Care Home: Streatham Common South, 22

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

What the care home does well Residents said that they are satisfied with the service they receive at the home. One of the residents said `I`m quite happy with the place`; another person said that he is glad that he has been assisted to move towards independent living. Two residents have been with staff on a weekend break to Hastings, which they enjoyed. One of the residents has been supported to manage his own medication. The home has developed contact with a supported employment project and a resident has obtained a job. The care plans are clear and well structured. Residents are involved in drawing them up and in reviewing them. What has improved since the last inspection? A new Manager has been appointed since the last inspection and he has worked methodically towards meeting the requirements and recommendations of the last inspection. All but one of the previous requirements and recommendations have been met or plans are in place to address them. Particular improvements are: o Medication practice has improved; there are now no gaps on the medication administration records. o Care plans now include information on how the residents will be supported to develop independent living skills; o Residents` names are now included on the electoral roll; o Assurance was given that the double room will only be occupied by people who wish to share; o Advice has been sought about compliance with legislation about smoking in public areas. CARE HOME ADULTS 18-65 Streatham Common South, 22 Streatham London SW16 3BU Lead Inspector Alison Pritchard Unannounced Inspection 24th July 2008 01:20p Streatham Common South, 22 DS0000022760.V368145.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 Streatham Common South, 22 DS0000022760.V368145.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. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Streatham Common South, 22 Address Streatham London SW16 3BU 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) 0208 765 0716 0208 764 2229 crownwise@yahoo.com none Crown Wise Limited Registration application being assessed Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 7 27th July 2007 2. Date of last inspection Brief Description of the Service: 22 Streatham Common South is a private residential home for seven adults with mental health needs. It is one of three homes in the locality owned by the same proprietor. The home is in a residential street overlooking Streatham Common, within walking distance of transport links, shops and leisure facilities. It is located in the ground floor and basement of a large house and is decorated and furnished to a good standard. Most of the people currently using the service have been at the home for many years and the home aims to provide them with the various degrees of support. Where appropriate, the home also helps to prepare people for independent living. Prospective residents are provided with an information pack about the home. The CSCI inspection report is available on request at the home and a copy is available in the communal lounge. Information about the current range of fees and whether there are any additional charges has been requested for inclusion in the final report. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and carried out over two days in July 2008. The inspection methods included discussion with residents and staff, inspection of residents’ files and a range of other records. Care plans were checked and aspects of these residents’ care were examined by case tracking. In addition staff and residents were sent surveys through which they could contribute their views to the inspection process. At the time of writing none of the surveys have been returned. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the Manager of the home in advance of the inspection and returned to us. The document provides information about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. The Registered Manager, staff and residents from the home facilitated the inspection visits; they were helpful and courteous throughout the process. What the service does well: Residents said that they are satisfied with the service they receive at the home. One of the residents said ‘I’m quite happy with the place’; another person said that he is glad that he has been assisted to move towards independent living. Two residents have been with staff on a weekend break to Hastings, which they enjoyed. One of the residents has been supported to manage his own medication. The home has developed contact with a supported employment project and a resident has obtained a job. The care plans are clear and well structured. Residents are involved in drawing them up and in reviewing them. Streatham Common South, 22 DS0000022760.V368145.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. Streatham Common South, 22 DS0000022760.V368145.