Setting

St Michaels Fellowship, 46 Herne Hill

Announced Inspection 7th July 2004 Residential Family Centre

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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.

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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.

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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.

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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?"

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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, 46 Herne Hill Page 1

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Do additional conditions of registration

Date of last inspection NA St Michaels Fellowship, 46 Herne Hill Page 2 Date of Inspection Visit 7th July 2004 ID Code

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Name of Establishment Representative at

the time of inspection Ms Alison Edwards St Michaels Fellowship, 46 Herne Hill Page 3

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D.3. Provider’s agreement

St Michaels Fellowship, 46 Herne Hill Page 4

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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.

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INTRODUCTION TO REPORT AND INSPECTION

This document summarises the inspection findings of the CSCI in respect of St Michaels Fellowship, 46 Herne Hill.

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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.

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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.

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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.

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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

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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, 46 Herne Hill Page 5 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. ‘46’, a residential family Centre run by St Michaels, is an establishment that provides accommodation, assessment and support for children and their parents. 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. Parents are therefore ‘looking after’ their own children whilst their ‘parenting skills’ are assessed by the staff team. The stated aims include ‘ providing fair, objective and comprehensive assessments of

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INSPECTION VISITS

families to assist local authorities and the courts in making decisions for the welfare of the child’. Centre staff seek to make formal counselling available for parents who may benefit from it, but do not provide counselling themselves. The home manager and staff team undertake formal twelve week assessments. Final reports aim to identify both risk and protective factors and make recommendations for after- care. An ‘eclectic’ approach based on the individual needs of families has been adopted, using a variety of theoretical models, concepts and ideas for ‘interventions with families’ that ‘place the child first’. St Michaels Fellowship, 46 Herne Hill Page 6

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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, 46 Herne Hill Page 7 This report is the first 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. An immediate requirement was left in regard to faulty window restrictors. This requirement was met within the given timescale. The manager had been registered individually with the Commission and satisfactory CRB (police) checks were available for all staff. The home manager and staff were co-operative with the inspection process and made documents required by regulation available for inspection, providing copies of documents on request.

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INSPECTOR’S SUMMARY

The centre was well managed, with dedicated and professional staff.

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Standards 1 – 2 (Purpose and Function)

Both standards were assessed and both were fully met. The centre’s purpose and function were clearly defined in the ‘Statement of Purpose’ and ‘Service Users Guide’. Admissions and ‘end of placements’ had been handled with sensitivity, and as required by Regulation and the centres own policy and procedure.

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Standards 3 – 5 (Quality of Care)

All three standards were assessed; All three standards were fully met. Placement plan documentation examined was in good order and had been subject to regular review with all necessary parties. The centre had established links with local specialist health care services and a General Practice. Permanent placement records were available and agreed with the parent service users.

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

Five standards were assessed; four were fully met and one was almost met. The rights of parents and children were promoted and protected by staff and centre policy. Requirements have been made to increase staff training in areas around physical intervention.

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Standards 11 – 13 (Protection)

Three standards were assessed; All three standards were fully met. Adequate systems were in place for the protection of children and vulnerable adults. Notifications had been made to the appropriate authorities as required. The staff team and manager are commended on the thorough assessment process undertaken to this end.

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Standards 14 – 18 (Staffing)

Five standards were assessed; three were fully met and two were almost met. Whilst staff were noted to be suitably qualified and experienced, action must be taken to ensure the required NVQ qualification by 2005 and additional areas of training required by the National Minimum Standards.

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Standards 19 – 22 (Premises)

Four standards were assessed; One was fully met and three were almost met. The centre was suitable for its stated purpose, clean and reasonably furnished. Requirements have been made in regard to hot water controls, electrical testing of equipment and the need for environmental health inspection and audit of bedroom furnishings. St Michaels Fellowship, 46 Herne Hill Page 8

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Standards 23 – 25 (Organisation and Management)

Three standards were assessed; Two were fully met and one was almost met. The centre had maintained good records as required by regulation other than a record of Visitors to the home.

