Care Home: Prema House

What the care home does well Feedback from service users spoken to and from surveys received was all very positive about the home and support received from staff. Comments made included; `I`m quite happy here`, `Staff are `very helpful when you ask for something they do it`, `Superb manager`, `Its alright, its quite nice here`. Service users needs are fully assessed before they move into the home making sure that their individual needs can be met. Service users are supported to make their own decisions, to take risks as part of leading an independent lifestyle and they are involved in the local community using local facilities. Meals provided at the home are of a good standard. Service users are confident about the home`s complaints process that their views are listened to and acted on by staff. The home has taken measures to protect service users from abuse. The home is clean and generally well maintained. What has improved since the last inspection? Only four requirements were specified at the last inspection, one had not been met at this inspection whilst due to changes in circumstances within the home a decision was made not to restate the other requirements. What the care home could do better: Service users` care plans and risk assessments addressing how individual needs will be met need to be regularly reviewed and updated to reflect any progress or changing needs. Information on advocacy needs to be available to service users. Some improvements are required in the home`s recruitment practices and procedures, in the delivery of training to staff and quality assurance systems used by the home. CARE HOME ADULTS 18-65 Prema House 45-47 Gleneagle Road Streatham London SW16 6AY Lead Inspector Ornella Cavuoto Key Unannounced Inspection 13th December 2007 10:00 DS0000022749.V335425.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 DS0000022749.V335425.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. DS0000022749.V335425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prema House Address 45-47 Gleneagle Road Streatham London SW16 6AY 0208-677-2302 020 8 696 6829 julie.baker@deepdenecare.org Ludmilia.iyavoo@deepdenecare.org Deepdene Care Ltd 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) Vacant post Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) DS0000022749.V335425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to five persons only aged 65 years and above Date of last inspection 20th April 2006 Brief Description of the Service: Prema House is a 24-bedded private home for adults with mental health needs. It is one of two homes in the Streatham area owned by the same proprietors. The home provides long-stay accommodation and support for people over the age of 45 and for up to five service users over the age of 65, all of who have enduring mental health problems. It is situated within easy walking distance of transport links, and all amenities offered in Streatham High Street. The building is made up of two large Victorian houses, converted to interconnect internally. There are 16 single and four double bedrooms, two of which are almost completely divided by a wall providing a high level of privacy. The registered providers plan to phase out the double rooms as service users vacate them, and convert them into single rooms with en-suite facilities. The home has a range of communal areas that includes two main sitting rooms, a small kitchen for residents to make drinks, and a number of small smoking rooms. The home employs a cook and a cleaner, as well as care staff who prompt and support residents in personal care and activities of daily living. There is a large and attractive paved rear garden. There are a number of internal stairs, and the home is not suitable for people with mobility problems. Prospective service users can get information about the service provided from the statement of purpose and service users guide. DS0000022749.V335425.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 that took place over one day. Since the last inspection the registered manager of the home had left and the deputy manager acted up in the position. A new manager was appointed in July 2007 and they were present for the duration of the inspection. The inspection involved talking to six of the service users and two of the care support workers. Other methods used included inspection of records and a partial tour of the building. In addition, service user surveys were sent out prior to the inspection of which eleven were completed and returned as well as the Annual Assurance Quality Assessment (AQAA) reference to which will be made in the report. Since the last inspection the home has undergone a lot of staff changes that has had an impact on the day- to- day running of the home. This was evident through the inspection with the home acquiring an increased number of requirements from the last inspection that was held although the quality of service overall remains of a good standard. What the service does well: What has improved since the last inspection? Only four requirements were specified at the last inspection, one had not been met at this inspection whilst due to changes in circumstances within the home a decision was made not to restate the other requirements. DS0000022749.V335425.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000022749.V335425.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 DS0000022749.V335425.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users do not currently have all the information they require about the home. Service users that move into the home have had their needs fully assessed. Service users are all issued with a contract when they move in. EVIDENCE: The home has a comprehensive statement of purpose and service user guide in place that in the main provides all the information needed apart from details about the fees charged by the service that should be included specifically in the service user guide. This is required under a new regulation introduced in September 2006 (See Requirements). The home has not had any new admissions to the home since the last inspection was held although one of the service users had been transferred to Prema House from the other home located nearby that is run by the provider. The personal file of this service user was looked at and there was evidence that detailed information and assessments from the referring local authority had been obtained prior to the service user being admitted to the home. The home also undertakes its own detailed needs and risk assessment of those service users that are referred to the home before they move in. DS0000022749.V335425.R01.S.doc Version 5.2 Page 9 The personal files of four service users were checked and all contained a licence agreement that outlined terms and conditions of their stay with the home. These had all been signed by the service user, their social worker, and a representative from the home. DS0000022749.V335425.