Inspection on 13/12/06 for York Road (31)

This inspection was carried out on 13th December 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Road (31) 19/06/08

York Road (31) 26/07/07

York Road (31) 22/02/06

York Road (31) 09/12/05

York Road (31) 14/02/05

York Road (31) 04/11/04

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 York Road (31) 31 York Road Sutton Surrey SM2 6HL Lead Inspector David Halliwell Key Unannounced Inspection 13th December 2006 9.30am York Road (31) DS0000036098.V322515.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 (31) DS0000036098.V322515.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 (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York Road (31) Address 31 York Road Sutton Surrey SM2 6HL 020 8642 6310 020 8642 9807 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) www.together-uk.org Together Working for Wellbeing Mr Martin Wolckenhaar Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: 31, York Road is an extensive Edwardian building, providing accommodation both in this substantial ex-family house and in an additional, more modern, annexe - located in the home’s back garden. The house is situated on a pleasant residential street with a ‘hail & ride’ bus service - and is located in the Belmont area (BR station), south west of Sutton - and slightly closer to Cheam Village, both these more principal towns having rail links also. There is limited parking on site, and extensive [free] parking on the broad street outside. The house provides a service to fourteen people aged 18 - 65 with severe or complex mental health needs. The house provides support to people who require a period of supported rehabilitation after discharge from hospital, prison, and alcohol / drug detoxification units. The main house provides a large (smoking) lounge, a (non-smoking) dining / living room and a substantial kitchen with good, modern catering facilities. A second small lounge is available in the ‘loft’ level of the house - this is used for meetings, reviews - and as a ‘bolthole’ for those seeking peace and quiet. All bedrooms are single occupancy and are well appointed. The rear garden provides a secluded retreat in good weather. The Annexe provides one activity area - where a computer is located, as well as bedrooms and the staff sleeping-in room. An administrative / staff office is provided in the other main room on the ground floor - close to the front entrance of the house. The average placement fee is £1050 per week. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit over 3 days undertaken by the new Inspector responsible for 31, York Road. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and 3 service users. Informal interviews were conducted with 3 other service users as a part of the inspection of the home. There were no requirements outstanding from the last inspection. 9 new requirements have been made as a result of this inspection and feedback on all these requirements and recommendations was given verbally to the Manager at the end of this inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £1050 per week. What the service does well: Service users / residents seen at the home responded positively to the Inspector’s enquiries about life at the home and the services provided. It was helpful that the Inspector was able to speak both with an ex resident and a prospective new resident, the former spoke positively about the care and support he received whilst at York Road and how it had prepared him for independent living. The latter also spoke with some optimism about his forthcoming move to York Road. He said he had appreciated the friendly, relaxed atmosphere at York Road that he experienced whilst he had completed several familiarisation visits to the unit. The support of staff was singled out by residents indicating that they feel well cared for, are well fed and feel safe. The Inspector reiterates a previous comment made: “the management and staff are highly committed and motivated to supporting the service user group and the service users confirm this positive attitude – through their generally high level of cooperation and engagement as a community”. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Improvements are required in the following areas: 1. Resident’s needs assessments carried out by the staff at York Road need to be documented on file and linked in with the Care Programme Approach care planning process. 2. Assessments of needs should include cultural and religious needs of service users as well as including all the other key areas of a person’s needs. 3. Assessments of needs need to be kept under review and revised appropriately when there is a change of circumstance for the resident. 4. York Road should provide all the residents with a comprehensive service user plan that covers all the identified residents needs, saying how the needs will be met. It is important that these care plans are kept under review and as appropriate to changing needs. 5. Medication records / MAR sheets should be signed directly after residents have been given their medication so that there are no gaps in these records in future and so that the individual residents pattern of medication administration is known and is accurate. 6. Staff need to follow the policy and procedures for dealing with complaints in future and that the policy is amended and updated to include the information referred to above. 7. The fire door at the top of the stairs entering the first floor corridor area must be fully repaired so as to ensure it closes fully onto the door stops / smoke seals and remains in good working order. 8. The Manager should draw up training files for each member of staff that identifies what training that individual has achieved and when; what their training needs are that need to be met and evidence of the training courses attended. 9. Staff files need to be reviewed and action taken to ensure that they are in good file order and containing the necessary information as described in Standard 34. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 7 10. The Manager needs to carry out a review of the previous risk assessments for the building ensuring that all risks are identified and strategies developed to meet any identified potential risks. 