Setting

St Michaels Fellowship 52 Palace Road

52 Palace Road Tulse Hill London SW2 3NJ

p.1

St Michaels Fellowship 52 Palace Road

Announced Inspection 15th November 2004 Residential Family Centre

p.1

Commission for Social Care Inspection

Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England.

p.2

Commission for Social Care Inspection

The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission.

p.2

The role of CSCI is to:

• Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.

p.2

Inspection Methods & Findings

SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase "Standard met?"

p.2

The 4-point scale ranges from:

4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) 'O' or blank in the 'Standard met?' box denotes standard not assessed on this occasion. '9' in the 'Standard met?' box denotes standard not applicable. 'X' is used where a percentage value or numerical value is not applicable. St Michaels Fellowship 52 Palace Road Page 1

p.2

Address

52 Palace Road, Tulse Hill, London, SW2 3NJ

p.3

Do additional conditions of registration

Date of last inspection NA St Michaels Fellowship 52 Palace Road Page 2 Date of Inspection Visit 15 th & 16th November 2004 ID Code

p.3

Name of Establishment Representative at

the time of inspection Patricia Pryce St Michaels Fellowship 52 Palace Road Page 3

p.4

D.3. Provider’s agreement

St Michaels Fellowship 52 Palace Road Page 4

p.6

INTRODUCTION TO REPORT AND INSPECTION

Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to assess whether the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 and / or the Children Act 1989 as amended.

p.6

INTRODUCTION TO REPORT AND INSPECTION

This document summarises the inspection findings of the CSCI in respect of St Michaels Fellowship 52 Palace Road.

p.6

INTRODUCTION TO REPORT AND INSPECTION

The inspection findings relate to the National Minimum Standards (NMS) for Residential Family Centres published by the Secretary of State under the Care Standards Act 2000.

p.6

INTRODUCTION TO REPORT AND INSPECTION

The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action.

p.6

INTRODUCTION TO REPORT AND INSPECTION

The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards.

p.6

INTRODUCTION TO REPORT AND INSPECTION

• Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Report of the Lay Assessor (where relevant) • Provider’s response and proposed action plan to address findings

p.6

INSPECTION VISITS

Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The report is based on the findings at the specified inspection dates. St Michaels Fellowship 52 Palace Road Page 5 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 52 Palace Road is a family assessment centre, one of five houses managed by St Michael’s Fellowship an established charity that promotes the protection and development of children by educating and supporting young mothers to develop good parenting skills. The parent’s capacity to respond to the children’s needs and to safeguard their welfare is assessed and the parents are given such advice and guidance as is considered necessary to enable them to do so. The stated aims include ‘ providing fair, objective and comprehensive assessments of families to assist local authorities and the courts in making decisions for the

p.6

INSPECTION VISITS

welfare of the child’. It is registered to provide accommodation and support to six vulnerable mothers between the ages of 15 and 22 years with a maximum of eight children accepted. It is located in a residential road in Tulse Hill, South West London. The premises are a large spacious detached house with six individual bedsits, each having it’s own kitchenette. Communal space includes a large lounge and playroom and garden with play area. The main catering kitchen is located on the ground floor. The young mothers with the support and guidance from staff undertake cooking and household chores. St Michaels Fellowship 52 Palace Road Page 6

p.7

INSPECTOR’S SUMMARY

(This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) St Michaels Fellowship 52 Palace Road Page 7 This inspection report is of the first inspection by the Commission for Social Care Inspection under the National Care Standards for Residential Family Centres, and therefore serves as an audit of the centre against the new requirements, identifying developments needed to meet the new requirements within a reasonable period of time. The centre has been in operation for almost sixteen years following extensive refurbishment to the structure and internal fittings. It was registered with the Commission in February 2004. This announced inspection was undertaken on the 15 th , 16th November 2004. It was well facilitated by staff that were courteous and assisted with the inspection process. The records and pre inspection requests were all prepared and organised for examination. The centre

p.8

INSPECTOR’S SUMMARY

had no service users in residence at the time of inspection therefore some standards were not assessed. Records were viewed for previous placed service users and found to be well maintained and stored securely. The house is large and spacious with plenty of communal space for relaxing and a large well-equipped playroom. Individual bed-sits are provided for the young people. The majority of the inspection time was focused on interviews with the manager and staff, examining the procedures of the centre, discussions on how the centre is achieving its aims and objectives and on the future plans for further development. The staff team are experienced and knowledgeable with sensitivity to assessing and supporting young people in developing parenting skills, they have continued to participate in training to update their skills.

p.9

Standards 1 – 2 (Purpose and Function)

