CARE HOME ADULTS 18-65
11 ALLENBY ROAD Maidenhead Berkshire SL6 9BF Lead Inspector
Steve Webb Unannounced 12 September 2005 @ 10:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 11 Allenby Road Address Maidenhead Berkshire SL6 9BF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 5699131 Owl Housing Limited Mrs Barbara Humphrey Care Home 6 Category(ies) of Learning Disability LD registration, with number of places 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 21/04/05 Brief Description of the Service: The service is operated by Owl Housing Limited, and is registered to provide accommodation and care for six service users between the ages of eighteen and sixty five, who have a learning disability. Most of the service users also have associated physical disabilities. The current service users all moved in together from the same hospital and have lived at the home since 1996. The accommodation is provided in a purspose-built, single storey unit in a residential area of Maidenhead. The home is staffed 24 hours a day. A new manager has been registered. There is disabled access to all relevant areas of the building and each service user has their own bedroom. The property has a small landscaped garden, with a level patio area and some raised beds, and is within easy reach of local transport links, shops and leisure facilities. The home has appropriate links with local day centres and health professionals.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out between 10.15am and 4.15pm on 12/9/05. The inspection included examination of records, policies and procedures, discussion with the manager and staff, and a tour of the building. The inspector also had lunch with service users and spent some time with the group afterwards. This was a very positive inspection overall, with all of the previous requirements having been addressed since the last inspection, and a number of ongoing improvements having been made to the environment, and the proportion of permanent staff in post. What the service does well: What has improved since the last inspection?
Individual bedrooms are being equipped with a wide range of appropriate sensory equipment to meet the needs of individuals. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 6 The service is able to guarantee that female service users have their personal care needs met by female staff, and will soon be able to rota shifts with both male and female staff at all times, once pending appointments are processed. Improvements have been made in the medication management system and a system of double signatories for each administration is now in place. Since the last inspection, there have been ongoing improvements to the physical environment and in the availability of specialist equipment necessary to effectively meet the needs of service users. The provision of the new overhead hoists is particularly beneficial. There are also ongoing plans for full internal and exterior redecoration, and other works, which will further enhance the environment. The recruitment of additional permanent and bank staff will enhance the consistency and continuity of care available and the development of a permanent staff team. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 1 and 2 were addressed at the previous inspection, and a requirement to ensure that up-to-date preadmission assessment and risk assessment formats were available had since been addressed. EVIDENCE: 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 Service users are consulted, where possible on some aspects of the day-to-day operation of the home, though there is room for improvement in areas such as quality assurance. (See Standard 39). EVIDENCE: The limitations on service users level of communication and understanding limit their ability to be involved in the day to day running of the home and areas like policy development. However, one service user attended part of the interview/assessment process for the organisation’s new assistant director. New staff visit the unit before their appointment is confirmed, where their interaction with service users is observed and evaluated. Service users are also asked their opinions of prospective staff as part of this process. Service users are involved to varying degrees in the planning of menus, where possible using images from cookery books etc. The staff also plan menus, activities etc. based on their long-term knowledge of the likes and dislikes of individuals. One serviced user did take part in a meeting during the planning of the new Mencap club facilities.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 10 At present the views of service users are not sought, where possible as part of the organisation’s quality assurance process, which remains an internal process. This is addressed later under Standard 39. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The rights of service users are respected, and they are enabled to make choices in their daily lives. The level of service user involvement in meal related tasks will be enhanced if the plans to combine the kitchen and dining room into a single space, go ahead. EVIDENCE: The daily routines of the house allow for residents to do things of their choosing, although where something such as a day centre session is booked, they are encouraged to attend. Should their mood indicate that participation might not be advisable they can opt out, however, and this occurred for one service user on the day of inspection. Four of the service users did attend sessions at the day centre during the inspection. All bar one of the service users has four, two-hour sessions at day centre per week. One service user attends Henley College for art sessions. Bedrooms are being equipped with a range of sensory equipment to meet individual needs, and provide stimulation. Bedrooms also had hi fi’s and other equipment to entertain service users when they chose to be in their rooms.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 12 Service users can move freely about the building and grounds. There was a very good level of interaction between staff and service users observed during the inspection, and staff were good at involving the service users in conversation and day-to-day activities. The current level of service-user involvement in meal preparation and other kitchen tasks is limited, at least partly by the size and layout of the kitchen, and the associated safety issues. The proposal to combine the kitchen and dining rooms as one space, would increase the levels of both active and passive involvement in these aspects of daily routines. Personal care support for female service users is always provided by female staff, but the male service users are not currently always supported by male staff. The unit are likely to be able to ensure this soon, if current applicants are confirmed in post. Service user’s mail is opened in front of them, and read to them. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Though none of the service users is able to manage their own medication, their welfare is protected by the home’s procedures and appropriate staff training. EVIDENCE: None of the current service users is able to manage medication for themselves. All medication is retained by the home and administered by staff. All of the staff receive medication training from a pharmacist, (six having had this training since the last inspection), and the medication system has been improved through the instigation of double signatories for each administration. Staff do not commence administration of medication until they have received the training and also completed an in-house assessment by another unit manager within the service. MAR sheets were appropriately completed including the quantities of medication coming into the unit, and there was a separate log for PRN (as required) medication. The home had not had a recent pharmacist inspection and the manager planned to invite them to visit. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The views of users and other parties would be addressed via the complaints procedure, though there had been no recent complaints. Service users are protected from abuse through the home’s policies and procedures and the upcoming staff training on POVA, (the Protection Of Vulnerable Adults). EVIDENCE: There had been no new complaints recorded since the last inspection, though one person had recorded a compliment regarding the noticeable improvements to the physical environment since the new manager came into post. The home has an organisational vulnerable adults protection procedure and whistle-blowing procedure; and a copy of the local multi-agency vulnerable adults procedure was also present in the home. The staff are scheduled to attend POVA training later in the month. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Service users live in a comfortable, safe and homely environment, which has been, and continues to be, further improved. The planned combining of the kitchen and dining room into a single space should offer further benefits. The home is clean and hygienic. EVIDENCE: The communal areas were pleasant and homely, although the décor was beginning to deteriorate in some areas. The entire unit, inside and outside, is reportedly scheduled for redecoration during this financial year. Since the last inspection, two bedrooms have had new carpets fitted, and the hallway, lounge and office have also been re-carpeted. One bathroom has been fitted with new flooring; and one bathroom, a toilet and two bedrooms have had individual hoists fitted to the pre-existing over-head tracking to facilitate ease of transfer of the service users. One further shower/toilet also has the over-head tracking present, and would benefit from the fitting of a hoist to enable the option of the shower to be made available to more service users.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 16 The plans to combine the existing kitchen and separate dining room into one open-plan area are still in discussion. It would be very beneficial for this work to be completed to enable service users to take part in food preparation more readily, both as observers and participants. The current kitchen is rather too small to facilitate this, especially for service users in specialised wheelchairs. It is suggested that some photos of the service users and of their holidays or other outings might be framed and placed on the walls. The home was found to be in a clean and hygienic condition, free of unpleasant odours. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 The degree to which service users are protected by the home’s recruitment procedure, may be compromised if written references are not always obtained. Copies of required staff recruitment records must be retained in the unit for inspection. The needs of service users are met by appropriately trained staff, who have access to a comprehensive training and development programme. EVIDENCE: Two new full-time staff and four bank staff had been recruited to the team since the last inspection. All prospective staff visit the unit and their interactions with service users are monitored. Where service users are able, their opinions are sought as well. Further permanent appointments were said to be awaiting recruitment checks to be completed. Inspection of the required recruitment records indicated that not all of the required records were available on site as required under regulation 17. None of the references for the two new employees was available, and the CRB for one was not available, (to enable its inspection as permitted under CRB guidance); though copies of ID, (driving license/passport), home office papers and permits etc. were present.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 18 The missing items were copied to the unit by fax on request. However, the faxed references contained no indication of whether the references had been telephone verified or not. (Regulation 19), and one appeared to be a telephone reference only. Copies of all of the required recruitment records must be retained confidentially in the unit at all times. All references must be in writing, (Regulation 19, (Schedule 2), and Standard 34), and whether or not they were further verified, should be recorded within the available recruitment records. Notwithstanding the above it is a positive development that a number of new permanent staff have been appointed, as this will maximise consistency and continuity of care for the service users, and should enable the new manager to develop a real sense of permanency in the team. The manager provided a copy of the staff training schedule, to date for 2005, which indicated a comprehensive range of appropriate training and induction being made available to staff. The manager had booked a team building/communication day in November, and the new staff were undertaking their induction. The inspector was also shown the Owl Housing staff development programme, which appeared to be thorough; taking staff through induction, core training, LDAF (if new to the client group), and then NVQ at the appropriate level. Three staff have almost completed their NVQ level 3 and three more are due to start in October. The manager has almost completed her Level 4 and Registered Manager’s Award, (RMA). 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 The views of service users and other parties are not systematically sought as part of a quality assurance programme, at present. There is a need to develop a system to take account of the views of service users and relevant others. EVIDENCE: Owl Housing have a quarterly system of quality monitoring, but this does not, as yet, include seeking the views of service users, relatives, advocates and other interested parties, and does not therefore constitute a quality assurance programme as required. A quality assurance system needs to be devised, which includes seeking the views of relevant parties, and their incorporation in a summary report, which is subsequently made available to those parties and the CSCI. The manager reported that she was seeking a suitable format from another unit to adapt for use. All of the requirements from the last inspection had been actioned.
11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x 2 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x 3 x Standard No 31 32 33 34 35 36 Score x x x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
11 ALLENBY ROAD Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 34 Regulation 17 Requirement Copies of the recruitment records specified in Schedule 4 of Regulation 17 must be retained securely in the unit for inspection. All references must be obtained in writing and a record made of whether they were subject to verification. A quality assurance system must be devised, which includes obtaining the views of service users and other relevant parties, amd the production of a summary report of findings. Timescale for action 17/11/05 2. 34 19 17/11/05 3. 39 24 17/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 34 Good Practice Recommendations Copies of the CRB for each staff member should be retained securely, on-site until they have been seen by the inspector. 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 11 ALLENBY ROAD H52-H01 S46683 11 Allenby Road V247314 120905 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
