Inspection on 13/11/06 for York Road (14a)

This inspection was carried out on 13th November 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Road (14a) 09/03/09

York Road (14a) 26/07/07

York Road (14a) 12/02/07

York Road (14a) 15/12/05

York Road (14a) 08/06/05

York Road (14a) 13/01/05

York Road (14a) 27/04/04

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 York Road (14a) 14a York Road Sutton Surrey SM2 6HG Lead Inspector James O`Hara Key Unannounced Inspection 13th November 2006 09:20 York Road (14a) DS0000007149.V319625.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 York Road (14a) DS0000007149.V319625.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. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York Road (14a) Address 14a York Road Sutton Surrey SM2 6HG 020 8643 9612 020 8643 1662 h4062@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mr Mohammad Iqbal Sohawon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: 14A York Road is a purpose built facility situated in a mainly residential street, between Sutton and Cheam. The home is close to local transport and facilities. Threshold Housing and Support owns the building although the residential unit is managed and staffed by Men Cap. The home provides care to six service users who have learning disabilities, autism and challenging behaviour. There are six single bedrooms, a lounge, dining room, kitchen and laundry. There are bathrooms and toilets situated through out the home. The home also has a large garden to the rear of the property. There is also ample parking to the front of the house. The home has its own transport in the form of a people carrier. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 9.20 and 1.30 pm on a Monday morning/afternoon. The registered manager, Mr Sohawon, was not present on the day of the inspection. The deputy manager, Ms Gawlik, ably supported the inspection process. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with the deputy manager. Records examined included service users plans, care plans, risk assessments, complaints, adult protection, staffing records, Criminal Records Bureau Checks, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed with Ms Gawlik. What the service does well: What has improved since the last inspection? What they could do better: There were four requirements set at the last inspection. The deputy manager provided evidence that one of these had been met. The registered manager York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 6 was not present on the day of the inspection so it was not possible to discuss the three outstanding requirements. As a result of this inspection eleven new requirements and five recommendations have been set. There are now fourteen requirements and seven recommendations. There were a large number of weaknesses identified during the inspection the most significant being the lack of monitoring of health and safety in particular fire safety in the home. Another area of concern was around recruitment of staff in particular the failure to obtain appropriate references and full Criminal Records Bureau Checks prior to staff commencing employment in the home. The home and Threshold Housing Association could do more to ensure that service users live in homely and comfortable environment. The home could do more to ensure that the service users care plans/needs assessments are kept under review by their placing authority. Staff at the home should receive regular supervision so that service users can benefit from having a consistent approach to their needs. Seven members of staff have left employment at the home since the last inspection. Three new members of staff have started working at the home and a new deputy manager will start working next month. The challenge to the service and to the registered manager is to build a new staff team and to ensure that all new staff receives induction and appropriate training in order to meet the needs of the service users. The inspector would like to thank the service users, the staff and the deputy manager for their support in the inspection process. 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. York Road (14a) DS0000007149.V319625.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 York Road (14a) DS0000007149.V319625.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users and their representatives with all the information they need to make an informed decision about whether or not to use the service. However the Statement of Purpose and Service Users Guide should be updated. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Service User Guide includes all the necessary information specified in regulation 5 of the National Minimum Standards. It was noted during a tour of the home that the kitchen and laundry room doors are kept locked. The deputy manager stated that this was for the safety of some of the service users and that service users always have access to the kitchen and laundry when staff is around. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 9 It is recommended that the homes Statement of Purpose and Service User Guides refer to restrictions on the freedom of movement within the home and the reason for the restriction so that any prospective service user has all the information they need to make an informed choice about the home. These restrictions should also be discussed and recorded in individual service user needs assessments/care plans. No new service users have moved to the home since the last inspection. The Mencap organisation has its own guidelines for service users selection and assessment prior to moving to the home. The home only accepts referrals following an assessment completed by a care manager. The home also completes an assessment. Compatibility with others already living in the home is also taken into account. Any prospective service user would have a gradual introduction to the home with a series of short visits and overnight stays. The time frame would be flexible depending on the service user. All service users have contracts/licence agreements stating terms and conditions and fees charged. The range of fees charged at the home is between £1209.33 and £1251.45 per week. York Road (14a) DS0000007149.V319625.