Setting

Road

Announced Inspection 29th June 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 Michael`s Fellowship, 84 Herne Hill Road Page 1

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Name of establishment

St Michael`s Fellowship, 84 Herne Hill Road

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Do additional conditions of registration

Date of last inspection NA St Michael`s Fellowship, 84 Herne Hill Road Page 2 Date of Inspection Visit 29th June 2004 ID Code

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Name of Establishment Representative at

the time of inspection Ms Helen Abbotts St Michael`s Fellowship, 84 Herne Hill Road Page 3

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D.3. Provider’s agreement

St Michael`s Fellowship, 84 Herne Hill Road 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 Michael`s Fellowship, 84 Herne Hill Road.

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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 Michael`s Fellowship, 84 Herne Hill Road Page 5 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. ‘84’, is a residential family centre run by St Michael’s. It is an establishment that provides accommodation, assessment and support for children and their parents. Emphasis has been placed on offering a service to families where there is parental mental ill health. 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

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INSPECTION VISITS

‘parenting skills’ are assessed by the staff team. The centre also seeks to make external counselling available for some of the parents, if considered necessary. The stated aims include: ‘ informing the professional network around a family of the needs of the children; the capacities of the family to meet those needs; and identify factors, which either promote or isolate children from experiences, which will give them the opportunity to grow and develop as any other healthy child”. 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. A variety of models for ‘interventions with families’ are used in the centre, the staff aiming to “understand the childhood experiences of parents of being parented, in order to understand their values, beliefs and practices”. St Michael`s Fellowship, 84 Herne Hill Road 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 Michael`s Fellowship, 84 Herne Hill Road 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. Any more urgent issues are identified in the report.

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INSPECTOR’S SUMMARY

The manager had been registered individually with the Commission and satisfactory CRB (police) checks were available for all staff. The home managers and staff were co-operative with the inspection process and made documents required by regulation available for inspection, providing copies of documents on request. The centre was well managed, with dedicated and professional staff.

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Standards 1 – 2 (Purpose and Function)

Both standards were assessed; One standard was exceeded and the other standard was fully met. The home manager is commended for the quality of information on the centre’s purpose and function provided 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 line with requirements.

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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.

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Standards 14 – 18 (Staffing)

Five standards were assessed; One was fully met and four were almost met. Whilst staff were noted to be suitably qualified and experienced, action has been required to ensure compliance with NVQ qualification requirement for 2005 and some 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 fire and environmental health inspection, audit of furnishings available, safety measures and repairs. St Michael`s Fellowship, 84 Herne Hill Road Page 8

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Standards 23 – 25 (Organisation and Management)

Three standards were assessed; All three were fully met. The centre had maintained good records as required by regulation and was being managed effectively. St Michael`s Fellowship, 84 Herne Hill Road Page 9 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 St Michael`s Fellowship, 84 Herne Hill Road Page 10

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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 at any one time shall not exceed five.

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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

No notification had been received. A fifth family had not been accommodated.

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Date

St Michael`s Fellowship, 84 Herne Hill Road Page 11

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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

1 11(5)(6) RFC8 RFC8 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) RFC14 RFC 14 The registered person must ensure that the centre has a minimum of 80% of its care staff qualified at level NVQ 3 or equivalent in the caring of children and Young People from 2005.

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STATUTORY REQUIREMENTS

Sch 2 RFC15 RFC 15 The registered person must ensure that all information required by Schedule 2 of the Residential Family Centre Regulations are available in personnel records. 29/10/04

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STATUTORY REQUIREMENTS

5 17(5)(a) RFC17 RFC 17 The registered person must ensure that action points are recorded in written staff supervision meeting minutes and supervision agendas include all areas listed in NMS 17.7. 29/10/04

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STATUTORY REQUIREMENTS

6 17(5)(a) RFC18 RFC 18 The registered person must ensure that training is provided for staff in all areas identified in NMS 18.5. 31/12/04 St Michael`s Fellowship, 84 Herne Hill Road Page 12 7 21 RFC19 RFC 19 The registered person must ensure that action is taken to address any outstanding issues identified in the Premises Health and Safety report of January 2004. 30/09/04

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STATUTORY REQUIREMENTS

8 22 RFC19 RFC 19 The registered person must ensure that recommendations made by the LFCDA (Fire Safety Authorities) are actioned. 30/09/04

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STATUTORY REQUIREMENTS

RFC19 RFC 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. 30/09/04

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STATUTORY REQUIREMENTS

RFC19 RFC 19 The registered person must seek advice and centre inspection from the environmental health authority. 29/10/04

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STATUTORY REQUIREMENTS

11 21(20(k) RFC19 RFC 19 The registered person must ensure that the faulty and noisy ventilation unit in the first floor toilet is repaired. 16/09/04

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STATUTORY REQUIREMENTS

12 21(2)(d) RFC20 RFC 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 and adequately decorated. 26/11/04

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STATUTORY REQUIREMENTS

11(4)(a) RFC20 RFC 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. 24/09/04

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STATUTORY REQUIREMENTS

10(1)(a) 11(4)(a) RFC22 RFC 22 The registered person must ensure that electrical appliances in use at the home are safety tested annually. 24/09/04

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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 St Michael`s Fellowship, 84 Herne Hill Road Page 13 RFC8 RFC 8 RFC 12 The registered person should provide staff with training in ‘breakaway’ techniques.

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GOOD PRACTICE RECOMMENDATIONS FROM THIS INSPECTION

RFC22 RFC 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. * 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 Michael`s Fellowship, 84 Herne Hill Road Page 14

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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 NO ‘Tracking’ care and support YES Group discussion with service users NO Group discussion with staff NO 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 YES Tour of Premises YES Inspection of policies YES

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PART B INSPECTION METHODS & FINDINGS

Date of Inspection 29/06/04 Time of Inspection 10.00 Duration Of Inspection (hrs) 9.00 Number of Inspector Days 1.2

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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 Michael`s Fellowship, 84 Herne Hill Road Page 15

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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? 4 A copy of the homes written ‘Statement of Purpose’ was examined by the inspector. 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 February 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. The required ‘Service Users Guide’ was also supplied and examined. The guide contained a summary of the information contained in the ‘Statement of Purpose’. Both documents were very well presented, with good quality photographs and easily accessible information on the overall structure of the organisation. Discussion with the staff and service users indicated that the documents had been distributed and read as

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

appropriate. Fees quoted below were based on a residential placement for one family, consisting of one parent and one child sharing one large bedroom. Each additional family member and any additional staffing hours required would incur an additional fee. Rent of £68.00 per week was also additional. All additional charges were clearly identified. Extra care had been taken to fully explain the Values and Beliefs of St Michaels in a ‘Statement of Values and Beliefs’ in the Statement of Purpose and to provide a useful local map, public transport information and lots of local contacts that would be of considerable assistance to new service users in the ‘Service Users Guide’.

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(if applicable):

Minimum £ 2080.0 Maximum £ X St Michael`s Fellowship, 84 Herne Hill Road Page 16

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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 made to 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. An ‘agreement’ examined by the inspector had been signed by the adult service user, social worker and home manager, and selection meeting minutes were available for the service user

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

accommodated at the time of the inspection. The homes expectations of how time would be spent in the home and expectations of behaviour were clearly laid out in the Service Users Guide 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. St Michael`s Fellowship, 84 Herne Hill Road Page 17

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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 file contained the placement plan, which was monitored by a designated key worker within the team. The key worker met with the parent service user 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 plan examined contained information required by Regulation 13 of the Residential Family Centres Regulations 2002 and NMS 3 (National Minimum Standard), and had been subject to regular review with evidence of service user involvement. Review notes had been signed by the service user, the social worker and the home manager.