Of the 2 standards assessed 2 were fully met. Young mothers and their children who use the centre know what to expect, how they will be treated and how the centre operates. Written information is provided in a Statement of Purpose that accurately describes what the centre provides, a summary of the Statement of Purpose is produced in a user’s guide and is mad available to service users. Codes of acceptable behaviour are included in the service user’s guide.

p.9

Standards 3 – 5 (Quality of Care)

Of the 2 standards assessed 2 were fully met . The centre had established links with local health care services and a General Practice. The health visitor is also a member of the house committee demonstrating a commitment of working closely together with the centre in achieving best results for the young parents and their children. Information on services and contact telephone numbers are included in the user’s guide. A worker from Sure Start Plus attends the centre every Friday for meetings with the young people. Although there were no current service users individual records of previous service users were viewed indicating that they had participated fully in the reviewing and assessment process and were given the opportunity to include their own views on the assessments made.

p.9

Standards 6 – 10 (Parents’ and Children’s Rights)

Of the 4 standards assessed 4 were fully met. There are policies and procedures in place that ensure accurately written daily records are made of progress made by the young mother, as well as assessments of their ability to care for their children, contributions are encouraged and sought from mothers and included in the reviewing process on a daily basis. Meetings are held with key workers weekly to discuss the previous weeks developments including the positives and negatives identified in the assessment process.

p.9

Standards 11 – 13 (Protection)

Of the 3 standards assessed 2 were fully met. Staff are well trained and knowledgeable in Child Protection issues. The centre has clear procedures in place that are known and understood by staff on the action to take of there is suspicion of abuse. The child protection procedures of the centre have been submitted to the Area Child Protection Committee. The centre has established links with GP and health centre. The forwarding of notifiable incidents to CSCI was the subject of a requirement. St Michaels Fellowship 52 Palace Road Page 8

p.9

Standards 14 – 18 (Staffing)

Of the four standards assessed 3 were fully met. The recruitment procedures for staff are thorough with an experienced and well-trained staff team in place, however standard disclosures are required for all members of the manager’s household. The registered manager is qualified and experienced with a DipSW and an MBA. She has valuable experience in working with young parents and children. The staff team are professional and have a variety of qualifications relevant to the role. The organisation provides excellent training and development opportunities for staff to further develop their skills. The staff team receive regular supervision.

p.10

Standards 19 – 22 (Premises)

Of the 4 standards assessed one was fully met. The premises are large spacious and suitable for the purpose. Equipment at the centre is well maintained. Service users are responsible for gas and electric used in their bed sits. There are sufficient numbers of bathroom/shower facilities conveniently located to bedrooms. Areas for further development are highlighted in the report; these include the supply of water control valves for the maintenance of water temperatures at safe levels, the audit to be conducted to ensure furniture conforms to British Standards.

p.10

Standards 23 – 25 (Organisation and Management)

Of the 3 standards assessed 3 were fully met. The centre is well organised and managed; records are maintained of all visitors to the centre. St Michaels Fellowship 52 Palace Road Page 9 Requirements from last Inspection visit fully actioned? NA

p.10

STATUTORY REQUIREMENTS

Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and Residential Family Centres Regulations 2002. No. Regulation Standard Required actions Timescale for action

p.11

Action is being taken by the Commission for Social Care Inspection to monitor

compliance with the above requirements. St Michaels Fellowship 52 Palace Road Page 10

p.11

COMPLIANCE WITH CONDITIONS OF REGISTRATION (IF APPLICABLE)

Providers and managers must comply with statutory conditions of their registration. The conditions applying to this registration are listed below, with the inspector's assessment of compliance from the evidence at the time of this inspection.

p.12

COMPLIANCE WITH CONDITIONS OF REGISTRATION (IF APPLICABLE)

Condition Compliance YES Age range of mothers 15-22 years. Maximum number 6, maximum number of children 8.

p.12

Comments

No service3 users resident at the time of inspection.

p.12

Date

St Michaels Fellowship 52 Palace Road Page 11

p.13

STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION

Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.

