. The Manager should ensure that a complaints log is devised to accurately reflect all complaints received with details of date, investigation route and the satisfaction of the complainant. The Manager should ensure that all staff receive supervision six times a year that covers all aspects of Standard 36.4. 3 YA36 Wheathill Road, 19 DS0000006907.V306678.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. 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