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inspection:

X St Michael`s Fellowship, 84 Herne Hill Road Page 18

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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 The registered manager described the special arrangements made with a local GP practice, to ensure that service users accommodated have access to doctors, regular immunisation programmes and health screening. One local hospital provided an emergency dental clinic and an accident and emergency department. Another local specialist psychiatric hospital also provided a 24 hour emergency clinic. The home manger stated that ‘Looked after Children’ medicals had been conducted by the local authority paediatrician and that a full range of health services had been accessed via GP referral, including psychiatry. The Service Users Guide contained contact information for local opticians, dentists and hospitals. 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

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

emergency situation. The service user accommodated had been risk assessed as being able to self –medicate. 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 the service user. At the end of every day the service users was able to read the noted 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 and dated by the service user. The unit copies were maintained chronologically and were stored confidentially and securely in the staff office. St Michael`s Fellowship, 84 Herne Hill Road Page 19

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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 some occasions during times when only one family had been in residence, or on the rare occasions of service users ill health. However, regular key work meetings had been held and had provided a forum for views on these occasions. Children were also able to attend the house meetings. The home manager stated that the centre had accommodated service users for whom English was not the first language, the services of an interpreter had been used on these occasions, although she acknowledged that this had proved less that satisfactory and she was reluctant to accept admissions that relied on communication by ‘interpreter only’. She stated that the centre also had access to a pool of sessional staff who

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

could be employed for specific pieces of work with service users if they had a particular skill or cultural background. Placement plans, placement plan reviews and daily recording procedures also provided service users with opportunities to have their views noted. The input of service users own CPN’s (Community Psychiatric Nurses) and of the centre’s visiting psychiatrist are also sought over key decisions. Key workers and the centres art therapist had also established a relationship with the local school where school aged children could be educated for the duration of the placement, and communicated ‘back and forth’ with teaching staff using a ‘communications book’. St Michael`s Fellowship, 84 Herne Hill Road Page 20

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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 to adhere to them. ‘House rules’ were specified and signed agreement sought as part of placement planning. The home manager stated that interpreters and advocates had also been involved in communication and negotiating as required. Older children were subject to an age-appropriate ‘behaviour agreement’ with their written agreement. St Michael`s Fellowship, 84 Herne Hill Road Page 21

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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 Standards of acceptable conduct are promoted throughout the centres information documentation. The ‘House Rules’, ‘Statement of Purpose’ and ‘Service Users Guide’ layout consequences clearly. Signed written agreement is sought as part of admissions procedures during which there are meetings where service users have opportunity to discuss and become familiar with the standards of conduct acceptable within the centre. The centre manager stated that the team had recently undertaken the production of a team ‘Values and Boundaries’ statement in addition to the ‘Equal Opportunities’ statement. The home also had an ‘Unacceptable Behaviour’ and ‘Visitors’ policy in place. Examination of the relevant policy and discussion with the centre manager indicated that although service users were responsible for their own visitors, only staff were permitted to

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

open the front door to visitors, they then completed the ‘Visitors book’ and monitored any comings and goings to the centre. 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 or if they were known to be Schedule 1 offenders. Visits took place in downstairs communal areas only. The pre-inspection documentation completed by the centre manager indicated that physical restraint was not used in the centre. Discussion with the centre manager indicated that restraint would only be considered in an extreme ‘duty of care’ situation, she acknowledged that further work was 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 sanctioned, and the children accommodated were usually very young, the registered person must also ensure that the

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is consistent with any relevant government guidance on approved methods of

restraint. St Michael`s Fellowship, 84 Herne Hill Road Page 22

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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 manager 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 verbally agreement before entering a bedroom. Further discussion with the centre manager and review of policy on child protection issues confirmed that staff have a master key that allow them access to all bedrooms in an emergency. The sharing of information with appropriate agencies was clearly documented and understood by staff with whom the inspector had contact. CCTV was not used, although baby monitors were used in the initial days of a placement to whilst a ‘night-time’ risk

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

assessment is completed. The centre manager stated that individual names were not used during the professional advice sessions held every two weeks with a consultant psychiatrist. The daily joint review of recordings enables service users to see what has been written by staff who have completed various levels of observation and evaluations during the course of the day. The payphone is situated in a recessed lobby in the main reception area. St Michael`s Fellowship, 84 Herne Hill Road Page 23

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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 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 this standard. The centres record of complaints was examined. The inspector noted that no complaints had been recorded. 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 would also be monitored during these monthly visits. The service users with whom the inspector had contact was aware of how and who to make a complaint to and stated that she felt comfortable to so should the need arise.

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substantiated:

X St Michael`s Fellowship, 84 Herne Hill Road Page 24

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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, another was undertaking advanced child protection training.