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In general service user plans include detailed information on their needs and personal goals. However the home could do more to ensure that the service users care plans are kept under review by their placing authority. All service users have individual risk assessments and risk management strategies in place so that service users can participate in activities in the home and in the community in a safe manner. EVIDENCE: Two service users files were examined. Both service users had a person plan book that included a communication profile, personal profile and important people in my life. The file also included weekly activity records, morning and evening routines, challenging behaviour guidelines. It was noted that all service users risk assessments are kept under regular review. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 11 Neither file included copies of the service users care plan/placement review. The deputy manager stated that the service users care managers had carried out these reviews but that no copy of the review had been requested by the home. The registered manager must contact all of the service users care managers and request a copy of the most up to date service users care plan/placement review and this must be kept on file. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 12 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. Provision is made so that all service users attend appropriate social activities, day centres and become part of the local community. Appropriate arrangements are made so that service users have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and eaten by the service users. EVIDENCE: York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 13 On the day of the inspection all but one of the service users had gone out. Service users attend various day services and colleges during the week and have a set home day when they carry out personal tasks such as cleaning, laundry, shopping and cooking. Service users attend the Jan Malinowski Centre, Cheam Centre, Hallmead Day Centre, Generates, Schola and Orchard Hill College. Some service users also attend social activities at the Tuesday Club, Gateway Club and the Sunday Club. Service users go to Church on Sunday if they wish and some service users go to the cinema and bowling. Since the last inspection seven members of staff have left employment at the home. The deputy manager stated that service users former key workers used to plan a significant activity once a month for the service users to attend. These included trips to Chessington Park and the London Eye. The deputy manager stated that once the homes new staff are fully inducted and assigned key working responsibilities then the home can once again plan for significant activities. Some service users are able to travel alone to Sutton for personal shopping or to visit cafes some service users need support from staff to do this. The pre inspection questionnaire indicated that the in house activities offered to the service users include arts and crafts, games and cooking. The home has visitor policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Visitors are welcomed and the service users families are invited to their reviews. Visitors can be seen in any of the homes communal areas as well as the service users bedrooms. A number of Commission For Social Care Inspection questionnaires were returned to the Commission as feedback. Generally relatives indicated that they were happy with the overall care provided. However some indicated that they were not able to visit their relative/friend in private. The deputy manager stated that all but one of the service users has regular contact with their relatives. One service user has a Mencap befriender who visits once a month. The deputy manager stated that staff supports service users to cook evening meals. The homes menus indicated that the meals presented to the service users were varied, balanced and nutritional. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 14 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. The arrangements for meeting the health care needs of the service users are good and service users receive personal support in the way they prefer. EVIDENCE: The service users wishes on how they are supported with personal care are outlined in their personal files. Service user files examined indicated that service users attend regular appointments with health care professionals. Service users have access to relevant professional support to maximise independence, including the Community Team for People with Learning Disability. Service users files include guidelines for staff to support some service users with challenging behaviour. These had been drawn up by the home with support and advice from health care proffessionals. Medication is stored in a locked cabinet in the office. Medication administration records checked on the day of the inspection were up to date and accurate. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 15 Service users medication records also contain a medication profile and recent photograph. The home has a policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. The deputy manager stated that new staff have attended or would attend induction training were topics such as finance, key working medication and food hygiene would be taught. The deputy manager stated that she has booked staff training on first aid and moving and handling. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse however unless all staff are trained on adult protection there is the risk that service users will not be protected in a consistent manner from abuse. EVIDENCE: The deputy manager stated that there had been no complaints at the home since the last inspection. The home has a copy of the local authority Adult Protection Policy on site. As previously stated seven members of staff have left employment at the home since the last inspection. Three new members of staff have started working at the home and a new deputy manager will start working next month. The registered manager must ensure that all members of staff attend training on adult protection. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 17 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, 27, 28 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home and Threshold Housing Association could do more to ensure that service users live in homely and comfortable environment. The welfare and safety of the service users and staff could be compromised if the home does not make suitable arrangements for fire safety in the home. EVIDENCE: It was noted during a tour of the premises that the laminate flooring on the ground floor had been damaged due to flooding. The deputy manager provided evidence that this was due to be replaced with the same type of flooring. It was discussed with the deputy manager that this particular flooring might not be fit for purpose given the nature of the service and the homes cleaning routine (the floors are mopped on a daily basis). There is also a risk that service users or staff could slip on the laminate flooring and if the flooring got wet again it would more than likely need to be York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 18 replaced. Following the inspection the deputy manager stated that she had discussed this with the homes service manager and that he was contacting the insurance company. The kitchen was in a poor condition with some drawers missing from cupboards and flooring coming away from the walls. It was also noted at the last inspection that the housing association was due to replace the kitchen cabinets. This task has yet to be completed. It is recommended that the registered manager contact the housing association to find out when the kitchen will be refurbished. The deputy manager produced the cleaning programme employed in the home. However it was noted that the kitchen floor was dirty around the base of the cupboards and fridge/freezer and that the doors to the kitchen and in the hallway were sticky to the touch and in need of washing down. The registered manager must ensure that the homes cleaning programme is adhered to. It was observed that the fire door leading to the office has been removed. The deputy manager stated that this was due to be replaced next month. Following a discussion the deputy manager contacted the London Fire & Emergency Planning Authority for advice and was informed that the door should be replaced as soon as possible and that a fire risk assessment should be carried out on the home. The registered manager must ensure that the fire door leading to the office is replaced as soon as possible. The registered manager must ensure that when there is any future issue were the fire safety of the service users and staff could be at risk then the homes fire risk assessment must be reviewed. It was noted that some of the tiles in V’s en suite bathroom are broken. The deputy manager stated that the home is also waiting for the housing association to repair a dripping tap in the bathroom. The registered manager must ensure that the broken tiles in V’s en suite bathroom and the dripping tap in the bathroom are replaced or repaired. The chest of drawers in C’s room is broken. The registered manager must ensure that the chest of drawers in C’s room is replaced or repaired. The dining room has recently been redecorated. It is recommended that the pictures are re hung in the dining room. The deputy manager pointed out that a light switch in the hallway was faulty and had been reported to the housing association on the previous Friday and today being Monday she was concerned that no-one had come to repair it. The York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 19 deputy manager was advised to contact the housing association and ask when the light switch was going to be repaired. A requirement was set at the last inspection that the registered manager must replace the bulbs in the circular ceiling lights in the homes communal areas and investigate the reason why they have a short lifespan. The deputy manager was not sure as to how this requirement had been progressed. This requirement will be discussed at the next inspection. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 20 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, 24, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes procedures for the recruitment of staff need to be more robust and provide the necessary safeguards to ensure that so far as reasonably practicable service users are not placed at risk of harm or abuse. Staff at the home should receive regular supervision so that service users can benefit from having a consistent approach to their needs. It is evident that the home is going through a period of major transition. The challenge to the service and to the homes management is to ensure that all new staff receives induction and appropriate training in order to meet the needs of the service users. EVIDENCE: The registered manager was not present on the day of the inspection. At the last inspection on the 13th December 2005 the inspector was concerned to note that Criminal Records Checks for all staff were not in place. The report stated that in the absence of a Criminal Records Checks and in exceptional York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 21 circumstances the Commission for Social Care Inspection would consider the employment of staff with a POVA check. At that inspection the registered manager was reminded that no one should be employed without a POVA and Criminal Records Check It is recommended that the registered manager employ the following guidance. Employers must always ensure that new staff has all documentation as stated in Schedule 2 of the Care Home Regulations before starting work with vulnerable people. POVA First is only to be used were the lack of staff places the service users health and welfare at critical risk. A number of conditions need to be in place if staff are to start work with POVA clearance only. • • • The employer must write to the Commission requesting and have agreement that staff start work at the home with POVA clearance only. The home must explain the critical risk to the service user/s. The employer must provide evidence that all other documentation as stated in Schedule 2 of the Care Home Regulations has been obtained for the new staff. The employer must ensure that new staff do not work alone with service users. The employer must ensure that the new staff has an identified senior member of staff to supervise them on each shift. The employer must ensure that the new staff completes induction training during this period. • • • As previously stated seven members of staff have left employment at the home since the last inspection. Three new members of staff have started working at the home and a new deputy manager will start working next month. The Commission would consider in these circumstances that the lack of staff placed the service users health and welfare at risk. A requirement was set at the last inspection that the registered person must ensure that records of all persons employed