Inspection on 09/12/05 for York Road (31)

This inspection was carried out on 9th December 2005.

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 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) 13/12/06

York Road (31) 22/02/06

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 Pennells Unannounced Inspection 9th December 2005 13:15 York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 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.V259313.R01.S.doc Version 5.0 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.V259313.R01.S.doc Version 5.0 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.V259313.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2005 Brief Description of the Service: 31, York Road is an extensive Edwardian building, now providing accommodation both in this substantial ex-family house and in an additional, more modern, annexe located in the 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 towns having train 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. 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 door. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was conducted across a winter’s afternoon when the manger was coming on duty, and so available to assist the inspector, as well as staff members and service users contributing to the process. The inspector was able to discuss issues arising from the pre-inspection questionnaire, to review previous requirements and recommendations from the last inspection visit, to examine current vital documentation, to speak with service users and staff, and to tour the home unhindered. The inspector is grateful to service users, staff members and the home’s manager for their welcome, positive cooperation, and for the hospitality shown to him during the visit. What the service does well: What has improved since the last inspection? Pharmacy inspections of the home’s management of medication are now in place and formally recorded - and associated support from the local chemist is actively provided. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 6 Details of service users’ wishes concerning dealing with urgent incidents - like being taken seriously ill, or even passing away - are now being recorded individually on a new form, both at the point of admission of a newcomer and currently retrospectively for existing service users. Electromagnetic door holders have now been provided to correctly hold open fire doors, which in communal areas are in permanent need of being open. Fire alarm records are now clearly showing which break glass points have been tested - on a routine basis. The ‘Landlord’s’ Gas soundness tests has now been undertaken on all gas appliances at the house and shown to be safe. Portable electrical appliances within the house have been tested and the report evidences the safety of appliances used. At least half of the staff members at the home are now qualified minimally to level 2 NVQ in Care, or equivalent, and so meet the national minimum standard. 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. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 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.V259313.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 – 5. Service users can expect that adequate information will be provided both prior to and during the assessment phase of an application to live at York Road. Assessment will include seeking an understanding of individual aspirations and needs and these are assessed against the home’s ability to meet them. The home provides opportunities to visit and stay at the home, ensuring that compatibility in every respect is checked out. Service users are provided with contracts / licences of occupancy - making explicit the terms and conditions of their stay at the home. EVIDENCE: All the above five standards are considered to be ‘met’. There is a comprehensive Statement of Purpose for the home and all service users have a Service Users Guide; a revised ‘Together’ version of this document is currently in draft. A License / Tenancy Agreement is also included for all service users to cover their stay at York Road; this loose-leaf folder of information is substantial, and quite comprehensive in content. A ‘Referral Officer’ handles all new enquiries / applications for placements. Following a initial phone referral, if the potential service user appears to be appropriate, further detail is sought from placing officers and two staff will then visit the referral at home or their current location, and complete a thorough assessment which is then brought back and reported to the staff team. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 9 The Care Programme Approach (CPA) assessments – stemming from multidisciplinary meetings concerning, and involving each individual - are heavily relied upon. Crisis Contingency Plans are also evolved for service users in case the placement should break down in a sudden ‘emergency’ situation. The home clearly achieves a good match, in most cases, between the service on offer and the service users resident at the home. Issues of maximising - or adjusting the use of - the placement can be raised by any party at regular case reviews - as well as by individual service users with their key workers, CPNs, Care Managers and / or other visiting health or social care professionals. An excellent six-week assessment format is also in place, which reviews initial progress post-admission, and identifies the longer-term aims of the placement. The introduction process to the home can be phased according to the individual needs of an prospective service user; visits prior to the accommodation being offered are usual, with the existing service users being involved in meeting and welcoming the newcomer - giving them a real ‘feel’ of the culture of the house, as well as allowing existing service users to consider, with staff assistance, the potential newcomer’s compatibility. The home is clear in its Statement of Purpose that is does not accept emergency placements; this due to the careful way in which an application is considered with regard to compatibility with other service users at the project, and the need for precise assessment allowing the project to identify that it can provide a suitable service. Each service user is provided with a license / tenancy agreement and also a three-way contract between the project, the individual and the funding local authority. The home’s Standard Care Contract makes explicit the requirement of the service user to engage with the project and itemises the aspects of input (care planning, decision-making, funding arrangements, etc.) specific to the house. Other documents on individual files - of a ‘contract’ nature - include Budgeting Agreements and Financial Agreements - thus making explicit all aspects of the interaction between the service user and the home. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Service users can be assured that their individual aspirations and needs will be fully recognised and recorded within a personal plan – which will be amended over time to recognise changes as appropriate. Service users can expect to be encouraged and enabled to make decisions for themselves; staff providing an unobtrusive support system to assist service users in their best interests. Service users will be consulted on both personal and communal aspects of life at the home; this through involvement fully in their own programme and in communal decision making processes. Service users can expect that the focus on independent actions and decision making will be assisted by staff providing a risk-taking perspective, thus supporting service users to make informed choices and judgements. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 11 EVIDENCE: Care Programme Approach (CPA) assessments are in place for all service users. A six-week assessment format is also in place, which reviews initial progress, and identifies the longer-term aims of the placement at York Road. Crisis Contingency Plans are also in place for service users - to address the situation should the placement break down in an unexpected ‘emergency’ situation. Other documentation provided on individual files includes Budgeting Agreements and Financial Agreements - thus making explicit all aspects of the interaction between the service user and the home. A fundamental focus of the house is respecting each individual’s right to openly express themselves, and to make decisions for themselves concerning their present lifestyle and future plans. The project aims to encourage the development of individual and independent decision-making skills. The rights of all at the home to be safe and respected, naturally, temper this aspect of ‘freedom of choice’. Any agreed ‘limitations’ will be formally agreed in care planning / risk assessments and are made known at the time of admission - or subsequently, and service users are expected to accept certain such ‘limitations’ as part of their rehabilitation programme – quite often these conditions are set in the interests of both themselves and others at the project. Planning Meetings - involving service users and staff - for managing the general day-to-day routines - are held most mornings, with a service user chairing the meetings. Notes are kept of decisions in the openly accessible House Diary, and housekeeping routines are monitored / supported through this mutual peer agreement and recording system. Formal ‘House Meetings’ are held twice a week. Further additional meetings / gatherings can be held as and when the staff feel this may be therapeutic or necessary. Service users are also invited to meet and contribute to the assessment of prospective service users and are also involved in staff recruitment through an introductory process. The assessment and care planning process identifies very clearly both immediate and possible risks regarding a service user and risk assessments and contingency plans are in place for emergency situations. The ethos of the house is clearly one of encouraging service users to succeed, and in actively working - though within clear boundaries - to achieve the maximum participation / engagement from each person whilst they are resident at the home. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 – 17. Service users can expect York Road to provide opportunities for selfdevelopment through engagement in both external and internal activities suited to individual needs and aspirations. Service users are free to engage in local community activities and access leisure facilities. Families, friends and partners can expect to be welcomed and integrated as part of a service user’s lifestyle, with service users rights to privacy and dignity respected. The home provides a nutritious diet designed to satisfy and encourage healthy eating and to provide a positive eating experience. EVIDENCE: The home runs along mutually cooperative lines, with all service users (usually willingly) undertaking domestic tasks around the house to ensure it is maintained in a clean and pleasant way for everyone’s benefit. This exercise in cooperative work also strengthens the ethos of the house - developing communication and self-help skills, and aiming to enhance the communal quality of life, which all will enjoy as a consequence. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 13 Purposeful time away from the home is positively encouraged, however the ‘low key’ therapeutic input at the home itself is also an important element to the home’s service; the engagement ‘in community’ of the service users is seen as important - to promote / develop social and coping skills which may directly be part of the care plan goals whilst resident at York Road. An important element in the work of the project is enabling service users to prepare themselves for rehabilitation within the local community - possibly through some type of ‘supported living’ environment first - but the goal is set. The service user may well need to develop personal skills - and these can be practiced within the supportive environment of the home, as well as using the experience of participating in wider community life. All service users have the ability to travel independently - to go out as part of their own programme, or socially, though some can need help to use the opportunities appropriately. Service users are free and independent to express themselves as they wish; many have televisions and sound systems / computer games in their rooms to allow some personal entertainment as well as sharing entertainment in the main communal rooms downstairs in the main