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

The centre manager confirmed that the centre used staff from a reputable agency and insisted on obtaining copies of relevant CRB checks before they commenced any sessional work in the centre. Agency guidelines were also available in the staff office as was a copy of the Local Area Child Protection Committee (ACPC) guidelines.

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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 adults who may have a mental illness. There was evidence that the centre staff received the necessary support and guidance from psychiatric services to enable them to respond appropriately to any verbal aggression. Breakaway techniques training to enable staff to respond safely to any physical aggression has been recommended in NMS 8, and training in ‘De-escalation’ techniques has been required under NMS.8. St Michael`s Fellowship, 84 Herne Hill Road Page 25

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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 The inspector examined the centres written record of notifications made. Notifications had been made to the relevant authorities within the required 24 hour timescale. 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. Pre- inspection placing authority questionnaires received by the Commission indicated that centre staff have always offered to meet with the placing authority social workers after any event or incident.

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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. 1

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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 Michael`s Fellowship, 84 Herne Hill Road Page 26

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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 only one adult and one child 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 has suitable qualifications and work history to undertake the role and has been in post since 2000. The Statement of Purpose examined contained her full employment history showing more than 20 years of family, child and adolescent experience. Pre-inspection questionnaires and personnel records examined indicated that there was one

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

full time staff vacancy. Both managers were qualified Social workers (Dip SW). One other member of staff had undertaken to begin the Dip SW course, supported by the organisation. Another member of staff had been studying Systemic Family Therapy for two tears. All staff had relevant qualifications and were qualified First Aiders. 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 Michael`s Fellowship, 84 Herne Hill Road Page 27

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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. Staff were responsible for recording the names of visitors to the home. The Visitors book was examined and found to be in regular use. Staff spoken with confirmed that they had received copies of the GSCC Code Of Conduct and Practice. St Michael`s Fellowship, 84 Herne Hill Road Page 28

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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? 2 Staffing levels were a minimum of one staff member on duty. 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 user and the number of individuals accommodated at the time. Night cover varied depending on the levels of risk identified during the first two weeks of a new admission and was either one or two members 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. Discussion with the centre manager indicated that she was investigating a suitable management training course to meet the required standard coming into place in 2005. Conditions of registration are in place in regard to staffing levels being agreed with the

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

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. 0 %

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(NB this is a requirement from 2005)

NO St Michael`s Fellowship, 84 Herne Hill Road Page 29

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

and supported. Key findings/Evidence Standard met? 2 Pre-inspection staff surveys received by the Commission indicated that staff viewed the level of support and supervision to range from “OK, but need more” to “quite good”. Discussion with staff indicated that supervisions were scheduled every two weeks, although written records and had not always been maintained. 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. Pre-inspection staff surveys and staff interviews indicated that staff were aware of how to support service users and their representatives to make complaints. Staff had written job descriptions. External specialist guidance and support to staff was also in place in regard to group

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

dynamics, team development and psychiatric consultancy. This guidance was provided in meeting forums and was scheduled on the duty rotas examined. Annual appraisals and personal development plans were not in place for all staff, although discussion with the centre manager indicated that she herself had been appraised and was in the process of setting up annual appraisals for the rest of the team. 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 both service users and team members had access to a qualified and police checked masseur every two weeks if they chose.

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

service. Key findings/Evidence Standard met? 2 Personal development plans were not in place. However pre-inspection questionnaire documentation, staff surveys and staff interviews 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. Training was not available in all areas identified in 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 Michael`s Fellowship, 84 Herne Hill Road Page 30

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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 centre had been undergoing some redecoration work and rooms were attractively decorated. 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 centre was locked and a security alarm enabled between the hours of 10pm and 7am for security, visiting rules were in place and visitors allowed in the downstairs communal areas between the hours of 12pm and 9pm. The premises are 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 supplied to the Commission. 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 January 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 had been inspected by the Fire Safety Authorities in July 2004.

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The registered person must ensure that recommendations made by the LFCDA (Fire

Authorities) are actioned (replacement of office door glass). 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. The inspector noted that an extractor in one of the service users toilets was faulty or clogged, and was making a loud noise.