p.13

STATUTORY REQUIREMENTS

Identified below are areas addressed in the main body of the report which indicate non- compliance with the Care Standards Act 2000, the Children Act 1989, the Residential Family Centres Regulations 2002, or the National Minimum Standards for Residential Family Centres. The Registered Person(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action

p.13

STATUTORY REQUIREMENTS

Schedule 5. RFC13 The registered manager must ensure that all notifications as listed in table 1 of Schedule 5 are notified to CSCI. 31/12/2004

p.13

STATUTORY REQUIREMENTS

2 16 RFC15 The registered manager must ensure that standard disclosures are sought for all members of the household accommodated at the managers flat. 31/01/2005

p.13

STATUTORY REQUIREMENTS

RFC19 The registered manager must ensure that consultation is sought with environmental health authority and that any requirements or recommendations made are implemented. 31/01/2005

p.13

STATUTORY REQUIREMENTS

4 21 (2) c RFC19 The registered manager must ensure that the stained carpet in the playroom is either cleaned or replaced. 31/01/2005

p.13

STATUTORY REQUIREMENTS

5 21 (1) a RFC19RF C 19 The registered person must ensure that an audit of the soft furnishings on premises is conducted to ensure that they comply with the Furniture and Furnishings (Fire) (Safety) Regulations 1988. 31/01/2005

p.13

STATUTORY REQUIREMENTS

11(4)(a) RFC20RF C 20 The registered manager must ensure that hot water outlets accessible to very young children are maintained at temperatures of between 41 and 45 degrees centigrade. 31/01/2005 St Michaels Fellowship 52 Palace Road Page 12

p.13

GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

Identified below are areas addressed in the main body of the report which relate to the National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Person(s). No. Refer to Standard * Recommendation Action

p.14

GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

1 RFC20 The registered manager should ensure that all bedrooms are provided with items as specified in standard 20.2 are provided

p.14

GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

2 RFC25 The registered provider should ensure that copies of Reg 26 visit reports are sent to the Commission regularly. * Note: You may refer to the relevant standard in the remainder of the report by omitting the 3-letter prefix e.g RFC10 refers to Standard 10. St Michaels Fellowship 52 Palace Road Page 13

p.14

PART B INSPECTION METHODS & FINDINGS

The following inspection methods have been used in the production of this report

p.15

PART B INSPECTION METHODS & FINDINGS

Direct Observation YES Sampling • Records YES • Care Plans / Care Pathways NA • Meals NA • Activities NA ‘Tracking’ care and support NA Group discussion with service users NA Group discussion with staff NO Interview of manager YES Service user survey- parents NA Service user survey- children NA Placing officers’ survey NO Staff survey YES Views of local social services department (child protection) NO Visiting Professionals’ feedback NO Tour of Premises YES Inspection of policies YES

p.15

PART B INSPECTION METHODS & FINDINGS

Date of Inspection 15/11/04 Time of Inspection 10.00AM Duration Of Inspection (hrs) 8.00 Number of Inspector Days 2

p.15

PART B INSPECTION METHODS & FINDINGS

The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Residential Family Centres have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase "Standard met?"

p.15

PART B INSPECTION METHODS & FINDINGS

4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls)

p.15

PART B INSPECTION METHODS & FINDINGS

"0" in the "Standard met?" box denotes standard not assessed on this occasion. "9" in the "Standard met?" box denotes standard not applicable on this occasion. “X” is used where a percentage value or numerical value is not applicable. St Michaels Fellowship 52 Palace Road Page 14

p.15

The intended outcomes for the following set of standards are:

• Parents and children who use the centre know what they can expect, how they

p.16

written form prior to admission

• Parents and children are admitted to and leave the centre in a planned and

p.16

what the centre sets out to do, how it will operate and the way in which it

will be provided. Key findings/Evidence Standard met? 3 Comprehensive information is provided for all service users and included in the Statement of Purpose. It describes for whom the centre is intended, that is young mothers between 15 and 22 years with their child/children. The statement also includes details of the assessment model and how it links with assessments using the Framework for Assessment of children in Need and their families. It provided all the essential information to enable parents make a choice and give a good idea of what they can expect from time of admission to the centre to time of discharge including the sharing of communal facilities. The service user’s guide included a summary of the statement of purpose and had recently been reviewed.

p.16

(if applicable):

Minimum £ 2080 Maximum £ 2080 St Michaels Fellowship 52 Palace Road Page 15

p.16

agreed with the parents and children and, where appropriate, the

purchaser, and handled with sensitivity and care. Key findings/Evidence Standard met? 3 There were no service users currently residing at the centre at the time of inspection. The registered manager reported on the admissions and discharge procedure in place at the centre, and how the process from admission to leaving the centre was handled with sensitivity and care. Initially referrals are made by local authority social workers, following the receipt of comprehensive assessments and personal histories consideration is then given to viability of the centre in meeting the individual’s needs, a meeting with all the professionals involved is held. The prospective service user is invited to the centre to gain a feel for the centre and decide if it is the appropriate setting. Service users are informed via user’s guide as well as at placement meetings and in the contracts of the expectations such as the time spent with children, methods of supervision and observation while living at the

p.17

agreed with the parents and children and, where appropriate, the

centre as well as codes of behaviour. Individual programmes are planned and based on referrals that identify the purpose and scope of the assessment centre for developing parenting skills and the capacity to do so, with consideration given to limitations. Leaving arrangements are planned in a sensitive manner and according to developments that have taken place during the time at the centre. Placements are extended when assessments determine extensions could benefit development. St Michaels Fellowship 52 Palace Road Page 16

p.17

The intended outcomes for the following set of standards are:

• Children and their parents have their needs assessed and written plans outline how the assessment will be undertaken. • Families have access to health care, education, employment and leisure

p.18

activities which promote their good health and well being, including their

mental health, in a safe environment. • Parents’ progress is recorded to reflect their ability to care for the children in a safe manner, promoting their welfare.

p.18

may be practicable with the parent/s and the placing authority, specifying:

• How the centre will undertake the assessment with the parents and • children, including detail of methods of supervision to be used; • How each child’s welfare and well-being will be promoted using any • relevant current local authority plan for that child; • How services will be provided for each resident for their care, treatment, • education and supervision; • The arrangements for contact and visitors; and • The objectives and intended outcomes of the placement. Key findings/Evidence Standard met? 0 This standard was not evaluated, as there were no persons residing at the centre at the time of inspection.

p.18

inspection:

X St Michaels Fellowship 52 Palace Road Page 17

p.18

has local knowledge of opticians, dentists and other primary care centres

such as guidance on substance misuse. Key findings/Evidence Standard met? 3 The service users’ guide includes telephone details of people in the community such as GP, health centre, Sure Start advisor. The manager and staff reported to the inspector on the involvement of the health visitor in visiting the centre every week, service users are also encouraged to visit the health visitor in order to develop the routine of taking the child/children for health checks. The health visitor is also a member of the house committee. Agreements were made with a local surgery where the GP is very supportive of young mothers and their children. The surgery is aware of the aims and objectives of the centre and the necessity for the temporary registration of new patients for duration of their stay at the centre. There is also guidance and information on the promotion of healthy living provided, articles on substance misuse and displayed on notice boards. Sure Start Plus

p.19

has local knowledge of opticians, dentists and other primary care centres

Groups are held weekly at the centre to enable young women meet and get more information on parenting. Service users’ bedrooms contain lockable cabinets for the storage of medication.

p.19

record for each family of their history and progress to which they have

access. Key findings/Evidence Standard met? 3 The centre has not had any young people in residence for several weeks. The manager reported on the method of involving service users in reading their files and to add their contribution. The inspector observed files retained securely for service users that been at the placement centre in the previous six months. These contained records made of progress and daily logs and observations made of development and assessments completed by staff, there were also signatures by service users acknowledging their participation in the progress, there were also entries made by service users indicating that they were consulted on and contributed to the assessment and reviewing process. St Michaels Fellowship 52 Palace Road Page 18

p.19

The intended outcomes for the following set of standards are:

• Parents and children using the centre feel well-informed and party to decisions made. • Parents and children enjoy sound relationships with staff based on honesty

p.20

and mutual respect

• Parents and children enjoy a level of comfort and security within the centre

p.20

effect on other residents

• The privacy of parents and children is respected and information about them is handled with appropriate confidentiality. • Parents and children are able to complain if they are unhappy with any aspect

p.20

significant others are sought over key decisions which are likely to affect

their daily life and their future. Key findings/Evidence Standard met? 3 The manager reported that the centre had procedures in place to involve the young mothers in contributing to the development of good parenting skills. The daily recording system used involves seeking the views of the service user/young mother and for reviewing and feedback on the previous days achievements. Underlying issues identified such as modelling behaviour are also discussed and recorded. The inspector observed records for a young mother that had been placed at the centre in recent months, there was written evidence available to indicate that she had been consulted with and contributed to these records.

p.20

Staff are able to set and maintain safe, consistent and understandable

boundaries for parents and children in relation to acceptable behaviour. Key findings/Evidence Standard met? 3 The written agreements and contracts issued to all service users include the codes of conduct expected of service users when living at the centre. To set and maintain safe and consistent boundaries key worker sessions are held weekly, these reflect on the positive and negative aspects of the previous week. For service users with less capacity in reading or literacy skills the home has produced the information in picture format. St Michaels Fellowship 52 Palace Road Page 19

