Inspection on 01/08/06 for 2 Central Avenue

This inspection was carried out on 1st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Central Avenue 02/12/08

2 Central Avenue 18/12/07

2 Central Avenue 04/07/07

2 Central Avenue 05/12/05

2 Central Avenue 20/07/05

2 Central Avenue 01/02/05

2 Central Avenue 20/07/04

2 Central Avenue 12/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Central Avenue (2) 2 Central Avenue Billericay Essex CM12 0QZ Lead Inspector Mrs Bernadette Little Key Inspection 1st August 2006 10:00 Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Central Avenue (2) Address 2 Central Avenue Billericay Essex CM12 0QZ 01277 655394 01277 655394 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Estuary Housing Association Limited Mr Russell Neil Groves Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Central Avenue is a Care Home for four service users with Learning Disabilities. It is situated between Billericay and Stock. The home is registered for service users up to and over 65 years of age. The premises comprise of a bungalow with four single bedrooms, a bathroom, a lounge, kitchen/dining room and a small conservatory area with access to a large garden to the rear of the premises. There is also a garage for the homes minibus. The laundry area is situated in a room behind the garage. The premises are in keeping with the local community. The weekly fee is £1,474.89p as advised by the registered manager at the site visit. Additional charges/costs are incurred by residents relating to chiropody, purchase of personal toiletries, bedroom furniture. The above information was detailed within the home’s documentation, for example the resident’s statement of terms and conditions and the Service Users Guide. This did not include information that residents are charged for incontinence pads or that one resident is being charged for the additional television services that are used by all residents in the lounge. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of Central Avenue and 7 ½ hours were spent at the home. Three residents were living at the home at the time of the inspection and one resident was in hospital long-term. Two residents, three staff and the registered manager were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for one resident were case tracked. A pre-inspection questionnaire had been received from the home prior to the site visit and information from this document was also used to inform this report. As it had been completed while the registered manager was on sick leave, the registered manager added some information to it at the site visit. Discussion of the inspection findings took place with the registered manager throughout the inspection and guidance and advice was given. Completed questionnaires were received from four users of the service prior to the site visit. The registered manager agreed that they were to some degree meaningless as the residents would have been unable to understand, and therefore actually answer the questions asked. Requests for comments/information was sent to three GPs, a visiting chiropodist and a relative. One response in total was received. What the service does well: What has improved since the last inspection? The laundry area is much improved and had been redecorated and refitted. A residents bedroom had been decorated, as had other parts of the home. The service user guide had been updated and was in the home. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 6 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. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provides prospective residents with information to enable to make an informed choice about the home. Residents had been provided with contracts. EVIDENCE: Current and updated versions of the Statement of Purpose and Service User Guide were available in home. It was noted positively that the Service User Guide also contained additional information in pictorial format showing what services the fees included and the additional personal things that residents had to pay for. This did not include any reference to leisure activities or holidays. The manager advised that a DVD version of the Service User Guide had been produced. A record had been kept that residents’ agreement had been sought before the filming took place. There had been no new admissions to Central Avenue for some time. Estuary have a clear policy and procedure that identifies that a full assessment will be undertaken, including input from other professionals as necessary. Trial visits are considered an integral part of this process. The admissions information did not identify that prospective residents or their representatives would be provided with a copy of the Statement of Purpose or Service User Guide as part of the process. The registered manager advised that as has he has not been party to an admission, he did not know at what point this would occur. It Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 9 is recommended that this information could be included within the admissions procedure. Pictorial format statement of terms and conditions were available on resident files. This referred residents for additional information to the Service User Guide. License agreements were also on file. It was noted positively that residents had signed their statement of terms and conditions and it was recorded that the manager had spent time with the resident explaining the content. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The care management documentation contained ample information to ensure consistency of care for residents. EVIDENCE: One of the three resident care plans was sampled. It contained a large number of working practice instructions, which covered all aspects of the residents needs, including medication, finance and end of life care. These provided detailed instructions on the residents care needs and clearly took into account the residents preferences and wishes. The care plan was supported by a number of risk assessments. The file evidenced recent review of both the care plan and the risk assessments. This led to two additional current care plan goals and actions for this resident, both of which related to increasing opportunities for lifestyle activities. It was noted positively that the resident had had the care plan explained to them, and this was recorded on a pictorial format and signed by the resident. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 11 Care notes were written regularly. It is recommended that staff do not use terminology that infantilises the resident, for example the resident was naughty. There was no risk assessment in place regarding residents leaving the premises unsupervised. Estuarys missing person procedure indicates that a risk assessment on this issue should be undertaken as routine practice for all residents. It was discussed with the manager that this would be appropriate at Central Avenue in light of the resident abilities and freedom of movement. New files were in the process of being completed with a person centred aspect and using pictorial format. The registered manager advised that it will take time for staff and key workers to sit with residents and work through them. Discussion with staff and observation of practice indicated that residents were involved in everyday decisions on life in the home, taking their individual abilities into account. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents accessed the community. The home is aware of the need to increase social and leisure opportunities for residents. Residents were provided with a varied nutritional diet. EVIDENCE: Comments from residents, and inspection of the record of activities and expenditure records demonstrated that residents to go out into the community for example to restaurants, pubs, shopping, the bank etc. Discussions with staff confirmed that residents are taken out for a meal about once a fortnight. Occasionally individual residents also attended shows, for example at the Cliffs Pavilion, and these are based on residents’ preferences and personalities. The registered manager explained that these sorts of leisure activities had not continued to be organised while he has been on leave. The registered manager advised that all seven permanent staff are qualified to drive the home’s minibus, but that there are occasions where there are no permanent staff on duty, and this can restrict residents opportunities for Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 13 outings and social events. He also advised that he is aware that they could do better in this aspect of residents’ lives. The manager confirmed that the previous hours allocated to the provision of community access workers had been removed, and that while residents’ day centres have closed, there has been no additional funding or support to the home to provide additional services and opportunities for residents. However, he advised that funding has been agreed to convert the homes garage and covered area into something like a mini Day Centre/craft area for the residents, and to which residents from other Estuary homes could also occasionally be invited to attend. The registered manager advised that he is awaiting confirmation from Estuary of the allocated budget for each residents holiday this year. It is understood that the practice will continue that the resident is allocated an amount to pay for the holiday, but must be able personally to fund the staff to escort and support them. Where a resident is unable to finance this, or where it is more appropriate for some residents, day trips will be planned instead. Records indicated that relatives/advocates are encouraged and supported by the home to maintain relationships with the residents. Where necessary, the registered manager will provide transport for relatives to visit the home and so they can attend the residents/relatives meetings. Comments from a resident and inspection of records indicate that residents get up and go to bed at appropriate times to suit themselves. