Inspection on 26/07/07 for York Road (31)

This inspection was carried out on 26th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 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) 13/12/06

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 26th July 2007 09:30 York Road (31) DS0000036098.V346253.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.V346253.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.V346253.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.V346253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 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.V346253.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 1 day undertaken by the 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 staff and service users. Informal interviews were conducted with other service users as a part of the inspection of the home. Since the last inspection carried out at York Road, good progress has been achieved by the Manager and his staff team in meeting the requirements and recommendations that were set. This is a positive achievement. There are now 2 requirements outstanding from the last inspection. No new requirements have been made as a result of this inspection however 4 new recommendations have been made. Feedback on all the 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: All those residents seen at the home responded positively to the Inspector’s enquiries about life at the home and the services that are provided for them. It was good to hear residents speaking positively about the care and support they receive at York Road. They said they do appreciate the friendly, relaxed atmosphere at York Road as well as the caring support of the staff group. Evidently they feel safe, well cared for and 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.V346253.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. York Road (31) DS0000036098.V346253.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 (31) DS0000036098.V346253.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): Standard 2. 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 may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may also now be assured that their needs will continue to be fully assessed at York Road and that fully completed documentation will be held on their files. EVIDENCE: Standard 2 – Three residents files were inspected at this inspection and the Inspector spoke with three residents. On inspection of the residents files good progress was seen in a number of areas that evidences a positive response to the last full key standards inspection carried out in December 2006. File order was tidy with the information set out in a helpful, logical and chronological sequence. On each file there was a detailed needs assessment and care plan that had 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. Improved needs assessments have now been carried out by staff at York Road and this work was evidenced on those files inspected. The Inspector also saw care plans for the residents that have now been drawn up York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 9 by the unit and are based not only on the needs assessment information supplied by the referring agencies but also on York Road’s own needs assessment of the residents needs. The unit’s care plans or service user plans for residents are 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. Although the needs assessments should also include any cultural or religious needs that the resident might have, evidence of this was not seen by the Inspector on those files inspected. It is recommended that this should in future be included as well as the coverage of all other key areas of a person’s needs. This will help to ensure that 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 key-work staff who were interviewed by the Inspector and who have responsibility for the care support of residents. York Road (31) DS0000036098.V346253.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): Standards 6, 7 & 9. 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. The individual service user plans seen by the Inspector on the residents’ files does now 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 – Three service user files were inspected and the Inspector spoke to 3 residents over the course of this inspection. The Manager informed the Inspector that once a prospective service user has taken up a place at York Road the clinical multi disciplinary care teams (MDTs) continue to provide their support to the resident together with that of the care team at York Road. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 11 The Manager also 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. A review of the individual care plans seen on the 3 residents files inspected included much more of the detail that had previously been lacking that evidences a comprehensive package of care is being satisfactorily delivered to the residents to meet their needs. The link between the CPA documentation and those needs assessments and York Road’s service user plans is also now considerably clearer. As an example, on one resident’s file the enhanced care programme approach needs assessment and care plan identified a number of complex needs in 5 key areas of the resident’s life. Specific care objectives were identified in the following areas: 1. Mental Health 2. Medication 3. Daytime activities 4. Living skills 5. Drug history. In the York Road care plan; actions had been identified in the plan that would assist the resident to make positive progress in each of these areas. Several objectives were to be monitored and reviewed by the York Road care team and by the resident. For this reason the previous 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, has now been met. Still required and as mentioned earlier in this report under Standard 2, following the needs assessment, a care plan will be required that includes planning for any cultural or religious needs identified for the resident. The residents files that were inspected also included 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. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 12 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 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.V346253.