at the home are kept in the home and include copies of everyones birth certificates, passport, and two written references obtained in respect of them. Schedule 2 of the Care Homes Regulations has been amended, copies of birth certificates are no longer required. On examination of the three new members of staff files it was noted that one member of staff did not have a Criminal Records Bureau Check or POVA York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 22 clearance on file. The deputy manager contacted the homes service manager and he was able to send a copy of the member of staffs POVA check to the home. It was noted that two of new members of staff references were taken up without a company stamp or company headed paper. The registered manager must ensure that references are taken up for the two new members of staff and any future members of staff on company headed paper and or include a company stamp. If the reference is a personal reference then this should be stated and the contact details of the referee should be held on file. A recent photograph of the member of staff should be included on their staff file. A requirement was set at the last inspection that the home manager must ensure that all staff receives regular recorded supervision. Staff files indicated that this requirement had not been met. The deputy manager stated previously only the registered manager supervised staff but now the she and a new deputy manager was due to start work then staff supervision would be divided between the managers and staff supervision would increase. This requirement will be viewed again at the next inspection. It is evident that the home is going through a period of major transition. A large number of staff has left since the last inspection and new staff have started work at the home an further staff will be recruited. The challenge to the service and to the homes management is to ensure that all new staff receives induction and appropriate training in order to meet the needs of the service users. The deputy manager stated that new staff have attended or would attend induction training were topics such as finance, key working, medication and food hygiene would be taught. The deputy manager stated that she has booked staff training on first aid and moving and handling. The deputy manager also stated that once the homes new staff are fully inducted they will be assigned as key workers. It is recommended that the registered manager records training attended by all members of staff. Staff should attend training relevant to the needs of the service users i.e. Challenging Behaviour and Autism. All staff should also attend training on adult protection, first aid, health and safety, moving and handling, fire safety, medication and food hygiene. York Road (14a) DS0000007149.V319625.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. As previously stated the home is going through a period of major transition. The challenge to the service and to the registered manager is to build a new staff team that can meet the needs of the service users. The home is failing to ensure that appropriate health and safety monitoring is taking place so that service users and staff are protected from harm. EVIDENCE: The registered manager was not present on the day of the inspection. The deputy manager stated that the registered manager is currently completing the Registered Managers Award and NVQ Level 4 in Care. The deputy manager is completing an NVQ level 3 in Care. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 24 As previously stated the home is going through a period of major transition. The challenge to the service and to the registered manager is to build a new staff team that can meet the needs of the service users. Regulations 26 visits are carried out by the organisation in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare a written report on the conduct of the care home. Copies of these visit reports are regularly sent to the Commission. A number of Commission For Social Care Inspection questionnaires were returned to the Commission as feedback. Generally relatives indicated that they were happy with the overall care provided. However some indicated that they were not able to visit their relative/friend in private, some said that they are not kept informed of important matters affecting their relative/friend and some said that their relative/friend is not able to make decisions but they (relative/friend) are not consulted about their care. Some comments included “X has been a resident since the home was opened. He is very content and he is well looked after”. “I am dissatisfied with some aspects of the overall care”. Three raised concerns about the health care needs of the service users. It is recommended that the registered manager seek the views of the service users relatives and friends about the quality of care provided in the home. Some relatives said that they were not aware of the homes complaints procedure. It is recommended that the registered manager send a copy of the homes complaints procedure to all of the service users relatives. The deputy manager provided evidence that the hot water temperatures throughout the home are checked on a monthly basis. It was noted during an inspection at the home next door 14b York Road (also an Mencap home) does not have a water tank and water is supplied directly from the mains system to the home and there is no need for a Legionella testing certificate. However the home does have a boiler for hot water. So that dead ends and showerheads and other high-risk areas can be checked the registered manager must ensure that Legionella testing is carried out at the home. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 25 The deputy manager was not sure of the homes procedure for testing for legionellas. It is recommended that the registered manager clarify the homes policy on legionellas in writing to the Commission and all staff at the next team meeting. The deputy manager could not locate the whereabouts of the Portable Appliance Testing Certificate and the homes file did not indicate that Portable Appliance Testing had been carried out. The registered manager must ensure that Portable Appliance Testing is carried out at the home and that a Portable Appliance Testing Certificate is kept on file for inspection. It is of concern that no weekly fire alarm system checks had been carried out at the home since the 29th of August 2006. From that date until Bonnells Electrical Services checked the system on the 6th of November 2006 the management and staff at the home could not have known if the fire alarm system was working. Given the previous issues raised in the environment standards of this report this lack of diligence could leave the service users and staff at great risk. The registered manager must ensure that the fire alarm system is checked on a regular weekly basis failure to carry out these checks in the future may lead to the Commission taking enforcement action against the home. York Road (14a) DS0000007149.V319625.