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 Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided for the potential resident needs to be accurate so that they can decide whether it will be a suitable placement. The information gathered by the home needs to be full and detailed so that the Manager of the home can decide whether they can meet the potential resident’s needs. EVIDENCE: We were given a copy of the home’s Statement of Purpose. The document contains most of the information required, but the document has been adapted from one which relates to another home that the managing organisation runs. The details of the building – the numbers of rooms and their sizes –have not been changed and the document states that it can provide care for 18 people. This is inaccurate and misleading. The document must be amended and a copy sent to the CSCI. The service user guide is being amended. The Manager of the home confirmed that the information about the home’s fees is not included in the guide. However detailed information about the breakdown of charges is included in the newest resident’s contract with the home. Information about the financial details required to be in the service user guide has been provided for the Manager; he has stated that this will be included in the revised document. This requirement was made at the last inspection of the home in 2007. In recognition that the Manager was not appointed to his post until November 2007 the date for compliance has been extended. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 9 The admission process of the home’s newest resident was examined. The initial application form is detailed but several areas on this person’s form had been left blank. The gaps included information about any history of risky behaviours (such as violence, sexual abuse, arson or suicide attempts) and relevant medical issues (such as epilepsy). Staff from 22, Streatham Common Southside, conducted an assessment and this was examined. Similarly, several sections of the assessment form were left blank. The reason for this was unclear. The blank areas included queries about depression, mood and the person’s perception of his mental health condition, all of which should have been relevant areas to consider as part of the assessment. Detailed information was received from the placing social worker and relevant details were obtained from the person’s previous placement. The statement of purpose includes the statement that only people whose needs can be met by the home will be admitted. The Manager confirmed that potential residents are not issued with written confirmation that the home can meet their needs. This is required by regulation. See requirements 1, 2, 3 and 4. Streatham Common South, 22 DS0000022760.V368145.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, 8, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are involved in care planning and reviews. The plans would be improved by the inclusion of the residents’ social histories and needs which arise from their culture, race, religion, sexuality and gender. EVIDENCE: Three care plans were examined. Each of the plans has a clear structure, identifying the resident’s needs and how the staff of the home will assist residents to meet them. The residents’ key workers complete the plans and the residents’ signatures confirmed their involvement in the process, and their agreement with the identified goals. Progress towards the goals is discussed at regular meetings of the key worker and the resident. Full reviews of the care plans are carried out every six months. The plans detailed restrictions on aspects of the residents’ behaviour, which was aimed at their protection. One example of this was the amount of money allocated to a resident for their daily use. Restrictions such as this, were supported by documented risk assessments and there was confirmation on file of the involvement of the person responsible for managing the resident’s Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 11 money. Other risk assessments described the way in which residents were being supported to develop skills and have a greater degree of independence. The residents’ files did not include information about their social history. We also noted that the care plans did not adequately reflect residents’ needs which arise from equality and diversity issues, such as their culture, race, religion, sexuality or gender. For example one document on a resident’s file stated the resident’s religion but included no details of how, or if, the person wished to express his religion. The inclusion of these matters in the assessment and planning processes would ensure that the plans reflect, and are informed by, a better understanding of the range of residents’ needs. See requirement 5. Residents are involved in decision making in the home in a number of ways. These include menu planning, cooking and discussion of issues of general concern at residents’ meetings. Streatham Common South, 22 DS0000022760.V368145.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. The residents have the opportunity to follow a range of activities which are appropriate for their ages and reflect their interests. Two residents enjoyed a recent weekend away in Hastings. Evening activities in the community are limited by staffing levels. The meals reflect a range of cultures, preferences and are planned with regard to residents’ health needs. EVIDENCE: Residents said that they join in activities at the home including playing pool; listening to music; watching television and cookery. Another residential home managed by Crownwise is close by, and they provide activities, which are also open to residents of 22, Streatham Common Southside. These include barbecues and social evenings. The evening staffing levels are for there to be one person on duty in the home after 4pm. This means that there are limited opportunities for residents to be accompanied on evening activities in the community. One of the residents is encouraged to play a part in household tasks, including cooking, cleaning and shopping as part of a rehabilitation programme. One of Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 13 the residents attends a day centre; another attends a centre which supports