p.20

standards of conduct are acceptable from them and their visitors and are

aware of the possible consequences of unacceptable behaviour. Key findings/Evidence Standard met? 3 Codes of conduct are outlined clearly in the service users’ guide and the contracts and agreements issued on admission. Service users are also informed of the possible consequences of unacceptable behaviour such as the termination of the placement. The manager informed the inspector of the support given by staff if a change in behaviour is observed, examples given included postnatal depression. For such changes noted referrals are made for psychological assessments. Another area focussed on at the assessment centre includes the development of parenting skills to deal appropriately with the child’s behaviour. The centre has rules and codes of behaviour expected of visitors. Notification of visitors must be received twenty-four hours in advance; these must also be agreed by the social worker. Service users are requested to entertain visitors in the communal

p.21

standards of conduct are acceptable from them and their visitors and are

lounge/areas and to be supervised while on the premises. The registered manager informed the inspector should a visitor exhibit codes of conduct that were unacceptable that then the police would be asked to intervene.

p.21

Staff respect parents’ and children’s privacy, and confidentiality is

balanced appropriately with the need to protect children. Key findings/Evidence Standard met? 0 The inspector was unable to evaluate this fully if this standard was met, as there were no service users residing at the home. The centre had procedural guidelines in place on privacy and confidentiality, these covered access to case records by staff and third parties including the circumstances when information would be passed to other professional such as child protection issues. Details of these and their significance and of the three way process are detailed in contracts. St Michaels Fellowship 52 Palace Road Page 20

p.21

a maximum of 28 days, and parents and children are kept informed of

progress. Key findings/Evidence Standard met? 3 The centre has produced a written policy and procedural guidelines on considering and responding to complaints clearly outlining the rights of all parents. The inspector observed the complaints procedure in operation at the home; it was also available in a picture format. It is included with the service user’s guide.

p.22

last 12 months:

Number of above complaints which were substantiated: X

p.22

12 months:

Number of above complaints which were substantiated: X St Michaels Fellowship 52 Palace Road Page 21

p.22

The intended outcomes for the following set of standards are:

• The welfare of children is promoted, children are protected from abuse, and an appropriate response is made to any allegation or suspicion of abuse. • Families are protected from abuse, neglect and self-harm • All significant events relating to the protection of children or vulnerable adults

p.23

understood by all staff (including junior, ancillary, volunteer and agency

staff). Key findings/Evidence Standard met? 3 The centre had a clear policy on ‘Child Protection’ and ‘Arrangements for protecting children accommodated on the unit’ were in place. Emphasis is placed on employing a staff team that is experienced and well trained and knowledgeable on the safety and protection of Vulnerable adults. All staff employed receive Child Protection training as part of their induction. Records viewed indicated that further training was provided that included a twelve-day course on CP. Key workers monitor and support parental and child development, procedures in place to ensure the safety of the child include the encouragement of service users to use the communal facilities as much as possible in order to monitor progress. On admission staff record accurately observations made of the child including body maps. The manager reported on the procedures in place, if a member of staff assessed and identified that service user’s behaviour had changed and

p.23

understood by all staff (including junior, ancillary, volunteer and agency

that there were concerns for the welfare child. Action would be taken such as crisis observations if there were serious concerns regarding the parenting skills, this would include entering bedrooms in emergencies.

p.23

abuse or self harm or inhuman or degrading treatment, through deliberate

intent, negligence or ignorance, in accordance with written policy. Key findings/Evidence Standard met? 3 Procedures in place for visits by family members or visitors include agreements by social services initially, there also agreements drawn up with service users specifying where visitors may be received and if not acceptable in bedrooms. The inspector was provided with evidence of an occasion when a visitor posed a risk to a service user and of the involvement of police. The visitor was subsequently barred from visiting the premises. The manager reported on the training provided to staff on dealing with and managing aggressive behaviour, staff are trained on early assessment of a situation and talking through with individuals to diffuse the situation. St Michaels Fellowship 52 Palace Road Page 22

p.23

persons and appropriate authorities of the occurrence of significant events

in accordance with Regulation 26. Key findings/Evidence Standard met? 2 The centre had written records available of all significant events that indicated relevant authorities were notified. The CSCI however had not been notified of one event. The registered manager must ensure that all notifications as listed in table 1 of Schedule 5 are notified to CSCI. Refer to requirements.

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

Residential Family Centres Regulations 2002 in the last 12 months.