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The registered person must ensure that the faulty and noisy ventilation unit in the first

floor toilet is repaired. St Michael`s Fellowship, 84 Herne Hill Road Page 31

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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 The centre has a total of five bedrooms. One extra bedroom was being used for storage. During a tour of the premises the centre manager indicated that two of the bedrooms requiring redecoration would not be occupied until the redecoration had been completed. 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. The one bedroom occupied at the time of the inspection was adequately furnished.

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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 and adequately decorated. Colour changing bath thermostats had been provided for the use of parents bathing their own children. However 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 Michael`s Fellowship, 84 Herne Hill Road Page 32

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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 The communal lounge adjacent to the kitchen and dining area were of good size and adequately furnished. The playroom was accessed via the dining area and was well stocked with toys, furnished with settees and a wall mural. The playroom was well organised and used for the play work undertaken by specialised centre staff and general playing space. All communal areas were noted to be clean and well furnished. Parents cook for themselves and their own children, as a consequence the domestic sized communal kitchen has five refrigerators and two shared freezers. The dining area was of a sufficient size for a family to eat together. High chairs were available. There was also a number of more private rooms where ‘key work’ and other meetings could be held. An area had been set aside for smoking near a garden door. The rear garden was

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

large and well stocked with outdoor toys. The laundry room was domestic in size, with adequate machines. Recent renewals work had left ‘footprints’ in the décor. Discussion with the centre manager indicated that re-decoration was planned. Staff sleeping-in quarters were not part of the centres communal rooms compliment. The property is leased from a housing association. There was a system in place for reporting repairs to the maintenance office of London and Quadrant housing association, who own the property. A problem with the ventilation of one of the toilets is subject to a requirement elsewhere in this report. St Michael`s Fellowship, 84 Herne Hill Road Page 33

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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 report compiled identified risks presented in each room. A fire risk assessment had also been undertaken. The Landlords Gas Boiler Safety Certificate was available and was dated 20/05/04. Small electrical appliances had not been safety tested annually. The inspector noted that as placements in the centre seldom exceed 12 weeks, and service users were encouraged to bring their own small electrical appliances with them, annual small appliance testing would be inadequate. A requirement and recommendation are made.

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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 has required the replacement of the glass in the office door panel. Environmental health inspection is required. Lockable medication cabinets were available in all bedrooms, and age appropriate safety aids provided, such as electrical socket covers, fire and stair guards. 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 and a faulty toilet under NMS 20. Policy and procedure available in the centre was sufficient to respond to foreseeable crises. Service contracts were in place for servicing laundry equipment.

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

St Michael`s Fellowship, 84 Herne Hill Road Page 34

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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. The centre had been in operation for four years. A copy of the 2004/2005 budget for the centre was supplied to the Commission. The budget headings indicated the registered person had sufficient information in regard to running the service. A pre-inspection questionnaire completed by the centre manager and 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 evidence that the registered persons had exercised effective leadership. St Michael`s Fellowship, 84 Herne Hill Road Page 35

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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? 3 All records listed above were available for inspection during the inspection (personnel records were examined on a subsequent visit) other than annual staff appraisals (discussion indicated an annual appraisal system was in the process of being introduced). Discussion with centre manager and documents seen indicated that due to the intense nature of the assessments undertaken at the centre, regular input was in place from specialist services linked with the centre itself and to individual service users. Service audits were also completed as part of the admissions procedures. 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 must be sent to the Commission (CSCI/Southwark). St Michael`s Fellowship, 84 Herne Hill Road Page 36

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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 Michael`s Fellowship, 84 Herne Hill Road Page 37

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Date

St Michael`s Fellowship, 84 Herne Hill Road Page 38

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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 Michael`s Fellowship, 84 Herne Hill Road Page 39

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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 Michael`s Fellowship, 84 Herne Hill Road Page 40

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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 Michael`s Fellowship, 84 Herne Hill Road / 29th June 2004

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

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St Michael`s Fellowship, 84 Herne Hill Road / 29th June 2004

Telephone: 020 7979 2000 Fax: 020 7979 2111

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St Michael`s Fellowship, 84 Herne Hill Road / 29th June 2004

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

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St Michael`s Fellowship, 84 Herne Hill Road / 29th June 2004

S0000047199.V164372.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 Michael`s Fellowship, 84 Herne Hill Road / 29th June 2004

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

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