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Standards 23 – 25 (Organisation and Management)

Requirements from last Inspection visit fully actioned? NA

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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

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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.

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COMPLIANCE WITH CONDITIONS OF REGISTRATION (IF APPLICABLE)

Condition Compliance YES The maximum number of adult members of families residing at any one time shall not exceed six.

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Comments

Condition Compliance YES Before a fifth family is admitted, the registered person shall notify the registration authority of the additional staffing arrangements to be put in place.

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Comments

St Michaels Fellowship, 46 Herne Hill Page 9

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Date

St Michaels Fellowship, 46 Herne Hill Page 10

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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.

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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

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STATUTORY REQUIREMENTS

RFC 12 The registered person must provide staff with training in anger management and de- escalation procedures and on the use of physical restraint of children. 26/12/04

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STATUTORY REQUIREMENTS

2 11(6) RFC8RFC The registered person must ensure that the centre has a stated policy of which all staff are aware, on the use and techniques of physical restraint of children, and the circumstances in which it may be used, which is consistent with any relevant government guidance on approved methods of restraint. 26/12/04

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STATUTORY REQUIREMENTS

3 15(a)(b) RFC14RF C 14 The registered person must ensure that the centre has a minimum of 80% of its care staff qualified at level 3 or equivalent in the caring of children and Young People NVQ from 2005.

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STATUTORY REQUIREMENTS

Sch 2 The registered person must ensure that all information required by Schedule 2 of the Residential Family Centre Regulations are available in personnel records. 0710/04

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STATUTORY REQUIREMENTS

5 17(5)(a) The registered person must ensure that training is provided for staff in all areas identified in NMS 18.5 (other areas of identified training need are the subject a requirement and recommendation elsewhere in this report). 05/11/04 St Michaels Fellowship, 46 Herne Hill Page 11 6 21 RFC19RF C 19 The registered person must ensure that action is taken to address any outstanding issues identified in the Premises Health and Safety report of June 2004. 07/10/04

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STATUTORY REQUIREMENTS

RFC19RF C 19 The registered person must also audit the soft furnishings on premises to ensure that they comply with the Furniture and Furnishings (Fire) (Safety) Regulations 1988. 07/10/04

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STATUTORY REQUIREMENTS

RFC19RF C19 The registered person must seek advice and centre inspection from the environmental health authority. 05/11/04

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STATUTORY REQUIREMENTS

9 21(2)(d) RFC20RF C 20 The registered person must audit the furnishings provided in bedrooms against the list in NMS 20.2. Steps must then be taken to ensure that rooms are fully furnished as per the minimum standard. 03/12/04

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STATUTORY REQUIREMENTS

11(4)(a) RFC20RF C 20 The registered person must ensure that hot water accessible to very young children, or people with disabilities which place them at risk from excessively hot water, is maintained at between 41 and 45 degrees centigrade at tap and other outlets accessible to them. 01/11/04

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STATUTORY REQUIREMENTS

10(1)(a) 11(4)(a) RFC22RF C 22 The registered person must ensure that electrical appliances in use at the home are safety tested annually. 01/11/04

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STATUTORY REQUIREMENTS

14(2)(g) RFC22RF C 22 The registered person must ensure that windows have suitably restricted opening to avoid the risk of a child falling. All windows above ground level must be fitted with restricted opening mechanisms.

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meet this requirement has been supplied

The registered person must take steps to ensure that all staff can effectively use the emergency systems and have knowledge of fire procedures in place at the home. 24/09/04

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meet this requirement has been supplied

RFC22 RFC 22 The registered person must ensure that all gas appliances are safe (faulty cooker/cooker control must be repaired). 24/09/04 St Michaels Fellowship, 46 Herne Hill Page 12 19(3)

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meet this requirement has been supplied

Sch 12(4) The registered person must ensure that a specific record of all visitors is maintained in the centre. 10/09/04

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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

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GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

RFC8RFC The registered person should provide staff with training in ‘breakaway’ techniques.