people to develop skills with a view to obtaining employment and has a part time job. Residents are encouraged to take up adult education classes – a resident said that he had previously attended swimming lessons and had computer skills training. Those residents who wish to do so are encouraged to attend places of worship, one of the current residents attends church regularly. The Manager stated on the AQAA that, over the next year, he hoped to encourage residents to take up therapeutic activities such as massage. Two residents went with staff for a weekend break to Hastings recently. Residents said that they enjoyed the holiday. Another break and day trips are being arranged. On the AQAA the Manager identified planning more holidays and trips, in consultation with residents, as an area for development over the n next year. The home assists residents to keep in touch with family and friends. A visitors’ record is maintained. The visiting policy states that visitors may come to the home up until 10pm and, by prior arrangement, may stay for a meal in the home. Residents, who have family who live out of London, are supported to make visits to them. We saw residents’ electoral poll cards, confirming that they are registered to vote and take part in the democratic process. This meets a recommendation of the last report. Residents plan the menu together with staff. Records of meals are kept. The record showed that there is a mix of dishes reflecting the cultures of the residents. Meals recorded included chicken curry with rice and peas; jollof rice and fried chicken and mixed grill. There were plentiful stocks of fruit and vegetables in the home. Residents said that they liked the meals, one person said that he sometimes helped with cooking and he enjoys this. There is a communal dining room on the lower ground floor and most residents choose to eat together there. One person chooses to eat separately from the rest of the household and is given money with which to buy food supplies. Streatham Common South, 22 DS0000022760.V368145.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. The systems for dealing with residents’ medication are generally satisfactory. One person is supported to manage his own medication. More details need to be available for staff about the circumstances in which, medication given on an ‘as needed’ basis is required. EVIDENCE: Care plans detail the level of support residents need with personal hygiene. On the AQAA, the Manager identified an area in which improvement is needed, is in giving residents the choice of who assists them with personal care tasks. Examples given were whether residents would prefer to be helped by a member of staff of the same gender, or cultural background. This would be a useful addition to care plans to ensure that the care provided reflects residents’ preferences and needs. In order to support this goal more male staff have been introduced to the team. The Manager highlighted the fact that the staff team does not reflect the racial profile of the resident group, in that the majority of staff are black and the majority of residents are white. The Manager said he would like this to be addressed through recruitment and staff deployment. This demonstrates an awareness of issues of diversity in the provision of care. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 15 The residents have a range of health care problems and these are noted on the care plans. Some documents need to be updated to reflect the current information about residents’ needs. For example a recent document in a file clarified the person’s mental health diagnosis, however the front sheet in the file, which gives details that are essential to know about the person, had not been updated to reflect the new information. This was pointed out to the Manager who assured us that he would make the necessary correction. There were clear details of residents’ appointments with other health care professionals, such as the GP, dentist, chiropodist and optician. The records included the reasons for the appointment and the outcome so that issues could be tracked easily. The files also contained good details from psychiatric professionals involved with the residents, including records of Care Programme Approach (CPA) meetings. The records included behaviours, which may be relapse indicators and detailed the action to be taken in such circumstances. One of the residents has been supported to manage his own medication. This is reinforced by a risk assessment, which is noted as requiring review every three months, and includes appropriate monitoring by staff. The resident has safe facilities in which to store medication. Other residents’ medication is stored safely and managed by staff. All of these residents had signed forms giving their consent to staff assisting with their medication. The medication file includes examples of signatures of the staff responsible for giving residents’ medication. There is useful information on file about the medications, their purpose, reasons it has been prescribed and any contraindications. There were no unexplained gaps on any of the medication administration records (MAR). There are also clear records of the return of medication to the pharmacist. This allows an accurate audit. Occasional spot checks are carried out to ensure that the records and balances of medication are in order. The Community Pharmacist visited the home in early February 2008 and found the medication stocks and records in good order. We found two issues which needed to be addressed: o Firstly, for there to be detailed information which explains the circumstances in which medication given on an ‘as needed’ basis is required. Two residents take medication on this basis and in each case a greater degree of clarity is required to ensure that staff use the medication consistently and appropriately. o The second issue is for the competency of staff in dealing with medication issues to be assessed and a written record maintained of the assessment. See requirements 6 and 7. Streatham Common South, 22 DS0000022760.V368145.