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are drawn up with service users and are generally comprehensive addressing all areas of need but regular reviews of the care plans had not been undertaken. Service users had been involved in making decisions about their lives but information on advocacy was not available. Service users are supported to take risks to encourage their independence but risk assessments to address these areas had not always been completed. EVIDENCE: Care plans for four service users were looked at. These were generally comprehensive and had addressed individual presenting needs relating to their mental health as well as areas of physical health, social and personal support. All the care plans had been signed by service users and there was a ‘comments’ box included on the care plan for them to write their personal views. However, none of the care plans had been reviewed at least six monthly as specified within National Minimum Standards (NMS) and updated to reflect any progress or changing needs. There was some evidence that annual reviews DS0000022749.V335425.R01.S.doc Version 5.2 Page 11 with placing authorities had taken place. In addition, goals being worked towards with individual service users and progress being made could be identified from notes of key worker sessions in place but attention to care plans is required (See Requirements). There was evidence from notes of key worker sessions held with service users that they had been supported to make decisions about their own lives. Service users spoken to confirmed this. They also reported how they manage their own finances. However, subject to a previous requirement that service users should be offered access to independent advocacy support when making decisions that may effect their future placement, this had not been addressed. The registered manager reported how information about advocacy support had still not been obtained. Yet, following the inspection the Operations Manager was spoken to who explained a pack about advocacy support had been put together. As this information was not available in the home for service users this requirement is to be restated (See Requirements). All service users whose files were looked at had detailed risk assessments in place that addressed risks presented by individual service users’ needs, for example in relation to their mental health and physical health. However, as was identified with care plans in place these also had not been reviewed and updated. Furthermore, although it was evident that the home does support risk taking as a means of supporting service users to live independently, for example one service user regularly travels alone to Ireland to visit family, there was no evidence that a risk assessment had been completed with the service user to identify any areas of concern or potential risks that could arise or of a risk management plan outlining action to be taken to reduce any identified risks (See Requirements). DS0000022749.V335425.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have been involved in fulfilling and valued activities and are involved in the local community. Service users have been able to maintain contact with family and to develop friendships and relationships. The home had promoted service users’ independence and individual choices. Meals provided at the home are sufficiently varied and enjoyed by service users. EVIDENCE: In relation to service users being supported to engage in fulfilling and valued activities one service user spoken to related how they attend college to do creative writing. Some of the other service users attend day centres locally with one service user attending a day centre that meets their specific cultural needs. In addition, the home aims to provide activities inside and outside of the house accompanying service users to restaurants, cinemas and walks in the park to encourage service users to socially interact. Service users spoken to confirmed how they were engaged in activities by staff and went out. There DS0000022749.V335425.R01.S.doc Version 5.2 Page 13 were also records in place of activities that had been organised and those service users that had participated. Service users spoken to confirmed that they were part of the local community and used facilities such as the local shops, library, cinemas, restaurants and cafes. All the service users had freedom passes to enable them to use local public transport. There was evidence from service users’ personal files that they had contact with family and friends and service users spoken to also reported that they had friends who visit them at the house and as mentioned in relation to Standard 9 one service user related how they regularly go to Ireland to stay with family. The home ‘s routines and house rules were identified as promoting independence and individual choice. Responses within surveys that were received from service users all indicated that they were able to do what they wanted at all times and at weekends. During the inspection service users were observed as coming and going from the house and that they had the choice to spend time with other service users or to be alone and spend time in their own rooms. Service users spoken to reported how they had a key to the front door of the house as well as one for their own individual rooms and that staff did respect their privacy only entering their room when permission was given. Also, they spoke of how they are involved in household tasks such as helping to prepare meals and do the washing up. The home had a five- week rolling menu in place that was looked at and meals included were sufficiently varied and nutritious. A lunch- time was observed the food cooked was appetising and service users appeared to enjoy the meal. The home carries out a daily audit on the food in which service users are asked about their enjoyment, the quality, presentation and portions of meals provided. There was also evidence from minutes of service user meetings held that the food had been discussed. All service users spoken to gave positive feedback about the food. Comments included; ‘The food is lovely’, ‘I think the food is very good.’ DS0000022749.V335425.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have received support in the way they prefer. Health care needs of service users have been met. Staff have adhered to medication policies and procedures to protect service users. EVIDENCE: Service users living at the home are able to carry out their own personal care although some of them require prompting and encouragement. Where service users needed support this had been addressed in their individual care plans and risk assessments. The home operates a key worker system to ensure service users receive consistency and continuity. Service users spoken to were aware of their key worker. They confirmed they did meet with them as one service user described to discuss and get help with ‘any problems I have’ and they were all positive about the staff and the support they received. Surveys received also all gave positive responses about staff treating them well. There was evidence within service users’ personal files that their physical and emotional health needs including their mental health had been addressed. Each service user had records of medical appointments attended and contact DS0000022749.V335425.R01.S.doc Version 5.2 Page 15 with health professionals that included community psychiatric nurses (CPN), psychiatrists, district nurses, GPs, opticians, dentists, chiropodists. A sample of medication record sheets was checked and all these were found to be accurate. Daily audits of the medication are carried out. It was reported that only staff that have completed medication training are allowed to administer medication. At the time the inspection took place none of the service users living at the home were self –medicating although the home supports service users taking responsibility for their own medication where it is assessed to be appropriate by all professionals involved in their care. DS0000022749.V335425.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were confident that their views were listened to and acted on. Service users have been protected from abuse. EVIDENCE: Surveys received from service users all stated that they knew how to make a complaint, who they would speak to if they were not happy and that they considered staff at the home listened and acted on what they said. These views were confirmed by service users spoken to at the inspection with one of them reporting how they complained about the food to the manager and ‘ She took care of it’. The home had not received any formal complaints since the last key inspection. It was noted that informal complaints had not been logged It is advised this is done to be able to identify any recurring themes or patterns of complaints (See Recommendations). There had not been any adult protection investigations undertaken in relation to the home since the last inspection. The manager was familiar with adult protection guidance and their specific responsibilities in respect to Protection of Vulnerable Adults (POVA). There was evidence that more established members of the staff team had completed training in this area. Other staff had only started working at the home in the last three months and so arrangements for them to undertake this training were still to be made. In respect to service users’ finances although as mentioned in respect to Standard 7 service users are able to take responsibility for their own finances DS0000022749.V335425.R01.S.doc Version 5.2 Page 17 the home does support some service users with the management of their finances. Overall, the system in place for this was found to be robust with individual records for each service user being maintained. Receipts had been kept for transactions but rather than these being organised so that receipts for each month and for each service were easily able to be identified for auditing purposes they were just all kept together. It is advised this system is reviewed. A sample of the records was checked and apart from a couple of minor errors these were generally accurate (See Recommendations). DS0000022749.V335425.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27,28 &30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that they find safe and comfortable but some replacement of furnishings are required. Service users’ bedrooms suit their needs. There are sufficient bathrooms and toilets and service users have ample communal spaces to use. The home was clean and hygienic. EVIDENCE: A partial tour of the premises was undertaken. Generally, the home was found to be well maintained apart from some work that was required in the toilets and bathrooms (See Standard 27 for further details) and although the last inspection noted the hall way carpet had been replaced, at this inspection parts were still identified as being very threadbare in places and potentially could cause people to trip posing a health and safety risk (See Requirements). Only one or two bedrooms were seen at the inspection but these were comfortable and personalised. The home has two shared bedrooms with service users having made a positive decision to share. At a previous DS0000022749.V335425.R01.S.doc Version 5.2 Page 19 inspection the registered provider had discussed the conversion of these two double rooms into single en -suite bedrooms. As a result a requirement was specified that a written plan for refurbishing the home specifically in respect to converting the double bedrooms should be sent to CSCI. This had still not been addressed when the last key inspection was held. At this inspection the manager who had only been recruited six months ago was not aware of any plans to change the double rooms. The operations manager was spoken to who reported that these plans have been placed on hold for the foreseeable future particularly as the service users were happy to continue to share. It was requested this is placed in writing to CSCI but due to this change of circumstances the requirement will not be restated in this report. The home had sufficient toilets and bathrooms but the floors were uneven and in some the tiles were loose. The manager reported that quotes had already been obtained for all the floors to be replaced and the work would be commenced in due course. The operations manager who was also spoken to after the inspection was held confirmed this. The lower ground floor of the home had a number of different communal spaces including a large dining area, two separate lounges one for smokers and the other for non -smokers. There was also a small kitchenette for service users to be able to cook for themselves and make snacks although the manager reported this was not in use for the time being as it had been identified that the cooker was not completely safe for service users to use and this had to be sorted out. The kitchen was also situated on the ground floor. This had recently been refurbished but the flooring was still to be done although the manager reported this was to be done along with the bathrooms and toilets floors. The garden was accessible through the lounges, which was paved. A large shed in the garden housed the laundry facilities. The home was clean and hygienic on the day the inspection was held and free from any offensive odours. DS0000022749.V335425.