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GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

The registered person should ensure that service users views in regards to staffing levels are discussed in house meetings.

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GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

RFC22RF C 22 The registered person should look at ways in which small electrical appliances bought into the home by service users can be safety tested before or during admission.

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GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

The registered person should label the keys on the bundle carried by the shift leader to enable individual keys to be identified in an emergency. * 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, 46 Herne Hill Page 13

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PART B INSPECTION METHODS & FINDINGS

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

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PART B INSPECTION METHODS & FINDINGS

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

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PART B INSPECTION METHODS & FINDINGS

Date of Inspection 07/07/04 Time of Inspection 10.00 Duration Of Inspection (hrs) 10.00 Number of Inspector Days 2.5

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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?"

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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)

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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, 46 Herne Hill Page 14

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The intended outcomes for the following set of standards are:

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

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written form prior to admission

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

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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 A copy of the centres Statement of Purpose was supplied to the Commission. It was noted that the document accurately described what the centre set out to do and the way in which the service would be provided. The staff information was clearly set out and had been reviewed in June 2004. All information required by Regulation 4 and Schedule 1 of The Residential Family Centres Regulations 2002 and NMS 1 (National Minimum Standard) had been included. It was noted that a ‘Complaints leaflet’ was also provided. When this leaflet was examined it provided adequate information for making a complaint and also re-assured service users that no recriminations would be made against them for making a complaint. The required ‘Service Users Guide’ was also supplied and examined. The guide contained a summary of the information contained in the ‘Statement of Purpose’.

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

Both documents were well presented and easily accessible. Fees were dependant on the level of support required and the size of the family accommodation.

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(if applicable):

Minimum £ 2,011.0 Maximum £ X St Michaels Fellowship, 46 Herne Hill Page 15

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

purchaser, and handled with sensitivity and care. Key findings/Evidence Standard met? 3 Examination of the homes admissions procedure and discussion with the home manager indicated that referrals were considered during a selection meeting, with representations and supporting assessment documentation from the placing social work and health teams being made to the St Michael’s social worker. If the unit was able to offer an appropriate service to the family concerned the family were then offered the opportunity to visit the home to meet other service users and ask questions before accepting the offer of a placement. During meetings with the family, ‘a placement agreement’ was devised, detailing the purpose and scope of the residential assessment of parenting skill and capacity. The ‘agreements’ examined by the inspectors had been signed by the adult service users, social workers and home manager. Selection meeting minutes were available for the service users

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

accommodated at the time of the inspection. The centres expectations of how time would be spent in the home and expectations of behaviour were clearly laid out in the Service Users Guide ‘ house rules’ supplied during the process of admission. Pre-inspection questionnaires completed by the centre manager and home policy indicate that the centre did not accept emergency admissions. Twelve week residential placements also included six-month post-placement resettlement support. St Michaels Fellowship, 46 Herne Hill Page 16

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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

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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.

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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? 3 Each service user had two files, a main file and a file of ‘running notes’. The files of the service users accommodated at the tine of the inspection were examined. The main files contained the placement plans, which were monitored by designated key workers within the team. The key workers met with the parent service users on a weekly basis to provide individual support, advice and guidance. The registered manager had provided support to

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

the key worker and maintained an oversight to ensure that needs were being identified and met. The placement plans examined contained information required by Regulation 13 of the Residential Family Centres Regulations 2002 and NMS 3 (National Minimum Standard). One service users placement plan was being revised as the family composition had changed and a new assessment was underway.