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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 find 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 York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 14 sign in. The visitor’s 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. The Manager told the Inspector that since the last inspection the resident who was attending a college of further education to study law has moved on from York Road to less supportive accommodation. Some other residents undertake unpaid voluntary work from time to time and one resident explained to the Inspector about some part time work that he does every week at Boots. 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 that some information is made available within the home about local activities for residents to take up if they wish. Standard 15 – Some of the residents interviewed by the Inspector told him that they do keep in regular contact with their families and friends. 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 visitor’s 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 user’s rights to privacy, respect and dignity are respected. Residents who were interviewed confirmed that they felt staff respected these rights. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 15 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 now at the top 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 resident’s 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.V346253.R01.S.doc Version 5.2 Page 16 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 and 21. 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. Service users may 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 and they may also be assured that their wishes with regards to critical illness or death will be handled with respect to their wishes. 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. The residents interviewed at this inspection said 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. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 17 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 continue to receive regular input from their CPNs. 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 that includes the procedures that staff need to take in order to ensure the safe administration of medication to residents. A member of staff who was interviewed indicated to the Inspector that they were aware of the policy and know what the procedures are when administering medication to the residents. The Manager told the Inspector that all staff administer medication to the residents and that staff receive regular training to do with the safe handling of medicines. However evidence seen in the staff training files at York Road indicate that it is some time since training has been received and the Manager agreed with the Inspector that a refresher course is now needed for staff this year so that staff remain appropriately skilled and resident’s needs continue to be met safely. This is a recommendation. 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 no unexplained gaps and the Manager explained that since the requirements made at the last inspection, 2 staff now administer all medications and both are required to sign the MAR sheet records immediately after the residents have been given their medications. This marks significant and positive progress since the last inspection and the previous requirement has now therefore been met satisfactorily. The Inspector looked at the medication records for each resident who uses PRN medication and it is confirmed that this guidance is 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 greatly assists the process of giving residents PRN medication. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 18 The Inspector undertook a stock take of medications held in the home, together with the Manager. Records kept were inspected and stock levels of medications were seen to be satisfactory. Appropriate medication cabinets were seen in the office including one for controlled drugs. Standard 21 – Evidence was seen by the Inspector that the resident’s wishes to do with their death or critical illness has been discussed with them and their wishes recorded on their files, signed and dated by the residents. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. 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. Service users may now be assured that their views are listened and acted on. Also that that they will be protected from abuse within the home. EVIDENCE: Standard 22 – The Manager informed the Inspector that the Complaints policy seen at the last inspection has been revised and now includes all the appropriate timescales and information that previously had been omitted (i.e. about how and when to contact the CSCI). A record is also now being kept of any complaints received by the unit. This record indicates that there have been no complaints made since the last inspection. The Manager confirmed this. The revised policy has also been provided to residents in an updated service user guide so that they are now aware of the revised procedure. Standard 23 – The Manager advised the Inspector that the “Working Together…” policy for the Protection of Vulnerable Adults has been revised and that staff have been provided with training and guidance about what actions they need to take if the need arises. The Inspector saw the policy in the Unit’s policies and procedures file, the procedures are robust for responding to suspicion or evidence of abuse or neglect and they include a whistle blowing procedure for staff. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 20 Training records seen by the Inspector evidence the fact that 4 staff have received POVA training in the last year but it is important that all York Road’s staff compliment receive this training at least once every 2 or 3 years. It is therefore recommended that the Manager ensure that those staff who have not done so, enrol on POVA training in the near future. This will help ensure that all staff are up to date with the policies and procedures and other issues to do with the protection of vulnerable adults at York Road. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 attention does need to be given to the larger and more structural types pf repairs and maintence issues identified in this report. 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, a number of single 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 now used as the smoking area for residents. The Annexe has a lounge / computer room and five bedrooms. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 22 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 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 laundry room floor has a hole in it. This compromises the impermeable flooring and therefore needs repair. • The hall, stairs and landing needs redecoration as the lining paper on the ceilings are all loose. Paintwork is also rather “tired”. • 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 has now been satisfactorily repaired. • The top floor shower room requires attention as some fungal growth was seen to be growing on the ceiling and this must be attended to as soon as possible. • The top floor bathroom needs some repairs to be carried out to it. There is a large crack along the edge of the bath and the wall that needs to be sealed and the bath panels are damaged and need replacement. • 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. Raised at the last inspection as a concern the Manager told the Inspector that the matter was in the hands of the Agency’s architect and surveyor and that a repair would be carried out very soon. This has not happened and must be attended to now. Apart from being very unsightly the damp may well present a health hazard to the residents and staff at York Road. • The kitchen ceiling has since the last inspection been repaired and was preventing the ingress or leaking of water through the roof. However the Manager has told the Inspector that the roof is leaking again and needs to be attended to. • Some of the kitchen fittings that needed replacement or repair have been attended to and now need to be painted in order to match the rest of the kitchen furniture. • The fire escape needs an overhaul. There are areas of heavy rust so much so that holes have appeared in the structure of it. • There is a broken shower in the annexe that needs repair. A new system of reporting all maintenance and repairs has, since the last inspection, been instituted in the home. A member of the staff team keeps a maintence and repair record and makes regular weekly tours of the home to ensure that all those items that can be attended to are done so quickly and York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 23 effectively. This has proved helpful in ensuring that small repairs and maintenance issues are addressed. This inspection has however revealed there are a considerable number of larger scale repairs required and it is important the agency at a senior level take responsibility for these repairs and get them seen to within a reasonable timescale. Many of the repairs identified above have now been outstanding for some time and the potential negative effect on the residents and staff is of concern. It is a requirement therefore that the larger maintenance and structural repairs identified above are addressed and put right. 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. 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. As has already been stated, at the time of this inspection the home was seen to be clean and tidy, hygienic and free from offensive odours. Systems are in place to ensure that the spread of infection is controlled and minimised. Laundry facilities are sited so that soiled articles are not being carried through the kitchen and hand washing facilities are appropriately provided to ensure staff can use them where appropriate. This helps to ensure the protection of the residents’ health and to ensure that the home is clean and hygienic. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 24 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 & 36. 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. Staff records may now be assured of the competence and qualifications of their staff and that recruitment processes are properly protecting them. Staff training and staff supervision practices still need improvements to be implemented. 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 at the last inspection by 3 staff who were interviewed. The Manager told the Inspector that there is a training programme underway to ensure that all staff hold an NVQ qualification by the end of this year. 3 staff have completed their NVQ training at level 3 and 5 staff are currently undertaking their NVQ training course. Evidence will need to be seen of NVQ certificates (for those staff still receiving training) on the staff York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 25 training files, that confirms that all staff have obtained their NVQ qualifications. 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. 3 staff files were inspected. Generally the files were in much better order than at the last inspection and most of the information required under the Standard 34 was in evidence although it is appreciated that still some of this information is held at the Agency’s headquarters. The previous requirement that all staff files be reviewed and action taken to ensure that they are in good file order and containing the necessary information as described in Standard 34 has now been met. 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. Standard 35 - The Manager informed the Inspector that a structured induction programme is offered to new staff. At the last inspection 2 new staff confirmed they had attended this induction training. The Regional Manager confirmed that the induction programme is mandatory training after the last inspection. The Manager informed the Inspector that the Agency does provide a good comprehensive training programme for staff that includes all the necessary areas of training to support staff in carrying out their roles effectively and efficiently. Staff who were interviewed said that they had been on training courses covering key areas such as the Protection of Vulnerable Adults. At the last inspection a requirement was made 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. The Manager was able to show the Inspector at this inspection these training files evidencing that this requirement has now been achieved successfully. It remains important and is therefore recommended that supervising staff members ensure they review the training their supervisees have received and where refreshers are needed for key areas of training, staff are enrolled appropriately. Standard 36 – The Manager informed the Inspector that since the last inspection the supervision process has been overhauled to ensure more regularity and so that the structured supervision format is implemented as required. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 26 He said that supervision is now conducted at least once every 6-8 weeks and records are kept and copied to individual staff concerned. Staff who were interviewed confirmed that they do now receive supervision more regularly and that they are provided with copies of their supervision notes. This acts as a reminder of what their work targets are and also what they have agreed with their supervisor etc. Inspection of staff files partly supported this however some staff supervision notes seen by the Inspector were not completely up to date, as an example in one member of staff’s file the last supervision notes were dated June 2006. Other staff files inspected were more up to date and others were right up to date. The Manager explained to the Inspector that whilst not all files contained supervision records all staff are now receiving supervision at least once every 6-8 weeks. However not all supervisors have typed up their handwritten notes of these sessions. This needs to be addressed and the Manager assured the Inspector that this would be done. Inspection of the supervision notes also identified a need for improvement in some of the essential topic areas of the supervision process, especially in the following areas highlighted below: • 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 agreed with the Inspector that there is still work to be done in continuing to improve the quality of staff supervision in the home. It is essential for instance that there is discussion in supervision with staff about how to implement in practice the home’s philosophy and aims when working with individual residents. Equally it is essential for the successful delivery of care to residents as well as providing job satisfaction for staff, that supervisors help them to monitor their work with individual service users and analyse the success or not of care plan outcomes in meeting their residents’ needs. For this reason a requirement remains in place for supervision. It is that supervision notes are maintained regularly and kept on staff files, also that areas of discussion in supervision must include the areas already discussed but that are to do with 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, York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 27 • Annual appraisals. York Road (31) DS0000036098.V346253.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 & 42. 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. Service users may be assured that they benefit from a well run home and that their health, safety and welfare are being promoted and protected. EVIDENCE: Standard 37 – At this inspection the Manager told the Inspector that he is half way through his NVQ for the Registered Manager’s Award [at Level 4] and is expecting to complete this by the end of 2007; he is previously a qualified Registered Nurse and he maintains his professional registration. It is important now that he does complete this training this year. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 29 The Inspector was shown by the Manager his job description that covers all the requirements set out under the Standard 37.3. Standard 39 – This Standard was not inspected at this inspection. Standard 42 – At the last inspection a requirement was made for the Manager to carry out a review of the previous risk assessment for the building and to ensure that all risks are identified and strategies developed to meet the potential risks identified. At this inspection the Inspector was informed by the Manager that he is now undertaking regular risk assessments and reviews for the building. Evidence of these risk assessments were shown to the Inspector and it could be seen that these are comprehensive in their coverage and they now form a part of the reports to the Area Manager and the Regulation 26 reports. This is helpful since risk assessments help to assure the health and safety of the residents. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 30 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 3 X X X X 3 X York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 Requirement Timescale for action 01/10/07 2. YA36 18 At the last inspection a need for repairs to the building was discussed with the Manager and agreed as being necessary to be attended to. Specifically discussed were repairs in the lounge to the exterior wall and to the kitchen ceiling and to the drawers and cupboard doors of the kitchen units. No progress has been made and apart from being very unsightly, could also represent a health hazard for residents. It is required that the maintenance and structural repairs identified in this report are addressed as a priority. Supervision notes must be 30/10/07 maintained regularly and kept on staff files, also that areas of discussion in supervision must include the areas already discussed but that are to do with the: • Translation of the homes philosophy and aims into working with individuals, • Monitoring of work with individual service users and the analysis of care DS0000036098.V346253.R01.S.doc Version 5.2 York Road (31) Page 32 • • • plan outcomes, Support and professional guidance, and the Identification of training and development needs, Annual appraisals. 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. 5. 6. Refer to Standard YA37 YA32 YA2 YA20 YA23 YA35 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. Needs assessments must include any cultural or religious needs that the resident might have and evidence be documented in the resident’s needs assessment. A refresher course on the safe handling of medicines is now needed for staff so that they remain appropriately skilled and resident’s needs continue to be met safely. That the Manager ensures that those staff who have not done so, enrol on POVA training in the near future. It remains important and is therefore recommended that supervising staff members ensure they review the training their supervisees have received and where refreshers are needed for key areas of training, staff are enrolled appropriately. York Road (31) DS0000036098.V346253.R01.S.doc Version 5.2 Page 33 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.V346253.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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