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Death of a resident accommodated in the centre. X • Referral of person working at the centre to Secretary of State as unsuitable to work with children. X

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Serious illness or accident to a resident. X

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Serious outbreak of infectious disease. X

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Allegation that a resident has committed a serious offence. X • Actual or suspected involvement of a child (including a parent aged under 18) in prostitution. X

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Serious incident necessitating calling the police to the centre. 1

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Absconding by a resident accommodated in the centre. X

p.24

Number of statutory notifications made to CSCI under Regulation 26 of the

• Serious complaint about the centre or persons working there. X • Instigation of child protection enquiry involving a child accommodated in the centre. X St Michaels Fellowship 52 Palace Road Page 23

p.24

The intended outcomes for the following set of standards are:

• Parents and children receive the care and services they need from competent staff. • There is careful selection and vetting of all staff and anyone else resident on the premises. • Staff are sufficient in number, experience and qualification to understand the

p.25

needs of parents and children and who are able to respond appropriately when

required. • Parents and children receive a service from staff who are themselves supported and guided in safeguarding and promoting the children’s welfare. • Staff are trained and enabled to carry out the role to which they are appointed.

p.25

that the Statement of Purpose is fulfilled, and that parents and children

receive the care and services they need. Key findings/Evidence Standard met? 3 The staffing information detailed in the ‘Statement of Purpose’ and information supplied in the pre-inspection questionnaire completed by the registered manager confirmed that suitable staff with the desired training and experience had been employed to work in the centre. The staff team comprises of a total of six highly qualified staff. The inspector viewed current rotas and rotas worked when service users were in residence. These indicated that sufficient numbers were present to meet the needs of the young people accommodated at the time. The registered manager has a Diploma in Social Work as well as a Diploma in Combined Social & Behavioural Sciences. She has also acquired an MBA. She has managed the centre for three years having previously worked in the voluntary and statutory sector. The deputy manager has over twenty years experience of working with children and

p.25

that the Statement of Purpose is fulfilled, and that parents and children

teenagers, she also has achieved a BA in Sociology and an MA in Psychotherapy. The other four residential assessment workers hold qualifications that are relevant in their role. All staff employed had received up to date training in first aid, these certificates were also displayed on the noticeboard.

p.25

last 12 months:

St Michaels Fellowship 52 Palace Road Page 24

p.26

centre, including evidence that all requirements of Schedule 2 of the

Residential Family Centre Regulations 2002 have been met in every case. Key findings/Evidence Standard met? 2 The inspector examined staff personnel records. It was observed that these were well organised and completed thoroughly, and contained all the essential information as required by Schedule 2 of the Residential Family Centre Regulations 2002. All staff had satisfactory CRB enhanced disclosures checks on file. The inspector observed the process used in the selection of staff, suitable candidates were appointed that had experience skills and qualification to compliment the staff team. One area identified for development and discussed with the manager included the provision of standard checks for members of the household accommodated in a flat at the premises. The registered manager must ensure that standard disclosures are sought for all members of the household accommodated at the managers flat. Refer to requirements.

p.26

centre, including evidence that all requirements of Schedule 2 of the

St Michaels Fellowship 52 Palace Road Page 25

p.27

out the placement plan, within the context that responsibility for children

rests with the parents unless otherwise arranged. Key findings/Evidence Standard met? 0 Not evaluated at this inspection, as there were no service users resident.

p.27

Percentage of care staff having completed Level 3 NVQ in caring for

children and young people or equivalent qualification. X %

p.27

All staff, including domestic staff and the manager, are properly accountable

and supported. Key findings/Evidence Standard met? 3 The staff team benefits from regular and consistent supervision. Pre-inspection staff questionnaires received by the Commission evidence that staff found the level of support and supervision satisfactory. Discussion with staff indicated that supervisions were scheduled every two weeks, written records of dates for this confirmed that this had been maintained. Staff (three) with whom the inspector had individual discussions confirmed that informal supervisions were also available in between times and also that they were clear about the lines of accountability within the centre organisational structure. It was reported that senior management of the organisation was dealing with an unresolved matter at the centre between two members of staff under the organisation grievance and disciplinary procedure. Pre-inspection staff questionaires and staff interviews indicated that staff were

p.27

All staff, including domestic staff and the manager, are properly accountable

aware of how to support service users and their representatives to make complaints, also how to use the home’s disciplinary procedures. Staff had written job descriptions. Annual appraisals and personal development plans were in place for all staff including the manager. St Michaels Fellowship 52 Palace Road Page 26

p.27

skills required to work with parents and children and fulfil the purpose of the

service. Key findings/Evidence Standard met? 3 The pre-inspection questionnaire documentation, staff surveys and staff interviews evidenced that all staff received a thorough induction training in their first six months. Topics included in the induction programme were using evidence based practice and assessment in a residential setting in the context of the wider process of protecting children, assessing parental strengths and difficulties. Records viewed also indicated that staff were provided with appropriate training opportunities as identified in supervisions and appraisals thereafter. Personnel records and centre policy provided evidence that the organisation reviews staff performance during probationary employment periods. Training were observed confirming that key skills were kept continually updated, these included training in court skills and child development, as well as community drug projects and drug awareness.