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inspection:

X St Michaels Fellowship, 46 Herne Hill Page 17

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

such as guidance on substance misuse. Key findings/Evidence Standard met? 3 Arrangements were in place with a local GP practice, to ensure that service users accommodated have access to doctors, regular immunisation programmes and health screening. A local dental surgery was able to offer treatment on a temporary basis, for the period of time that the individuals within each family are accommodated in the centre. Each parent service user had been required to sign a consent form for medical treatment and first aid provided by home staff to either the parent or child accommodated in an emergency situation. Service Users were provided with a safe lockable area to store medications within their rooms.

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

access. Key findings/Evidence Standard met? 3 Daily running logs had been maintained for each parent service user. At the end of every day the service users were able to read their notes and add any corrections. These corrections were then carried forward to the next day. Two copies were made of each days notes, one to be kept by the service user and one to be maintained in the homes records. Both copies had been signed by the service users. The centre copies were maintained chronologically and were stored confidentially and securely in the staff office. St Michaels Fellowship, 46 Herne Hill Page 18

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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

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and mutual respect

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

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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

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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 home manager planned to hold service users ‘house’ meetings on a weekly basis, discussion and examination of meeting records indicated that this had not been achieved on all occasions, at times when only one adult had been accommodated. However, regular key work meetings had been held and had provided a forum for views to be expressed. Children were also able to attend the house meetings. The pre-inspection questionnaire completed by the centre manager identified areas of the running of the centre influenced and changed by listening to service users during meetings. The centre had access to a pool of sessional and agency staff who can be employed for specific pieces of work with service users if they had a particular skill or cultural background. Placement plans, placement reviews and daily recording procedures also provided service

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

users with opportunities to have their views noted. The input of the service users advocate, solicitor (acting as advocate for the parent), child and adult social worker and Community Psychiatric Nurse, if appropriate, were also sought over key decisions. The inspector noted that the assessment of one family had been extended, as the family circumstances and composition had changed during the assessment process. This was viewed by the inspectors to be supportive of the rights of the parent and children involved. Initial assessment periods had focused on assessing the risks of families accessing the community without the support of the team and night monitoring, with a view to reducing initial restrictions to personal freedom and privacy where possible. The written reports of monthly inspections conducted by the responsible individual examined by the inspector noted ‘service user consultations’ undertaken as part of the internal

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

inspection process. St Michaels Fellowship, 46 Herne Hill Page 19

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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 ‘Statement of Purpose’ and ‘Service Users Guide’ examined provided a clear indication of the standards of acceptable behaviour boundaries within the centre, and the consequences for breaches in agreements made. ‘House rules’ were clearly specified and the service users signed agreements sought as part of pre-placement admissions planning. The centre provided ‘daily diary sheets’ for people with a learning disability that did not rely on text only information. The pre-inspection questionnaire completed by the centre manager indicated that some service users with a learning disability had advocates and that communications could also be supported using ‘signed-language’ and/or interpreters as required. The inspector noted that day-to-day decision making, evidenced during observation of a team meeting held on the day of the announced inspection, demonstrated

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

an appropriate balance between the rights of the parent and the need for child protection. St Michaels Fellowship, 46 Herne Hill Page 20

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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? 2 Discussion with some of the parent service users accommodated indicated that the centre had communicated its expectation of the behaviour of visitors well. Examination of the relevant policy and discussion with the centre staff indicated that although service users were responsible for their own visitors, only staff were permitted to open the front door to visitors. Service Users were required to sign an agreement to acknowledge their responsibility in regard to the conduct of their visitors. The centre did not admit any visitor seeking to enter the centre who was clearly under the influence of drugs or alcohol. Visits took place in communal areas only, required ‘24 hour’ centre notification and were allowed between the hours of 12pm and 9pm. This information was clearly communicated to service users in the centres documentation.

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

Further work is required in the area of staff training in the use of ‘Safe Holding’ techniques, ‘De-escalation’ and also ‘Breakaway’ techniques.

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A recommendation is also made for the registered person to provide staff with

training in ‘breakaway’ techniques. Whilst it was evident that use of physical restraint was not routinely sanctioned, and had not been used the registered person must also ensure that the centre has a stated policy

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children, and the circumstances in which it may be used, which is consistent with any

relevant government guidance on approved methods of restraint.