11. The staff supervision process needs to be overhauled to ensure regularity and a structured format as described above. Records should be maintained and staff should receive copies of the key areas of discussion and decisions made. 12. The process of identifying repairs and maintenance needs to be reviewed and a single record kept of all the needs identified with a log of the progress gained or otherwise of repairs and replacements and all actions taken. 13. Copies of NVQ certificates and NVQ training enrolment forms should be kept as records on the staff training files. 14. The Registered Manager must complete the registered Managers course as soon as possible. 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 (31) DS0000036098.V322515.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 York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. While residents may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may not be assured that their needs will continue to be fully assessed at York Road nor that fully completed documentation will always be held on their files. EVIDENCE: Standard 2 – Four residents files were inspected at this inspection and six residents were spoken with formally and informally. On inspection of the residents files good needs assessments and care plan information was seen on each of these files to have been supplied by the referring agencies. Given the complex and high needs of the people who are service users at York Road this information is as comprehensive and detailed in all aspects as would be expected. However needs assessments carried out by staff at York Road were not evidenced on those files inspected. The Inspector discussed this with the Manager who agreed that this information was not on the files. He explained that the care plans drawn up by the unit are partly based on the information supplied by the referring agencies. The unit’s care plans for most residents are York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 10 also a part of the Care Programme Approach and are reviewed by the clinical care team regularly, a process which includes the resident and the care support team at York Road. The Manager agreed that it would be helpful if information relating to the Unit’s assessments of the residents needs were written down and for the reviews and held on the files of all residents. The needs assessments should also include any cultural or religious needs of the resident as well as including coverage of all other key areas of a person’s needs. The files seen and inspected did not contain comprehensive needs assessments and so it may be that not all the residents’ needs are being met. Residents told the Inspector that they are involved in their care plans reviews appropriately and are able to make their views and wishes known in the process. This was also confirmed by the 3 key-work staff who were interviewed by the Inspector and who have responsibility for the care support of residents. It is a requirement therefore that on placement at York Road a full needs assessment for each resident is carried out. Also that these assessments are documented, held on file, kept under review and revised appropriately. York Road (31) DS0000036098.V322515.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The individual service user plans seen by the Inspector on the residents files did not fully reflect the assessed and changing needs and personal goals of the residents. Service users can be assured that they will be supported to make decisions about their lives with assistance as needed and that they will be supported to take risks as part of an independent lifestyle. EVIDENCE: Standards 6 – As indicated above, 4 service user files were inspected and the Inspector spoke to 6 residents over the course of this inspection. Once a prospective service user has taken up a place at York Road the clinical multi York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 12 disciplinary care teams (MDTs) continue to provide their care support to the resident together with that of the care team at York Road. The Manager informed the Inspector that the York Road care team base the service user plans they devise for residents on the information provided to them by the MDTs and then as circumstances and the needs of the residents change the York Road care staff review the needs assessments and accordingly amend the care plans. However the individual care plans seen on the 4 residents files inspected, lacked the detail necessary to evidence that a comprehensive package of care is being satisfactorily delivered to the residents to meet their needs. As an example, on one residents file the enhanced care programme approach care plan identified a number of complex needs in 12 areas of the residents life. Specific care objectives were identified in each of the 12 areas in order to assist the resident to make positive progress in these areas. Several objectives were to be monitored and reviewed by the York Road care team and by the resident. These included physical health, living skills, daytime activities, social networking, substance misuse, finance and housing issues. When the York Road resident’s file was inspected the service user plan seen for that resident did not cover all the planned objectives only those for daily living activities. The Inspector discussed this with the Manager who agreed that the service user plan was inadequate but also said that the records held on the residents file did not reflect the actual work undertaken by the care team for that resident. It is a requirement that the unit at York Road provide all residents with a comprehensive service user plan that covers all the residents needs, identifying how the needs will be met and that these care plans are kept under review as appropriate to changing needs. The residents files inspected did include most of the information required under schedule 3 of the National Minimum Standards. All residents at York Road are allocated a key worker and they sign their care plans when in agreement with the content. Standard 7 – Service users interviewed by the Inspector confirmed that the staff at York Road do respect their rights to make their own decisions where appropriate. Care staff also made it clear that they involve the residents wherever possible in making their own decisions in order to assist in supporting a positive move towards independence. The Manager told the Inspector about the daily meetings and the community meetings that are held in the unit which involve the residents as much as is possible, to make decisions about different aspects of their lives. This includes menu planning and daily activities as well as planning the routine maintenance tasks that have to be undertaken every day and which involves the residents. Residents confirmed with the Inspector that they attend the daily meetings and the community meetings together with staff. Minutes of the community meetings were shown to the Inspector, they are written by the residents and York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 13 are kept in the dining room for easy reference by the staff and the residents alike. Standard 9 – The Manager informed the Inspector that risk assessments are undertaken for each resident to assist in their taking responsible risks. Inspection of the files confirmed that these risk assessments had been undertaken. Care support staff also confirmed that they are involved with their residents in completing these risk assessments in order to support residents to lead as independent a lifestyle as possible. The clinical care teams are also involved in these assessments appropriately. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 14 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): Standard 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are able to take part in appropriate activities and are to a reasonable extent involved in local activities. Residents have appropriate relationships and their rights and responsibilities in their daily lives are recognised and respected by the staff in the unit. Residents are offered a healthy diet and they are assisted in learning cooking and food preparation skills. EVIDENCE: Standard 12 - The Inspector did not find any evidence that indicated whether or not residents were involved in activities which they did before they entered the home. There was evidence that care support staff appropriately encourage the maintenance of resident’s relationships with family and friends if residents also wish to do so. The Manager told the Inspector that visitors to the home are encouraged and that they use the visitor’s book to sign in. The visitor’s York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 15 book was seen in the front entrance porch was evidently in regular use. The Manager also said that residents are enabled to take part in appropriate activities by the care staff, although when the Inspector looked at the files there was no evidence to show how a person’s cultural needs had been assessed and considered in care planning terms. This needs to be addressed. One resident is currently attending a college of further education to study law and other residents undertake unpaid voluntary work from time to time. The resident who is studying law spoke with the Inspector and is clearly very committed to completing these studies and in achieving the opportunities that this experience will provide him. He was also pleased with the support of the care staff at York Road that has helped him find the energy to undertake this work. Standard 13 - Interviews with residents demonstrated that they do attend some local community events although their wishes for an active community social life are somewhat limited. Information is made available and staff do encourage residents to be involved as much as possible in local activities. Some residents told the Inspector that they like to go to the shops. Service users make full use of local public transport facilities in order to get out and about and to see friends and family. Residents interviewed said that they thought local transport facilities were good. The Manager informed the Inspector that relations with the local neighbourhood are positive and he does try to keep local residents appraised of developments relevant to them. He informed the Inspector that he ensures complaints are dealt with efficiently and residents concerns are dealt with effectively. All residents living at 31, York Road are registered to vote in elections and are supported by staff to do so if they wish. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Standard 15 – Some of the service users interviewed by the Inspector told him that they do keep in regular contact with their families and friends. One resident said that he sees his father every weekend and that he enjoys the seeing his father and keeping in touch. Staff were seen to encourage the residents to keep and maintain contacts with family and friends so that they benefit from having appropriate relationships. There is a visitors room in the house that can be used by visitors who wish to see their relatives in the house. Standard 16 - Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 16 Residents who were interviewed confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. Interviews both with staff and residents confirmed that residents participate in household chores as a part of the community living experience and weekly “chores” are detailed in the weekly action sheets. There is a specific room at the front of the house for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Standard 17 - With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoy. The Inspector saw suitably planned menus for the week ahead. Specific needs are catered for and alternative choices are provided. Residents are able to state their preferences when the menus are planned and there are discussions about this at the residents community meetings, which are held regularly. Residents prepare their own food at breakfast and at lunch times, staff assist them when necessary as part of the rehabilitation programme. Evening meals are generally cooked by a resident together with a member of staff and residents take turns in the cooking of evening meals. A bowl of fresh fruit was seen to be available in the kitchen for residents. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, & 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users could be assured that they will receive personal support in the way that they prefer and require and that their physical and emotional needs will be met. Service users can rely on the home providing a well managed service with regards to medication although greater attention needs to be paid to the completion of records by staff. EVIDENCE: Standard 18 – The Manager explained to the Inspector that residents are expected to be up and about each morning by 9.30am so that they are able to participate in their care packages and this includes their need to take their medications at 9.30 each morning. All 6 of the residents interviewed at this inspection said that they understand why they have to be up by 9.30am. They York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 18 confirmed with the Inspector that they do choose when to go to bed, when to have a bath, what they wish to wear and what activities they do during the day. They all said that they have allocated housework chores on specific days of the week. Residents do not have a choice of their allocated key worker however the Manager said that they have a chance to discuss any issues they may have or which arise subsequent to the allocation of their key workers. Residents did not raise any concerns with the Inspector about their key workers. Residents at York Road receive regular input from their CPNs and at the time of this inspection a CPN was seen to be visiting the home to visit one of the residents. Standard 19 – With regards to the health care of the residents the Manager informed the Inspector that all residents are supported to keep well through accessing appropriate healthcare and associated mental health care support. All residents are signed up with one of the 3 local GP surgeries and some are registered with a local dentist. The Manager said that whether or not a resident uses the dentist is left up to the resident’s own decision but staff will encourage residents to use this service if required. Residents who spoke with the Inspector said that they go to see their GPs as and when necessary but they said they prefer not to go to the dentist. Standard 20 - The unit’s policies and procedures manual contains a policy for medication which includes the procedures that staff need to take in order to ensure the safe administration of medication to residents. 3 staff who were interviewed indicated to the Inspector that they are aware of the policy and know what the procedures are when administering medication to the residents. The Manager told the Inspector that all staff administers medication to the residents and that staff receive regular training to do with the safe handling of medicines. All 3 staff interviewed said that they had received medication training whilst at York Road. The Manager informed the Inspector that no resident at the time of this inspection self-administers medication. Inspection of the medication records MAR sheets found several unexplained gaps where staff signatures or reasons why the medication was not taken, had not been written down after medication was given. The Inspector asked the Manager about this and he explained that this might have happened when staff signed the MAR sheets sometime after the medication had been given. It is a requirement that medication records / MAR sheets are signed directly after residents have been given their medication so that there are no gaps in these records in future and so that the individual residents pattern of medication administration is known and is accurate. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 19 At the last inspection a requirement was made that there be clear guidance for each resident where PRN medication is being used. The Inspector looked at these records for each resident who uses PRN medication and it is confirmed that this guidance is now in place for each resident and is held in the medication files and so is readily accessible for staff and residents alike when needed. The guidance sets out clear individual information signed off by the resident’s GP which will greatly assist the process of giving residents PRN medication. This previous requirement has now therefore been met. A weekly stock take of medication is completed and records kept were inspected and seen to be satisfactory. Appropriate medication cabinets were seen in the office including one for controlled drugs. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 20 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): Standards 22 & 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may feel that their views are listened to but they may be more reassured that their concerns would be acted upon if the complaints policy and procedures for the unit were being fully implemented. Service users may be assured that they will be protected from abuse within the home. EVIDENCE: Standard 22 - Records indicate that there have been 2 complaints made by residents since the last inspection. The Manager confirmed this. However the records to do with these complaints were not completed beyond the first stage of the procedure. No record was made of how or if the complaint was resolved and by when and whether it was dealt with within the timescales set out in the unit’s polices and procedures. The Manager acknowledged that the recording of these 2 complaints is inadequate and does not meet the standard expected. He assured the Inspector that this would be dealt with as required. The Unit’s policy for dealing with complaints was inspected and needs to be updated to include revised information about how and when to contact the CSCI. The policy refers to the NCSC and does not provide any contact information. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 21 It is a requirement that staff follow the policy and procedures for dealing with complaints in future and that the policy is amended and updated to include the information referred to above. Standard 23 – At the last inspection a requirement was made in relation to this standard. The registered provider was asked to revisit / revise the MACA policy on Vulnerable Adults - to commit to adhering to the local authority processes more closely. In order to check whether this need had been addressed since the last inspection the Inspector looked at the policy held in the unit and spoke to the Manager about it. The Manager advised the Inspector that the policy has been revised and that staff have been provided with training and guidance about what actions they need to take if the need arises. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 22 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): Standards 24 & 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they can live in a safe and comfortable house although more regular and routine maintenance is desirable to maximise their safety. York Road is clean and hygienic. EVIDENCE: Standard 24 - York Road provides accommodation both in the main house and in an additional more modern ‘annexe’ located in the garden. The house provides a large lounge (smoking area), bedrooms, a dining / living room (non-smoking) and a substantial kitchen with good catering facilities. A small lounge is also available in the ‘loft’ level - this is used for meetings, reviews, etc. The Annexe has a lounge / computer room and five bedrooms. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 23 There are adequate toilets available throughout both the house and the annexe; there are six bathrooms and five shower facilities available. As a part of this inspection the Inspector made a tour of all areas of these premises together with the Manager. These were the findings on the day of the inspection: • The bathroom ceiling adjacent to room 11 is cracked and the paint is peeling from condensation and requires redecoration. • The 1st floor bathroom light is cracked and broken and needs replacement. Whilst the Inspector was on the premises the Manager spoke to the handyman and it was agreed that this light fitting is to be replaced. • The fire door on the 1st floor that was the subject of a requirement at the last inspection for repair as it was damaged was again inspected and found still to be damaged. The hinge at the top of the door was pulling out of the wooden frame and as a consequence the door was not able to close. This is a serious matter being that it is a fire door and so the Inspector drew this to the attention of the Manager who made immediate arrangements for the handyman to make proper repairs to the door. Work on this had started before the end of this inspection. The Manager explained that since the last inspection this door had been repaired 3 times and the Manager showed the Inspector evidence to substantiate that his had been done. What was evident from this was that substantial repairs were needed and it seems that this is now being addressed. • The top floor shower room required attention at the last inspection as it had an inappropriate exposed fluorescent light fitting which needed to be changed to a more appropriate type of sealed lighting unit. This has now been carried out satisfactorily. However some fungal growth was seen to be growing on the ceiling and this must be attended to as soon as possible. • There is serious damage to the main lounge room external wall caused by the ingress of water from the outside. This has caused the decorations to fall off the wall and the plaster to be lifted from the wall. The Manager told the Inspector that the matter is currently in the hands of the Agency’s architect and surveyor and that a repair will be carried out very soon. • During the course of the inspection of the premises several rooms were without working light bulbs and as some of these rooms – toilets – have no windows it is essential that when a light bulbs fails it is replaced speedily as without light there may be a health and safety hazard caused and a resident may become injured. • The kitchen ceiling is seriously damaged from the ingress or leaking of water through the roof. The Manager told the Inspector that this leak has been repaired and that there are plans for the ceiling to be repaired and redecorated. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 24 • • Some of the kitchen fittings need replacement or repair. 2 drawer fronts were missing and the cupboard door under the sink is badly warped and will need replacement. At the last inspection it was identified that the bath in the bathroom at the top of the house needed replacement as it was now at the end of its life, this has now been done. The home is kept cleaned - and tidy - by a ‘task force’ of service users and staff who complete an excellent job in keeping the house looking clean and being odour-free. It is recommended that the process of identifying repairs and maintenance is reviewed and a single record is kept of all the needs identified and a log kept of the progress or otherwise of repairs and replacements and all actions taken. Standard 30 – Within the home’s policies and procedures manual information is provided relevant to the control of infection. The home also has an infection control procedure which staff who were interviewed said they were aware of. Some training is provided by the agency and staff told the Inspector that they had received training in this area of work. The laundry was inspected and the floor is impermeable and the floors and walls are readily washable. Apart from 2 of the light bulbs not working it was in good condition. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 25 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): Standards 32, 34 & 35. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Staff records need to be overhauled thoroughly to ensure that service users may be assured of the competence and qualifications of their staff and that recruitment processes are properly protecting them. Documentation for staff training and staff supervision also needs to be reviewed and updated. EVIDENCE: Standard 32 – The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. Evidence of this was not seen by the Inspector on staff files but was confirmed by the 3 staff interviewed, one of whom has relatively recently been recruited. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 26 Staff do not have copies of the General Social Care Standards / Code of Volunteers are not used within the home. This should be provided to staff. The Assistant Manager who has responsibility for staff training told the Inspector that there is a training programme underway to ensure that all staff are NVQ qualified by the required date. 3 staff have completed their NVQ training at level 3 and 5 staff are currently undertaking their NVQ training course. No evidence however was available to confirm this information and it is recommended that this is rectified by placing copies of NVQ certificates and NVQ training enrolment forms on the staff training files. Residents interviewed told the Inspector that staff are approachable and the Inspector saw staff taking time to deal with resident’s questions. Standard 34 - There is in place an appropriate recruitment policy. 5 staff files were inspected. Generally the files were in poor order; there were no section dividers, different information was mixed up together and not in chronological order. Some of the information required under the Standard 34 was not in evidence although it is appreciated that some of this information is held at the Agency’s headquarters, copies of certain information must be gained and held on the office files for use by the Manager and for inspection by the CSCI. Key findings: 1. Only on 2 of the files inspected were there copies of an application form, 2. Only on 2 files copies of 2 references including one from the last employer, 3. There were no employment contracts on file between the staff member and the agency, 4. No job descriptions were held on any of the staff files, 5. Identification and a photograph was seen on one member of staff’s file, 6. There was no evidence of staff qualifications including NVQ, 7. No evidence of any staff induction except on one member of staff’s file, 8. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. It is a requirement that all staff files are reviewed and action taken to ensure that they are in good file order and containing the necessary information as described in Standard 34. Staff interviewed did confirm that have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home, however a copy should be available for reference in the unit. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 27 Standard 35 - The Manager informed the Inspector that a structured induction programme is offered to new staff however documentary evidence of this was not seen by the Inspector although it was supported in interview by staff. The Manager informed the Inspector that the Agency does provide a good comprehensive training programme for staff which includes all the necessary areas of training to support staff in carrying out their roles effectively and efficiently. Staff who were interviewed all said that they had been on training courses covering key areas such as the Protection of Vulnerable Adults. However there was little evidence available at the time of this inspection to substantiate this. It is therefore a requirement that the Manager draw up training files for each member of staff that identifies what training that individual has achieved and when; what their training needs are that need to be met and evidence of the training courses attended. Standard 36 – The Manager informed the Inspector that staff do receive ongoing support in the work they undertake. They also receive formal 1:1 supervision. However on inspection of the files the information seen did not evidence that staff are receiving regular and structured supervision. On one member of staff’s file supervision records ceased after August 2005 and no updates or records were available for any supervision sessions held thereafter. On another member of staff’s file the last supervision record was dated October 2005 and for another member of staff June 2006. Regular staff supervision is essential and should be structured to include the: • Translation of the homes philosophy and aims into working with individuals, • Monitoring of work with individual service users and the analysis of care plan outcomes, • Support and professional guidance, and the • Identification of training and development needs, • Annual appraisals. The Manager has informed the Inspector that this form of supervision will be offered to all staff in the near future. This is welcomed, as this form of structured supervision will greatly assist the unit in meeting some of the needs identified in this inspection report. The Inspector is advised that all staff will receive supervision at least once every 2 months. It is a requirement that the staff supervision process is overhauled to ensure regularity and a structured format as described above. Records should be maintained and staff should receive copies of the key areas of discussion and decisions made. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 28 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): Standards 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users cannot be fully confident that they benefit from a well run home. When the full quality assurance system is developed as described in this report they will be confident that their views and those of other involved important parties do underpin the monitoring and review of the homes developments. The health and safety of service users and staff are generally being protected by the policies and working practices in the home. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 29 EVIDENCE: Standard 37 - The Manager is still hoping to gain an NVQ for the Registered Manager’s Award [at Level 4] now by the end of 2007; he is previously a qualified Registered Nurse and he maintains his professional registration. It is important that he does complete this training this year. Some problems have been identified in this report about the unit not maintaining full and appropriate documentation that reflects the actual practice and work of the team. Documentation records need to evidence this as well as evidencing that the unit’s policies and procedures and being fully employed. Standard 39 – At the time of this inspection the Area Manager and the Quality Assurance Manager were also visiting the home and the Inspector was able to have a detailed discussion about the quality assurance process for the unit at York Road. The Inspector was informed that the process for gathering feedback about the quality of services provided is being reviewed but in future it will include seeking information feedback from all the key stakeholders as well as reviewing several aspects of the services provided within the home and talking both to staff and residents alike. All this information is to be analysed and will form the basis of a development plan for the unit. These developments are to be welcomed as a very positive step in the development of the quality assurance process. The Inspector spoke also to the Registered Manager about the development of the quality assurance system that currently gathers information from the residents to do with food, the environment, and to do with staff support. This information is useful in that it helps the Manager develop the services provided. This feedback information is sought annually by the Organisation centrally and the analysed information is provided to the Manager to highlight development issues. The Inspector said that the process should also seek feedback from the families and carers of residents, from referring professionals and other key stakeholders who all have a valuable contribution to make to this process and whose views will assist in the further development of effective service provision at York Road. Survey questions need to be developed in order to provide feedback, which covers aspects of the service such as key working, care, plans, rehabilitation programmes and activities. It is recommended therefore that the quality assurance is developed