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 50 of the staff had obtained a relevant qualification or were working towards one. The home’s recruitment practices and procedures have not completely protected service users. Not all staff have been appropriately trained to meet needs of service users. Staff have not had an annual appraisal or received regular supervision. EVIDENCE: The manager reported that one of the three senior care support workers (SCSW) working at the home had completed a National Vocational Qualification (NVQ) Level 3 whilst the other two SCSWs were working towards a NVQ level 3. Of the four care support workers presently employed at the home one had a NVQ Level 2 and the registered manager reported the other three were in the process of enrolling to start studying for the qualification. One of two bank staff had a nursing qualification and were doing a return to work course to be able to re- register to work as nurse. This meets the target specified within the NMS that staff should have obtained or working towards a relevant qualification. DS0000022749.V335425.R01.S.doc Version 5.2 Page 21 In terms of recruitment four staff files were checked, three of which belonged to staff that had been recruited since the last inspection. There was evidence that up to date Enhanced Criminal Record Bureau (ECRB) checks had been obtained although for one staff member this initially could not be identified. Instead, only a copy of the application form was on file. It was reported that ECRBs for staff are generally held at the provider’s head office. A copy of the ECRB was faxed over for inspection but it is advised that basic details of ECRBs including the serial number, date sent and received should be kept on all staff files. All staff files included two references and appropriate identification had been obtained. Records of the interview process undertaken were also available. Yet, it was noted for two of the staff that employment gaps had not been addressed and reasons for these obtained and noted down (See Requirements and Recommendations). Staff files all included an individual record of training completed. From this it was evident that there were gaps in training for new staff in respect to mandatory topics including manual handling and food hygiene. These staff had only started working in the home in the last three months. However, training records for more established staff also showed that mandatory topics had not been updated as required, for example in terms of fire safety and manual handling and there was no evidence available to demonstrate that measures had been taken to ensure training in these areas had been arranged. The provider did acknowledge within the AQAA for the home that this was an area for improvement and gave staff turnover as a reason for difficulties in addressing this matter. However, measures need to be taken to ensure staff receive training so that individual and joint needs of service users can be met. There was evidence that two of the three new staff whose files were checked had received a basic induction. The other staff member was spoken to and they confirmed they had received an induction although it is important a record of this for all staff is kept within their individual files. The operations manager reported that an induction that met with Skills for Care specifications was to be introduced in February 2008 (See Requirements). It was evident from staff files seen that staff had not had regular supervision to ensure they received at least six supervision sessions annually. Neither had annual appraisals completed with them (See Requirements). DS0000022749.V335425.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall service users benefit from a home that is well managed. Generally, the home is run in the best interests of service users with systems in place for selfmonitoring but not all these have been implemented. Generally, the health and safety of service users and staff have been protected and promoted but some areas are in need of improvements. EVIDENCE: A new manager has been recruited since the last key inspection and had been in post since July 2007. The manager is suitably qualified having qualifications for both general and mental health nursing as well as a diploma in addictions. They have relevant experience having managed a unit within a care home and the AQAA states they will be supported to complete the Registered Managers Award (RMA). In relation to an application for registration the manager reported they had submitted this in October 2007 but was still waiting to hear DS0000022749.V335425.R01.S.doc Version 5.2 Page 23 about an appointment for a ‘fit persons’ interview. It is advised this is followed up with the regional registration team to check on the progress of the application (See Recommendations). In respect to Standard 38 a previous requirement regarding on call arrangements of the home is not to be restated. Concerns about team leaders being placed on the on call rota and having the knowledge, training and skills to make decisions that may be the responsibility of the manager were identified as no longer being relevant. The manager reported that they had sole responsibility for any decisions to be made out of hours. The home carries out a number of audits to ensure that standards within the home are maintained, for example in relation to the meals provided, the medication and finances. Feedback from service users about aspects of the day- to- day running of the home had been obtained from service user meetings that had been held. The home’s AQAA had been comprehensively written and contained relevant and clear information supported by evidence. The manager reported and it was also specified within the home’s AQAA that the operations manager carries out unannounced monthly audits