building. Dress and demeanour is also indicative of the ‘individuality’ of each personality. Staff members engage closely with service users, and are able to intervene / counsel service users if their choice of activity may put themselves - or even their placement at the home - at risk. Any restrictions are only imposed - and then clearly negotiated and care planned - if there is a clear need to ensure the safety and welfare of an individual service user, or the protection of others, either within or external to the home. Contact with service users’ family and close friends is usually arranged / agreed within the care plan, where necessary; some contacts can be useful and some, perhaps, not so. Each individual is, however, at liberty to be in touch with whosoever they chose. The approach to this standard is entirely individual, as some families may have ‘stuck by’ a service user, whereas sometimes relations can have been strained / estranged, or even terminated. Service users and Staff share the responsibility for cooking. Breakfast is ‘ad lib’ - principally dependant on when a service user rises. Service users and staff present at the home during the day jointly cook a lunch [usually a snack meal]. Service users take turns to help cook the supper [the main meal], supported by staff, unless a service user self-caters. Service users again spoke at this visit of the good quality of the food that was served. The well-provided kitchen was kept clean and tidy; the facilities are good. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 – 21. Service user can rely on the home to assist them to keep well, through accessing appropriate healthcare and associated mental health care support. Service users can rely on the home providing a well-managed service relating to medication where service users are assessed as being unable to handle such issues themselves. Service users can rely on being cared for and supported throughout times of trauma as well as good health, with information about support needs provided. EVIDENCE: Health care services are available to service users as if they were generally in the local community; two principal surgeries were used; one in Belmont and one in Cheam. No district nursing services were being used, however Community Psychiatric Nurses (CPNs) visit individuals on a 1:1 basis with frequencies varied according to identified need. Access to other services is through local community contacts; it would be unusual for a domiciliary visit to be made; the expectation is ‘normalised’ community based access. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 15 One admission has been made to hospital in this past year (through A&E though not for ‘accident emergency’ purposes) - this being a voluntary readmission to hospital following medical advice. Contingency plans designed to address issues of relapses were clearly in place. Health Service funded pharmacy advice and inspection visits are now accessed from a qualified pharmacist from Frith’s in The Broadway, Cheam Village. The use of ‘best practice’ Monitored Dosage System (MDS) formats of dispensing has also now been adopted as far as the medication dispensation allows it; it is accepted that the medication status of many service users is likely to change frequently during a rehabilitation phase, and therefore the ongoing use of source containers remains acceptable when the possibility of ‘repeat’ prescriptions is not an ongoing reality. Medication records examined showed consistently maintained documents, with some variation, however in regard to records of prn (‘when required’) medication. Such items must be kept consistently, and staff must be given the tools to comply with these instructions. If the MAR system requires the use of both front and back of the MAR sheets, then in-house sheets created to monitor administration must also be provided with such formatted sheets. The manager / registered provider must establish a much clearer set of Criteria for each and every PRN (‘when required’) medication used at the home; a standardised format for each medication is recommended for this purpose. York Road does not provide a ‘home for life’. It was advised, nevertheless, that the main detail of a service user’s thoughts regarding who should be contacted and what should happen, should they suddenly fall seriously ill, or suffer a major trauma [or even suddenly pass away] should be recorded in order that the service can respond appropriately in what would be a significantly traumatic event for everyone. The manager has now introduced a format to capture this information and it is being introduced throughout the home. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Complaints and suggestions will be positively handled by the home, resulting in an enhanced service for all service users and staff. Adult protection issues will be appropriately recognised and handled at the home, however as guidance is currently to an extent conflicting, the provider must ensure a single version policy by blending their with the local authority. EVIDENCE: The home has a clear complaints and suggestions procedure, which features prominently in the service User Guide, etc. The manager declared ten complaints in the last twelve months; again the inspector comments that it good to see comments / criticisms being used to improve service delivery. The majority of in-house complaints related to maintenance issues. A number of the complaints were from neighbours who have expressed various concerns about the home’s noise and service user’s behaviour outside the premises. The manager has striven to address these issues positively – transparently offering to attend the local Residents Association meetings, if that was felt helpful. The home has previously evidenced that they take the protection of service users seriously and are keen to protect their wellbeing. The home has a copy of the local authority’s Vulnerable Adult policy and procedure and MACA has its own policy also. The previously-made recommendation that the registered provider should revisit / revise the MACA policy on Vulnerable Adults - to commit to adhering to the local authority processes more closely, and to include reference to the POVA legislation – now becomes a requirement – this due to the inspector’s concerns that staff may well find themselves relating differently to an abuse issue, dependent on whether they rely on the local authority’s procedure (which has the ascendancy) or the employer’s document. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 – 30. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once the minor repairs and issues relating to radiator surface risks are addressed, the home will be a safe environment in which to live, without unnecessary risk. EVIDENCE: 31, York Road now provides accommodation both in the substantial main ‘family house’ and an additional more modern ‘annexe’ located in the garden. The main house provides a large lounge (smoking area), a dining / living room (non-smoking) and a substantial kitchen with good catering facilities. A second small lounge is available in the ‘loft’ level of the house - this is used for meetings, reviews, etc. The Annexe has a lounge / computer room and five bedrooms. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 18 The house has recently been re-inspected by a LFEPA Fire Safety Officer – who has agreed a programme of rectification works with the registered provider. The fire door at the top of the first flight of stairs, on entering the first floor corridor area, was not closing properly and must be adjusted to ensure it closes fully onto the door stops / smoke seals. The sizes of rooms and the other facilities at the home are openly declared in the home’s Statement of Purpose. Other than not providing en-suites, all rooms are close to meeting the national minimum standards. Service users were happy with their accommodation in general; it was good to see, during the inspection tour, how personalised most rooms were. A sample of bedrooms were inspected on this (and during previous) visits; bedrooms are spacious, well decorated and have suitable furniture and fittings. Despite the short-term nature of the home, rooms are certainly well lived in and personalised. The bedrooms have suitable locks and the privacy of service users is respected; rooms are only entered with a service user’s permission, or in emergency situations. There are more than adequate (11) toilets available throughout both the house and the annexe; there are six bathrooms and five shower facilities available. The bath in the bathroom at the top of the house is now at the end of its life – chipped and enamel-less - this must be replaced; the lack of enamel can lead to cross-infection issues in communal areas such as this. The top floor shower room has an inappropriate exposed fluorescent light fitting; this must be changed to a more appropriate type of sealed lighting unit. Staff daytime accommodation is provided in the main house as the main office room - a spacious and relatively comfortable (though busy) area. In the annexe there is space for the staff sleeping-in on call, as well as the flat doubling up as a staff room / second office – useful for report writing, etc. Although the house has no specific need to provide adaptations for people with disabilities, the premises do have radiator surfaces in small enclosed areas which could compromise the safety of service users if they are feeling unwell when using the toilet / bathing facilities. After previous discussion with the manager, it was agreed that the house should risk-assess high-risk areas (bathrooms and toilets) for safety from burns and isolate or remove potential high-risk radiators. The small radiator in the single internal toilet opposite the bathroom on the top floor is an example of a space where this must be removed or covered. The home is kept clean and tidy by a daily ‘task force’ of service users and staff who complete an excellent job in keeping the house looking clean and odour-free. The service user group should be proud of their ongoing achievement; the inspector encourages them to continue to take a pride in this excellent accommodation. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Service users can be assured that they will be supported at all times by staff who are experienced and competent in their work, being provided in sufficient numbers to meet their identified needs. Service users can expect to be provided a service that generally ensures their safety and protection from abuse and danger through a thorough recruitment process and staff training – though staff training in First Aid would equip staff members to address any emergency issues more competently. EVIDENCE: Of the current 12 staff, one is qualified in NVQ above level 3, one is already qualified at level 3 and has completed their Assessor’s Award, and five staff members are undertaking their NVQ in care at Level 3, and aim to complete it either by the end of 2005 or very early in 2006. The information here shows that the home will, hopefully, achieve the 50 target as set by this Standard by the end of the year, so the standard will be met. Staffing levels are provided at an absolute minimum of three staff on duty during the day, with a management staff member - and two staff (one awake, one asleep) available at nights. Relief staff are brought in of cover for shifts cannot be rota’d by full time staff. It is again good to see that, if an agency worker is used, consistency is being sought and provided - by the use, wherever possible, of the same familiar faces. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 20 ‘Together’ has an equitable recruitment process in place, monitored and assisted by the central Human Resources Department. The Criminal Records Bureau has now checked all staff members. The home checks references, health status, previous employment, identity, and qualifications prior to employment. Some new staff were having to await start dates due to the lack of CRB checks being returned promptly. Staff files seen were generally quite comprehensive - as required by revised Schedule 2. Induction is thorough; probationary reports were seen for recent staff at both three and six months - before full employment is confirmed. The inspector had, previously, the opportunity to meet and talk with a ‘new starter’ staff member at the home. They confirmed that they had received five days of ‘shadowing’ a senior worker at the project in the home, before ‘going it alone’ (but still working as part of a lead team) - with appropriate checklists of induction material supplied. The new worker had also received two training days at the organisation’s headquarters covering the areas of Confidentiality & Equal Opportunities. ‘Together’ has a clearly organised staff training section, which provides training opportunities, which staff at York Road can access. In the past year or so, courses undertaken by staff have covered such areas as: Newby Competencies, Dual Diagnosis, Fire Safety Awareness, Medication, and Therapeutic Community Workshop. All staff members have recently attended a five-day course in co-occurring psychosis and substance abuse problems (‘Dual diagnosis’) and all but three staff have recently completed Food Hygiene training. Staff training in First Aid – of which there are only 4 staff currently qualified must be made a priority to ensure that every shift, 24/7, is covered by a qualified worker. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42. The registered manager and the home work within and operate management systems that ensure that service users benefit from a well-run, competently managed, open and safe environment. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures, and the day-to-day conduct of the home. Service users can be assured that their welfare, health and safety is safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: The registered manager will be once again waiting a start date to recommence his NVQ for the Registered Manager’s Award [at Level 4]; he is previously a qualified Registered Nurse - who still maintains his professional registration and is clearly competent in the management role. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 22 The manager’s recent serious illness (and another hospitalisation at the time of writing this report) has meant that he had to drop out of the previous course for the NVQ Level 4 Registered Manager’s Award, however he is confident that he will attain the qualification - as required by this Standard - once he is fully restored to health. The registered manager should aim to achieve his NVQ Registered Managers Award at Level 4 as soon as is practicable. It is clear that the home is run on ‘open’ lines - the home would not be able to function as it does, if this were not the case; the policy is an ‘open door’ approach to contact both between staff, including the manager - and the service users. The previous inspection report awarded this standard a ‘4’ in recognition of the open attitude of the management, staff and service users towards each other. The rating is reiterated this time. The inspector once again found, in conversation with staff members – and service users, that they felt valued as ‘team members’ - and as individuals. ‘Together’ is an organisation is keen to elicit the opinions of service users; the organisation conducts regular service user surveys - and the manager regularly canvasses the opinions and feedback from visiting care managers and other professionals. The Area Manager and other representatives of the organisation also regularly visit the home and comment on the service. Regulation 26 reports compiled by the registered Provider about the home – seen at the home - must be copied regularly to the Commission, as required under this Regulation. Excepting the issues identified in the ‘premises’ sections (fire doors and hot radiator surfaces) and the First Aid staff training deficit, the home was found to be reasonably safe, and well covered with regard to health & safety issues in general. It is hoped that at future visits the ongoing maintenance issues will be found to have been ‘kept going’ – ensuring a year-round guarantee of protection. The home maintains good focused risk assessments and hazard notices and safety instructions were in place as appropriate. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 1 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York Road (31) Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 4 3 X 1 3 X DS0000036098.V259313.R01.S.doc Version 5.0 Page 24 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 YA20 Regulation 13(2) & 17 Requirement Medication records must be kept consistently, and staff must be given the tools to comply with these instructions. If the system requires the use of both front and back of the MAR sheets, then in-house sheets should also be provided with such back-page formatted sheets. The registered provider must establish a much clearer set of Criteria for each and every PRN (‘when required’) medication used at the home. The registered provider should revisit / revise the MACA policy on Vulnerable Adults - to commit to adhering to the local authority processes more closely. (A previously repeated recommendation - now made a formal requirement.) 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. DS0000036098.V259313.R01.S.doc Timescale for action 31/01/06 2. YA20 13(2) & 17 31/01/06 3. YA23 13(6) 31/01/06 4. YA24 13(4) & 23(4) 31/12/05 York Road (31) Version 5.0 Page 25 5. YA27 23(2)(j) The bath in the bathroom at the top of the house must be replaced; the lack of enamel can lead to cross-infection issues in communal areas such as this. The top floor shower room with an exposed fluorescent light fitting must have a more appropriate type of lighting unit provided. Risk assessments must be conducted in high-risk areas regarding the danger from hot surface radiators. (Timescales of 15/12/04 & 01/06/05 not met.) The small radiator in the single internal toilet opposite the bathroom on the top floor must be removed or covered. 28/02/06 6. YA27 23(2) (c) (p) 31/01/06 7. YA29 13(4) 31/12/05 8. YA29 13(4) (a) (c) 31/01/06 9. YA35 13(4) Staff training in First Aid must be 28/02/06 made a priority to ensure that every shift, 24/7, is covered by a qualified worker. Regulation 26 reports compiled by the registered Provider about the home must be sent regularly to the Commission, as required under this Regulation. (Timescales of 15/12/04 & 01/06/05 not met.) 31/01/06 10. YA41 26 York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The registered manager should achieve his NVQ Registered Managers Award at Level 4 as soon as is practicable. York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI York Road (31) DS0000036098.V259313.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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