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

balanced appropriately with the need to protect children. Key findings/Evidence Standard met? 3 Discussion with the centre staff and examination of policy in this difficult area indicated that an adequate balance between the need to respect the privacy of families with the need to protect the children had been achieved. The centre manager and service users with whom the inspector had contact confirmed that each service had a bedroom door key, and that staff knocked and sought verbal agreement before entering a bedroom. The sharing of information with appropriate agencies was clearly documented and understood by staff with whom the inspector had contact. CCTV (closed circuit television) was not used, although baby monitors were in use, and bedroom doors left open in the evenings during the initial days of a placement, whilst a ‘night-time’ risk assessment was completed. Centre staff expect bedroom doors to be kept open when the family is inside, but only during

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

the child’s waking hours, once the child is asleep the staff are happy for the bedroom door to be closed. The daily joint review of written recordings by staff enabled service users to see what had been written by staff who had completed various levels of observation and evaluations during the course of the day. The payphone was situated in the reception area. St Michaels Fellowship, 46 Herne Hill Page 21

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

progress. Key findings/Evidence Standard met? 3 The inspector read the centres ‘Complaints’ procedure and ‘Complaints leaflet’ and was pleased to note that options of who a complaint could be made to and the procedure to be followed were clearly documented, including the option of making a complaint directly to the CSCI (previously the NCSC). The investigation procedure met with the standard. The centres record of complaints was examined. The inspector noted that two complaints had been recorded and been dealt with appropriately. The centre has recently registered with the Commission, and introduced unannounced inspection visits under regulation 25 by the registered individual as a consequence. The existence and progress of complaints investigation had also been monitored in these monthly visits. The service users with whom the inspectors had contact were aware of how and who to make a complaint to and stated that they felt comfortable to so should the need arise.

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substantiated:

X St Michaels Fellowship, 46 Herne Hill Page 22

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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

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

staff). Key findings/Evidence Standard met? 3 There was evidence through discussion with the centre staff, and examination of centre documentation that routine links had been established with other agencies concerned with child protection, eg the placing authority, schools, hospitals, general practitioners and the centres health visitor and centre staff did not work in isolation from them. There were clear procedures in place for responding to allegations or suspicions of abuse, either by staff, or by parents, or by other children in the centre. The centre had a clear policy on ‘Child Protection’ and ‘Arrangements for protecting children accommodated on the unit’ were in place. Pre-inspection questionnaires completed by the centre manager indicated that Child Protection training provided by the local ACPC formed part of induction training for all staff members. The centre manager confirmed that the centre used staff from a reputable agency.

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

Agency guidelines were also available in the staff office as was a copy of the Local Area Child Protection Committee (ACPC) guidelines. St Michaels Fellowship, 46 Herne Hill Page 23

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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 The centres ‘Vulnerable Adults’ policy was examined. The statement has been written with reference to the Department of Health guidance ‘No Secrets’ 2000 and provided adequate information to enable staff to make decisions and take appropriate action. The centre provides a service for adult parents or carers who may have a learning disability. Examination of the pre-inspection questionnaire completed by the centre manager and personnel records indicated that staff had been employed who had experience of working with service users with a learning disability. Requirements and recommendations have been made under NMS.8 (National Minimum Standard) in regard to staff training in breakaway and safe restraint techniques. St Michaels Fellowship, 46 Herne Hill Page 24

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persons and appropriate authorities of the occurrence of significant events

in accordance with Regulation 26. Key findings/Evidence Standard met? 3 A record of notifications made was maintained in the centre. Pre-inspection surveys completed by placing authorities provided evidence that the centre had communicated significant events and changes well, enabling social workers to attend emergency meetings in between scheduled reviews as required. Procedures examined confirmed that centres written procedures offered sufficient guidance to staff to ensure that all relevant parties were notified of any significant events in accordance with Regulation 26.