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 3 2 3 3 3 4 X 5 3 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 1 25 3 26 X 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 1 X York Road (14a) DS0000007149.V319625.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 YA34 Regulation 17-(2) Sch4.6 Requirement The registered person must ensure that records of all persons employed at the home are kept in the home and include copies of everyones birth certificates, passport, and two written references obtained in respect of them. This is a previous requirement timescale for action was 15/12/05. Schedule 2 of the Care Homes Regulations has been amended; copies of birth certificates are no longer required. The registered manager must ensure that references are taken up for the two new members of staff and any future members of staff on company headed paper and or include a company stamp. If the reference is a personal reference then this should be stated and the contact details of the referee should be held on file. A recent photograph of the member of staff should be York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 28 Timescale for action 31/12/06 included on their staff file. 2. YA6 14 (2) The registered manager must contact all of the service users care managers and request a copy of the most up to date service users care plan/placement review and this must be kept on file. The registered manager must ensure that all members of staff attend training on adult protection. The home manager must replace the bulbs in the circular ceiling lights in the homes communal areas and investigate the reason why they have a short lifespan. This is a previous requirement timescale for action was 31/03/06. The registered manager must ensure that the homes cleaning programme is adhered to. The home manager must ensure that all staff receives regular recorded supervision. This is a previous requirement timescale for action was 31/03/06. The registered manager must ensure that the fire door leading to the office is replaced as soon as possible. The registered manager must ensure that when there is any future issue were the fire safety of the service users and staff could be at risk then the homes fire risk assessment must be reviewed. The registered manager must ensure that the broken tiles in V’s en suite bathroom and the dripping tap in the bathroom are replaced or repaired. The registered manager must ensure that the chest of drawers DS0000007149.V319625.R01.S.doc 31/12/06 3. YA23 13 (6) 31/01/07 4. YA24 23(2)d 31/12/06 5. 6. YA30 YA36 23(2)d 18(2) 15/11/06 15/11/06 7. YA24 23 (4) 30/11/06 8. YA24 23 (4) 15/11/06 9. YA27 23(2)b 31/12/06 10. YA27 16(2)c 31/12/06 York Road (14a) Version 5.2 Page 29 11. YA24 23(2)d 12. YA42 13(4)a 13. YA42 23 (4) c (v) 13(3) 14. YA42 in C’s room is replaced or repaired. The deputy manager was advised to contact the housing association and ask when the light switch was going to be repaired. The registered manager must ensure that Portable Appliance Testing is carried out at the home and that a Portable Appliance Testing Certificate is kept on file for inspection. The registered manager must ensure that the fire alarm system is checked on a regular weekly basis. So that dead ends and showerheads and other high-risk areas can be checked the registered manager must ensure that Legionella testing is carried out at the home. 15/11/06 31/12/06 13/11/06 15/11/06 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. Refer to Standard YA1 Good Practice Recommendations It is recommended that the homes Statement of Purpose and Service User Guides refer to restrictions on the freedom of movement within the home and the reason for the restriction so that any prospective service user has all the information they need to make an informed choice about the home. These restrictions should also be discussed and recorded in individual service user needs assessments/care plans. It is recommended that the registered manager contact the housing association to find out when the kitchen will be refurbished. It is recommended that the pictures are re hung in the dining room. It is recommended that the registered manager employ DS0000007149.V319625.R01.S.doc Version 5.2 Page 30 2. 3. 4. YA24 YA24 YA34 York Road (14a) the following guidance. Employers must always ensure that new staff has all documentation as stated in Schedule 2 of the Care Home Regulations before starting work with vulnerable people. POVA First is only to be used were the lack of staff places the service users health and welfare at critical risk. A number of conditions need to be in place if staff are to start work with POVA clearance only. • The employer must write to the Commission requesting and have agreement that staff start work at the home with POVA clearance only. The home must explain the critical risk to the service user/s. The employer must provide evidence that all other documentation as stated in Schedule 2 of the Care Home Regulations has been obtained for the new staff. The employer must ensure that new staff do not work alone with service users. The employer must ensure that the new staff has an identified senior member of staff to supervise them on each shift. The employer must ensure that the new staff completes induction training during this period. • • • • • 5. 6. 7. YA42 YA22 YA39 It is recommended that the registered manager clarify the homes policy on legionellas in writing to the Commission and all staff at the next team meeting. It is recommended that the registered manager send a copy of the homes complaints procedure to all of the service users relatives. It is recommended that the registered manager seek the views of the service users relatives and friends about the quality of care provided in the home. York Road (14a) DS0000007149.V319625.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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