although evidence of just one audit completed in September 2007 was available on the day of the inspection. In addition, subject to a recommendation at the last inspection there was still no evidence that customer satisfaction surveys had been completed with service users, relatives and professionals that have links with the service as part of self –monitoring with results compiled in a report to be made available to service users and other interested parties including CSCI. Any aims or outcomes for service users should also be outlined within a development plan or the home’s business plan (See Requirements). External health and safety risk management consultants perform three monthly health and safety audits in the home. After each audit an action report is produced specifying any areas that need to be rectified. Only one of these reports was available for inspection of an audit carried out in March 2007. This was very comprehensive. It addressed all areas of the environment and included fire safety. However, despite the home having a valid certificate for electrical wiring it was noted in the report that it had been identified that the electrical wiring system was defective but clarification or evidence as to whether this had been addressed could not be provided at the inspection. Maintenance certificates for gas safety and portable electrical appliances were in place and the fire alarm system had been checked although it was noted that fire extinguishers had not been looked at since November 2006. There was evidence that weekly tests of the fire alarm call points had been carried out but not that the home had had practice fire drills. It was reported these are routinely carried out when the fire alarm was tested. However, these should be carried out at different times and recorded separately. Evidence of water temperatures having been tested to prevent risk of scalding was not in place. This was discussed with the manager who considered service users were not at DS0000022749.V335425.R01.S.doc Version 5.2 Page 24 risk as they were able to test water temperatures themselves but this needs to be addressed within a risk assessment (See Requirements). DS0000022749.V335425.R01.S.doc Version 5.2 Page 25 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 2 3 X 2 X ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000022749.V335425.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Version 5.2 Page 26 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 YA1 Regulation 5A(2)(a)&(b)& 5B(2). Requirement Timescale for action 30/04/08 2. YA6 3. YA7 4. YA9 The registered provider must ensure that as required by regulation a break down of fees charged by the home is detailed within the homes service user guide. 15(2) The registered provider must ensure that service users’ care plans are reviewed at least six monthly and updated to reflect any progress or changing needs of individual service users so that all their needs are fully addressed. 12(2)(3) The registered provider must ensure that service users are offered advocacy support, particularly when making decisions that may effect their future placement, and that this is recorded on their files. (Previous timescale of 10/11/05 & 31/07/06 not met). 12(1)&13(4)(b) The registered provider must ensure that risk assessments are reviewed and updated as necessary. Also, that all aspects of risk taking by DS0000022749.V335425.R01.S.doc 31/05/08 31/05/08 31/05/08 Version 5.2 Page 27 5. YA24 23(2)(b) 6. YA34 19 & Sched 2 7. YA35 18 (1)(c) 8. YA36 18(2) 9. YA39 24 service users is assessed and measures to reduce any identified hazards/risks are specified to address the health and welfare of service users. The registered provider must ensure that the hallway carpet is replaced as part of maintaining the environment of the home to an acceptable standard for service users. The registered provider must ensure that as part of recruitment and to protect service users that any gaps in employment are addressed with prospective employees and reasons given are recorded. This information should be kept in staff files. The registered provider must ensure that staff receive refresher training in respect to mandatory topics as required to ensure service users’ individual and joint needs can be met. The registered provider must ensure that all staff receive at least six supervision sessions annually and annual appraisals are carried out with staff to look at their personal development and identify any training needs. The registered provider must ensure that as part of self monitoring customer satisfaction surveys are completed with service users, relatives and other stakeholders annually and results are compiled in a report and made available to service users and other interested parties including DS0000022749.V335425.R01.S.doc 31/07/08 31/05/08 31/05/08 31/07/08 31/07/08 Version 5.2 Page 28 10. YA39 26 11. YA42 23(2)&23(4) (c)(Iv)(e) CSCI. A development plan in which identified aims and outcomes for service users are outlined should also be drawn up. The registered provider must ensure that monthly provider visit/audit reports are kept within the home and these are accessible for inspection The registered provider must ensure: - Evidence is sent to CSCI that the defective electrical wiring noted by the external health & safety audit has been rectified. -Fire extinguishers within the home are serviced. -Fire drills are carried out at different times of the day and records kept of these. - Water temperatures are tested monthly to prevent risk of scalding unless this is assessed as unnecessary as part of a risk assessment. 31/05/08 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA22 YA23 Good Practice Recommendations It is recommended that the registered provider record all informal complaints to monitor recurring themes and patterns It is recommended that the registered provider review how receipts are kept for service users’ transactions and these are kept together according to the month they took place for auditing purposes It is recommended that the registered provider keep basic details of Criminal Record Bureau checks on staff files. It is recommended that the registered provider follow up DS0000022749.V335425.R01.S.doc Version 5.2 Page 29 3. 4. YA34 YA37 on the progress of the manager’s application for registration. DS0000022749.V335425.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000022749.V335425.R01.S.doc Version 5.2 Page 31 - 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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