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. The homes complaints safeguarding procedure contribute to the protection of residents. The complaints procedure should detail the timescales within which investigations will be made. EVIDENCE: The complaints record had no entries after January 2006. The Manager confirmed that no complaints had been received. He expressed his concerns about this and said that he reminds residents about the complaints procedure but nevertheless no complaints had been made. All residents have been given a copy of the complaints procedure and it has been explained to them. The complaints procedure, is included in the statement of purpose. It does not give any timescales within which the home will investigate a complaint. This is required so that the procedure complies with regulation; complaints are dealt with promptly and that residents are clear about the process. See requirement 8. Residents who we asked about these matters said that, in the event of a concern or complaint, they would have someone to discuss the matter with, and they were aware of their right to complain. One of the files seen uses a risk assessment to address a resident’s vulnerability and incorporates a number of safeguarding measures. Recently the behaviour of a previous resident had been threatening to other members of the resident group. The staff took the appropriate action to protect the residents and to act in all of their best interests. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 17 All of the staff have undertaken training in safeguarding issues and a copy of the local authority safeguarding procedure is available at the home. No investigations of this nature have been made over the last year. Streatham Common South, 22 DS0000022760.V368145.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, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well decorated, furnished and clean. There is adequate communal space available and a patio garden to the front of the home. The vacant bedroom is attractive and comfortable. EVIDENCE: There are five single bedrooms and one double bedroom, currently occupied by one resident. The Manager said that there are no plans to admit anyone to the vacant place in the double bedroom. Shortly after the inspection a single room at the home became vacant. This room was viewed, it is clean and attractively decorated. There is a communal lounge, dining room and laundry area in the basement of the home. The communal lounge has a pool table which some of the residents enjoy playing. The home is not suitable for people with mobility needs as the communal areas are down a steep staircase. There is a pleasant level access patio area with seating and flowers at the front of the property, overlooking Streatham Common. Currently residents may Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 19 smoke in the communal lounge, but this does not adequately comply with the new legislation concerning smoking in care homes. There are plans to add a canopy to the patio area so that it can be used as a smoking area in all weathers. This has been discussed and agreed with the local responsible Environmental Health Authority. All areas of the home that were viewed were clean and in a good state of repair and decoration. There are adequate laundry facilities for the numbers of residents in the home. Streatham Common South, 22 DS0000022760.V368145.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff working at the home and they have benefited from the NVQ training programme. The staff recruitment procedure needs some improvements to ensure it adequately protects residents. EVIDENCE: The staff team consists of the Manager, a Deputy Manager, a Senior Support Worker and seven Support Workers, six of whom are part time. Three of the part time workers also work at other Crownwise homes. They are known to the residents through the informal contact between the homes. The staff rota shows that on weekdays there are generally two people on duty between 8am and 2pm, three on duty between 2pm and 4pm, and one person working in the evening until 8pm. One person is available in the home overnight; they sleep in the home and are available to assist residents as needed. Additional management support is available through the on-call system. These staffing levels mean that there are limited opportunities for residents to be accompanied on activities out of the home in the evening. All but one member of staff has achieved NVQ 2 or 3, or are working towards the qualification. Since the Manager has been in post he has reviewed the Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 21 training received and required by the staff team and has implemented a training and development programme. The ‘in house’ training programme is delivered by the Manager of the home and so far has included care planning, medication issues, food hygiene and risk assessment. Other topics planned for 2008 are health and safety; first aid; infection control and safeguarding vulnerable adults. The Manager stated his intention for the induction programme to be improved so that