as described above. Standard 42 – The Inspector asked the Manager if there was a risk assessment for the building and he informed the Inspector that this has not been carried out recently, the last assessment being completed when the new service was opened some 4 or 5 years ago. Risk assessments for the building are useful in helping to assure the health and safety of the residents and therefore it is York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 30 required that the Manager carry out a review of the previous risk assessment for the building ensuring that all risks are identified and strategies developed to meet these potential risks. Appropriate policies were seen in the manual for the unit at York Road covering health and safety; moving and handling; and fire safety. The Manager informed the Inspector that all staff receive training in: • Moving and handling • Fire safety • First aid • Food hygene • Infection control. Unfortunately as already stated earlier there was no documentary evidence to support this although staff interviewed did say that they had received training although some were unsure of exactly when. Cleaning materials and hazardous materials are being stored in a secure area in the cellar of the house and the door to the cellar has an appropriate warning notice on it. However when carrying out the inspection the Inspector found the door open and unattended with the keys in the lock. This was brought to the attention of the Manager immediately as there is a potential risk identified. The Manager assured the Inspector that this will not be allowed to happen again and staff will be reminded of the potential dangers to the residents of unsupervised access to hazardous materials. The Manager told the Inspector that a weekly health and safety check is carried out by staff in order to ensure that any potential hazards are identified and dealt with. Records of these checks were shown to the Inspector. The Manager said that regular checks are carried out on all the unit’s services such as gas, electrical systems, fire alarms, fire prevention systems and that daily records are kept for fridge and freezer temperatures (these were inspected and all seen to be within the acceptable temperature ranges). Food is being stored correctly and is labelled with dates of when food is opened and when it’s expiry date is. Accidents are being appropriately recorded and the Inspector saw the log for this. No accidents were recorded since the last inspection. A record is being properly kept of: • Weekly fire alarm tests • Monthly fire extinguisher checks • Fire practice drills. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 31 The Area Manager and other representatives of the organisation regularly visit the home and comment on the service. Regulation 26 reports compiled by the Registered Provider concerning the home are now copied regularly to the Commission - as required under this Regulation. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 32 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 1 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 1 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 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 2 X 2 X 2 X X 2 X York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? No. 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 That on placement at York Road a full needs assessment for each resident is carried out. Also that these assessments are documented, held on file, kept under review and revised appropriately. That the unit at York Road provide all residents with a comprehensive service user plan that covers all the residents needs, identifying how the needs will be met and that these care plans are kept under review as appropriate to changing needs. That medication records / MAR sheets are signed directly after residents have been given their medication so that there are no gaps in these records in future and so that the individual residents pattern of medication administration is known and is accurate. That staff follow the policy and procedures for dealing with complaints in future and that the policy is amended and updated to include the information referred to above. Timescale for action 01/03/07 2. YA6 15 01/03/07 3. YA20 13 01/01/07 4. YA22 22 30/01/07 York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 34 5. YA24 13(4) & 23(4) The fire door at the top of the stairs entering the first floor corridor area must be adjusted to ensure it closes fully onto the door stops / smoke seals. That the Manager draw up training files for each member of staff that identifies what training that individual has achieved and when; what their training needs are that need to be met and evidence of the training courses attended. 1/01/07 6. 18 31/01/07 7. YA34 17, 19 That all staff files are reviewed and action taken to ensure that they are in good file order and containing the necessary information as described in Standard 34. That the staff supervision process is overhauled to ensure regularity and a structured format as described above. Records should be maintained and staff should receive copies of the key areas of discussion and decisions made. 31/01/07 8. YA36YA36 18 31/0107 9. YA42YA42 10,13,16,18 That the Manager carry out a review of the previous risk 23, assessment for the building ensuring that all risks are identified and strategies developed to meet these potential risks. 31/02/07 York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 35 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. 3. 4. Refer to Standard YA37 YA32 YA39 YA24 Good Practice Recommendations The registered manager should achieve his NVQ Registered Managers Award at Level 4 as soon as is practicable. That the Manager places copies of NVQ certificates and NVQ training enrolment forms on the staff training files. It is recommended therefore that the quality assurance is developed as described above. That the process of identifying repairs and maintenance is reviewed and a single record is kept of all the needs identified and a log kept of the progress or otherwise of repairs and replacements and all actions taken. York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 36 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. Extracts may not be used or reproduced without the express permission of CSCI York Road (31) DS0000036098.V322515.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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