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

Residential Family Centres Regulations 2002 in the last 12 months.

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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

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

• Serious illness or accident to a resident. X

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

• Serious outbreak of infectious disease. X

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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

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

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

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

• Absconding by a resident accommodated in the centre. X

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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, 46 Herne Hill Page 25

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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

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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.

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

receive the care and services they need. Key findings/Evidence Standard met? 2 Examination of the staffing information contained in the centres ‘Statement of Purpose’ and information supplied in the pre-inspection questionnaire completed by the centre manager confirmed that staff of with suitable training and experience had been employed to work in the centre. Staff duty rotas were examined. At the time of the inspection visit three families consisting of a total of three adults and four children were accommodated. The rota cover was found to be adequate and allowed for a considerable amount of handover discussion, shift preparation and administration. The centre manager was a qualified social worker (Dip/SW) and had suitable qualifications and work history to undertake the role. She had been in post since 2002. The deputy home manager, relatively new to the team in 2004, also had relevant experience of residential

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

management, working with families and working with service users with a learning disability. Staff had a variety of qualifications and experience appropriate to working in the family centre, including qualifications in psychology. Some staff were noted to be undertaking social work and systemic family therapy courses at the time of the inspection. Discussion with the centre manager indicated that appropriate courses in regard to the required NVQ qualifications were being researched. The registered person must ensure that the centre has a minimum of 80% of its care staff qualified at level 3 or equivalent in the caring of children and Young People NVQ from 2005.

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last 12 months:

St Michaels Fellowship, 46 Herne Hill Page 26

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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 Personnel records were examined. It was noted that some personnel records were incomplete and did not contain all information required by Schedule 2 of the Residential Family Centre Regulations 2002. It was noted that more recent staff appointments were in good order. All staff had satisfactory CRB checks on file.

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The registered person must ensure that all information required by Schedule 2 of the

Residential Family Centre Regulations are available in personnel records. Visitors who were not subject to police CRB checks were not allowed unsupervised access to private areas of the centre. St Michaels Fellowship, 46 Herne Hill Page 27

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

rests with the parents unless otherwise arranged. Key findings/Evidence Standard met? 3 Staffing levels were a minimum of one staff member on duty (at night). Rotas examined indicated that during the daytime up to four members of staff had been on duty on some days depending on the needs of the service users. Pre-inspection service user surveys indicated that the service users felt vulnerable when only one member of staff was on duty at night. A recommendation is made for the registered person to ensure that service users views in regards to staffing levels are discussed in house meetings. Staff cover varied depending on the levels of risk identified during the first two weeks of a new admission and was either one member of staff sleeping in at night or one waking staff and one sleeping staff. Staff were noted to be suitably experienced to complete these duties, although areas of training required have been identified elsewhere in this report. Conditions of registration

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

were in place in regard to staffing levels being agreed with the Commission in the event that the centre accommodates 5 families (discussion with the centre manager indicated that this would occur only rarely and would be the result of the partial time overlap of placements).

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

children and young people or equivalent qualification. X %

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(NB this is a requirement from 2005)

NO St Michaels Fellowship, 46 Herne Hill Page 28

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

and supported. Key findings/Evidence Standard met? 3 The dates of supervision meetings held were noted during examination of home documentation. Supervision meetings between the home managers and staff had been held monthly and a written record kept on file. Staff with keyworking responsibility or a particular issues to deal with were usually supervised more frequently (i.e. fortnightly). Staff with whom the inspector had contact 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. Written guidance and Policy was available in all areas identified in NMS 17.3. Staff had written job descriptions. External specialist guidance and support to staff was also in place in regard to group dynamics and team development. This guidance was provided in meeting forums and was scheduled on the duty rotas examined.

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

The inspector was pleased to note that the centre manager and team acknowledged the stress that the assessment had on both the staff and the service users. Confidential counselling was available for team members and could be accessed directly.