it incorporates the Skills for Care ‘Common Induction’ standards. The staff would benefit from training in the specific health conditions – mental and physical - presented by the resident group. Issues of this kind do not currently feature in the training identified for the rest of the year. Since the last inspection one person who works at the home has been recruited although his main place of work is another home within the Crownwise group. The recruitment records were brought to us for inspection. We found that the file contained a copy of a passport, which was issued twelve years before the application was made, and no recent photograph. Although the person’s employment history included relevant experience in other work settings, references were not taken from these employers. This shows that a more rigorous approach to staff recruitment is required. These required improvements were pointed out verbally to the Manager of the home as recruitment was underway at the time of the inspection visits. See requirement 9. The Manager stated that an aim for the next twelve months is to ensure that the induction programme complies with the Skills for Care common induction standards. Streatham Common South, 22 DS0000022760.V368145.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. The manager is experienced and working towards achieving the appropriate qualification. He intends to develop further the quality assurance systems. Health and safety matters are generally well managed and the home has complied with the majority of recommendations of the Environmental Health authorities. EVIDENCE: The Manager was appointed in November 2007 to manage 22 Streatham Common Southside and St Andrews, another home operated by Crownwise. The Manager’s hours are split between the two homes and Deputy Managers are available at each home in his absence. The other home is in the Streatham Hill area. An application was made to the CSCI for registration under the Care Standards Act. The application was being assessed at the time of the inspection visits. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 23 The Manager has substantial experience of the management of residential care homes. He has achieved NVQ 4 and is studying for the Registered Manager’s Award. The Proprietor visits regularly as required by Regulation 26 of the Care Homes Regulations. The reports showed that she includes discussions with staff and residents as part of the visits. The Manager stated on the AQAA that over the next year he plans to make improvements to the quality assurance systems by seeking further input from stakeholders on how the home is meeting the needs of the residents. We looked at a range of health and safety records. Environmental Health officers visited the home in March 2008. They made a number of recommendations and the majority of these have been implemented. One issue, which remains outstanding, is creating a smoking area, which meets the new legislation applicable to registered homes. The Manager stated that this is to be addressed by providing a canopied area on the patio to the front of the home. This will be monitored at future inspections. The fire risk assessment is dated 1st January 2006 and needs to be reviewed. See requirement 10. Tests and services of the fire safety systems are carried out at frequent intervals. Drills are scheduled to take place every three months. Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 2 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 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 25 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 5 Timescale for action The registered person must 01/10/08 revise the service users guide in accordance with recent changes in legislation. The date for compliance was 30.11/07. As the Manager was appointed in November 2007 we have extended the timescale for action. The Registered Person must 01/10/08 revise the statement of purpose to ensure its accuracy. A copy must be sent to the CSCI. The Registered Person must 01/09/08 ensure that assessments of potential residents are completed in detail so that they have adequate information with which to decide whether their needs can be met at the home. The Registered Person must 01/09/08 ensure that potential residents are issued with written confirmation that their needs can be met at the home. The Registered Person must 01/10/08 ensure that care plans are improved by the inclusion of the DS0000022760.V368145.R01.S.doc Version 5.2 Page 26 Requirement 2. YA1 4 3. YA2 14 4. YA3 14(1)(d) 5. YA6 12(4)(b) Streatham Common South, 22 6. YA20 13(2) 7. YA20 13(2) 8. YA22 22(4) 9. YA34 19 10. YA42 23(c)(v) residents’ social histories and needs which arise from their culture, race, religion, sexuality and gender. The Registered Person must ensure that staff have access to detailed information which explains the circumstances in which medication given on an ‘as needed’ basis is required. The Registered Person must ensure that the competency of staff in dealing with medication issues is assessed and a written record maintained of the assessment. The Registered Person must ensure that the complaints procedure includes timescales within which the home will investigate a complaint. The Registered Person must ensure that the recruitment procedures are rigorous to ensure that staff are suitable to work at the home. The Registered Person must ensure that the fire risk assessment is reviewed annually. 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Streatham Common South, 22 DS0000022760.V368145.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!