p.28

skills required to work with parents and children and fulfil the purpose of the

St Michaels Fellowship 52 Palace Road Page 27

p.29

The intended outcomes for the following set of standards are:

• Parents and children live in pleasant, well designed and maintained

p.29

surroundings providing sufficient space and adequate facilities to meet their

needs. • Parents and children enjoy homely accommodation, decorated, furnished and maintained to a high standard, providing adequate facilities for their use. • Shared spaces complement and supplement residents’ private rooms. • Parents and children stay in accommodation that provides physical safety and security.

p.29

its purpose and function, serves the needs of the parents and children, and is

maintained in good order throughout. Key findings/Evidence Standard met? 2 The premises are a large detached house and in keeping with the surrounding residential area. Records viewed evidenced that essential servicing and repairs were maintained for the centre. It is within easy reach of local public transport and health centres. It is unsuitable for individuals with physical disabilities. The main door is not normally locked but will be locked by staff if there are particular external risks; this is a security measure as it is at high risk of being entered by unauthorised persons. Procedures in place include service users being informed that a member of staff is required to unlock the door; this also enables members of staff to monitor visitors to the centre. The door lock is automatically released when the fire alarm is activated. At the time of inspection there were no service users, a programme of

p.29

its purpose and function, serves the needs of the parents and children, and is

decorating was in operation. The overall appearance was domestic in style with individual touches such stencilling adding to the décor, redecorating was taking place for some areas requiring it, as the centre was unoccupied. The garden is well maintained with a play area provided for children. The communal lounge was well furnished with comfortable sofas; the playroom is located off this area. There were no indications that furnishings and fittings conformed to requirements. The registered person must complete an audit of the soft furnishings on premises to ensure that they comply with the Furniture and Furnishings (Fire) (Safety) Regulations 1988. The carpet in the playroom was stained and must be replaced or renewed. Refer to requirements. The environmental health authority had not conducted an inspection of the premises. The registered manager must ensure that consultation is sought with environmental health and that any requirements or recommendations made are

p.29

its purpose and function, serves the needs of the parents and children, and is

implemented. Refer to requirements. St Michaels Fellowship 52 Palace Road Page 28

p.29

has usable floor space, fittings and furnishings sufficient and suitable to meet

individual needs and lifestyles. Key findings/Evidence Standard met? 2 Service users are provided with individual bedsits, each has an individual kitchen. Service users are responsible for gas and electric bills for individual accommodation. The positioning and number of bathrooms and toilets was adequate. There were no hot water control measures in place to prevent risk of scalding or burns to young children. The registered manager must ensure that hot water accessible to very young children is maintained at between temperatures of 41c and 45 c degrees at tap and other outlets accessible to them. Refer to requirements. Over-ride devices were in place to allow access to bathrooms and toilets in an emergency. All six bedrooms were viewed; these were pleasantly decorated and spacious. As the programme of decorating was underway it was not possible to assess if all the essential items as listed in standard 20.2 were available. The registered manager should

p.30

has usable floor space, fittings and furnishings sufficient and suitable to meet

ensure that all bedrooms are provided with items as specified in standard 20.2 are provided. Refer to recommendations. St Michaels Fellowship 52 Palace Road Page 29

p.30

both for shared activities and for private use, in those centres which do not

operate with fully self-contained flats. Key findings/Evidence Standard met? 3 All bedrooms are bedsits with individual kitchens but there are a range of other shared spaces available for service users. There is a large comfortable lounge, a playroom, a communal kitchen, and a laundry. The registered person must ensure that an audit of the soft furnishings on premises is conducted to ensure that they comply with the Furniture and Furnishings (Fire) (Safety) Regulations 1988. Refer to requirements and standard 19. Sleeping in accommodation for staff is not part of the communal area.

p.31

Positive steps are taken to keep parents, children, staff and visitors safe from

risk from fire and other hazards. Key findings/Evidence Standard met? 2 The registered manager has responded to all the recommendations made from a recent visit by LEFDA. A fire risk assessment has been completed. Regular fire drills are conducted at the home. Soft furnishings were an area that concerned the inspector as referred to in standard 21. Refer to requirements. St Michaels Fellowship 52 Palace Road Page 30

p.31

The intended outcomes for the following set of standards are:

• Parents and children enjoy the stability of an efficiently run service and purchasers have confidence that they are getting value for money. • The service’s work with parents and children is continually adapted in the light of information about how it is operating. • There are adequate records of both the staff and families using the service.

p.32

The registered person has the necessary ability to plan, budget and administer the

finances to ensure that the service is run on a sound financial basis. Key findings/Evidence Standard met? 3 The centre provided the inspector with a business and financial plan, this indicated that resources were well managed, and that this contributed to its financial viability. There was evidence that a commitment was made to equal opportunities in the centre. The manager informed the inspector on the ways steps had been taken to develop good relationships with neighbours in the community. There were no records of any complaints received from neighbours. The registered manager demonstrated strong leadership skills; the staff team is well organised and stable with some staff having worked at the centre for some time. From discussions with management and staff there was a commitment demonstrated to delivering the best possible service to achieve best outcome for young mothers and their children. St Michaels Fellowship 52 Palace Road Page 31

p.32

record the monitoring, and takes any required follow up or consequential action:

• each family’s placement plan and placement agreement; • deposit and issue of money and valuables given for safe keeping; • accidents and injuries; • illnesses, whether physical or mental; • complaints and their outcomes; • allegations or suspicions of abuse and their outcomes; • a record of visitors to the unit; • staff recruitment records and conduct of required checks for any newly • recruited staff; • statutory notifications of incidents; • disciplinary measures; • use of physical restraint; • risk assessments and subsequent action; • medication, treatment and first aid at the unit; • duty rosters as actually worked; • the unit’s Daily Log; • absences; • records of valuables and money held in safe keeping; • fire drills and tests of alarms, emergency lighting and fire equipment; • annual staff appraisals; and • minutes of staff meetings.

p.33

record the monitoring, and takes any required follow up or consequential action:

Key findings/Evidence Standard met? 3 All records listed above were available for inspection; indications were that these were regularly reviewed. As stated earlier in the report there were no service users accommodated at the time but the files for previous placed service users were stored securely and viewed by the inspector. Evaluation questionnaires are given to social workers and the young mothers after the placement has ended. The centre is visited in accordance with Regulation 25 of the Residential Family Centres. Copies of these visit reports should be sent to the Commission. Refer to recommendations.

p.33

The service maintains satisfactory records about the staff, parents and

children involved with the service and major events affecting them. Key findings/Evidence Standard met? 3 The inspector observed records held for service users recently placed at the centre. Information required by Regulation 19(1)(a) and Schedule 3, 4 and 5 of the residential Family Centre Regulations 2002 was in place for the service users previously accommodated. There was sufficient room for archiving of information and secure storage. Records were retained for a minimum of three years from the date of the last entry. Staff records are held at the headquarters but were taken to the centre for observation by the inspector. St Michaels Fellowship 52 Palace Road Page 32

p.33

Date

St Michaels Fellowship 52 Palace Road Page 33

p.35

D.1 Registered Person’s comments/confirmation relating to the content and

accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on <enter date(s) of inspection here> and any factual inaccuracies:

p.35

D.1 Registered Person’s comments/confirmation relating to the content and

Please limit your comments to one side of A4 if possible St Michaels Fellowship 52 Palace Road Page 34

p.35

Action taken by the CSCI in response to provider comments:

Amendments to the report were necessary YES

p.36

Action taken by the CSCI in response to provider comments:

Comments were received from the provider YES

p.36

Action taken by the CSCI in response to provider comments:

Provider comments/factual amendments were incorporated into the final inspection report YES

p.36

Action taken by the CSCI in response to provider comments:

NO Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate

p.36

Note:

In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office.

p.36

report:

Action plan was received at the point of publication YES

p.36

report:

Action plan covers all the statutory requirements in a timely fashion YES

p.36

report:

Action plan did not cover all the statutory requirements and required further discussion NO

p.36

report:

Provider has declined to provide an action plan NO

p.36

Public reports

It should be noted that all CSCI inspection reports are public documents. St Michaels Fellowship 52 Palace Road Page 35

p.36

Date

Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.

p.37

St Michaels Fellowship 52 Palace Road / 15th November 2004

Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF

p.38

St Michaels Fellowship 52 Palace Road / 15th November 2004

Telephone: 020 7979 2000 Fax: 020 7979 2111

p.38

St Michaels Fellowship 52 Palace Road / 15th November 2004

National Enquiry Line: 0845 015 0120 www.csci.org.uk

p.38

St Michaels Fellowship 52 Palace Road / 15th November 2004

S0000047206.V191831.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection

p.38

St Michaels Fellowship 52 Palace Road / 15th November 2004

The paper used in this document is supplied from a sustainable source

p.38