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

service. Key findings/Evidence Standard met? 2 Personal development plans were not in place. However pre-inspection questionnaire documentation and personnel records indicated that staff received a thorough six month induction training and were also provided with individually appropriate training opportunities in subsequent years. Personnel records and centre policy provided evidence that the organisation reviews staff performance during probationary employment periods. Although training was not available in all areas identified in RFC NMS 18.5.

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identified in NMS 18.5 (other areas of identified training need are the subject a

requirement and recommendation elsewhere in this report). St Michaels Fellowship, 46 Herne Hill Page 29

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The intended outcomes for the following set of standards are:

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

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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.

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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 large home is located close to local schools, leisure facilities, health services, public transport routes and shops. The home benefits from a large back garden, with outdoor play equipment, and was not noticeably different from any other home on the road. The premises were used for the business of the Residential family centre alone. The centre had appointed a Health and Safety representative from within the team. A ‘Health and Safety’ report, completed by the representative, was examined by the inspector. The report systematically identified hazards and repairs in each room of the centre.

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The registered person must ensure that action is taken to address any outstanding

issues identified in the Premises Health and Safety report of June 2004.

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The registered person must also audit the soft furnishings on premises to ensure that

they comply with the Furniture and Furnishings (Fire) (Safety) Regulations 1988. The centre was inspected by the Fire Safety Authorities in July 2004 and arrangements were found to be satisfactory. The centre had not been inspected by the Environmental Health Authority.

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The registered person must seek advice and centre inspection from the

environmental health authority. St Michaels Fellowship, 46 Herne Hill Page 30

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

individual needs and lifestyles. Key findings/Evidence Standard met? 2 During a tour of the premises the inspectors noted that not all bedrooms had sufficient furnishings, discussion with one service user indicated that a comfortable chair would be a welcome addition to the bedroom he was using. Each family has one bedroom, and an additional bedroom if necessary, depending on the size of the family group. The positioning and number of bathrooms and toilets was adequate. Over-ride devices were in place to allow access to bathrooms and toilets in an emergency. Staff had a separate toilet.

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list in NMS 20.2. Steps must then be taken to ensure that rooms are fully furnished as

per the minimum standard. Hot water temperatures were not thermostatically controlled at outlet or subject to regular recorded temperature checks.

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maintained at between 41 and 45 degrees centigrade at tap and other outlets

accessible to them. St Michaels Fellowship, 46 Herne Hill Page 31

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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 Staff on ‘sleeping in’ duty have the use of a self contained flat-let on the ground floor. Service Users have the use of a communal kitchen diner, lounge and playroom/resource room. High chairs for young children were available. A quiet lounge was available for keyworking and other meetings. The children’s playroom and adult resource room were undergoing re-organisation at the time of the inspection visit. An area had been set aside for smoking near a rear garden door. The rear garden was large. The laundry room was domestic in size, with adequate high useage machines. The property is leased from a housing association. There was a system in place for reporting repairs via the central St Michaels Fellowship office. St Michaels Fellowship, 46 Herne Hill Page 32

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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 During at tour of the premises and review of centre documentation the inspector noted that the centre staff were acting responsibly in regard to health and safety issues, appointing a team representative to monitor Health and Safety issues in the home. The ’health and safety’ report compiled, identified risks presented in each room. The Landlords Gas Boiler Safety Certificate was available and was dated 01/07/04. Emergency gas leak services had been responsibly summoned when a member of staff detected a smell of gas in the days before the inspection visit. The centre manager stated that one of the gas cooker controls had been found faulty. At the time of the inspection visit the repair was awaiting completion.

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The registered person must ensure that all gas appliances are safe (faulty

cooker/cooker control must be repaired).

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bought into the home by service users can be safety tested before or during

admission. A fire alarm system had been serviced regularly and drills undertaken with the required frequency. Fire procedures were communicated to each service user and staff member during induction and resettlement into the home. An inspection by fire safety authorities conducted in July 2004 found fire safety arrangements to be satisfactory. Environmental health authorities had not inspected the premises. Lockable medication cabinets were available in all bedrooms, and age appropriate safety aids provided, such as electrical socket covers, fire and stair guards were available as necessary. Discussion with the centre manager indicated that staff had not undertaken food hygiene training. This has been addressed in a requirement made under NMS 18. Requirements are also made in regard to thermostatic hot water control in NMS 20. Policy and procedure available in the centre was sufficient to respond to foreseeable crises.

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bought into the home by service users can be safety tested before or during

Service contracts were in place for servicing laundry equipment. An immediate requirement was issued on the day of the inspection in regard to missing window opening restrictors in one of the service users bedrooms. It is noted that the Commission was notified that remedial action had been taken promptly. The registered

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a child falling. All windows above ground level must be fitted with restricted opening

mechanisms. It was also noted that night staff on duty on the day of the inspection were unfamiliar with the large bundle of keys that they had access to and could not readily identify bedroom door keys should they need to do so in an emergency, whilst the circumstances of the night wake cover booked on that occasion were that of an emergency. The registered person must

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take steps to ensure that all staff including sessional staff can effectively use the

emergency systems and have knowledge of fire procedures in place at the home.

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A recommendation is also made to label the keys on the bundle carried by the shift

leader to enable individual keys to be identified in an emergency. St Michaels Fellowship, 46 Herne Hill Page 33

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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.

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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 residential family centre was one of a group of services operated by an independent charity, St Michael’s Fellowship, an organisation that has been operating for over a century. The centre manager had sufficient budget information to manage the home. Discussion during the inspection indicated that the centre had good relationships with neighbours in the local and wider community. Conditions applied as part of the centres registration had been complied with. A commitment to equal opportunities statement was in place. There was overall evidence that the registered persons had exercised effective leadership. St Michaels Fellowship, 46 Herne Hill Page 34

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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.

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

Key findings/Evidence Standard met? 2 All records required were available for inspection. Unannounced inspections of the premises and services by the registered individuals under Regulation 25 of the Residential Family Centres Regulations 2002 had been recently introduced. Copies of these visit reports have been supplied to the Commission (CSCI/Southwark) and were noted to cover all areas identified in RFC NMS 24.5. Discussion with the home manager indicated that a specific visitors book was not maintained, as the centre required notice of a visit 24 hours in advance. The names of visitors had been recorded in the daily diary and on daily log sheets, but not in a specific log.

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The registered person must ensure that a specific record of all visitors is maintained

in the centre. St Michaels Fellowship, 46 Herne Hill Page 35

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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 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 accommodated at the time of the inspection visit. 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. St Michaels Fellowship, 46 Herne Hill Page 36

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Date

St Michaels Fellowship, 46 Herne Hill Page 37

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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:

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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, 46 Herne Hill Page 38

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Action taken by the CSCI in response to provider comments:

Amendments to the report were necessary YES

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Action taken by the CSCI in response to provider comments:

Comments were received from the provider YES

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Action taken by the CSCI in response to provider comments:

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

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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

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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.

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report:

Action plan was received at the point of publication YES

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report:

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

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report:

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

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report:

Provider has declined to provide an action plan NO

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Public reports

It should be noted that all CSCI inspection reports are public documents. St Michaels Fellowship, 46 Herne Hill Page 39

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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.

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St Michaels Fellowship, 46 Herne Hill / 7th July 2004

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

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St Michaels Fellowship, 46 Herne Hill / 7th July 2004

Telephone: 020 7979 2000 Fax: 020 7979 2111

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St Michaels Fellowship, 46 Herne Hill / 7th July 2004

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

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St Michaels Fellowship, 46 Herne Hill / 7th July 2004

S0000047194.V166807.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

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St Michaels Fellowship, 46 Herne Hill / 7th July 2004

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

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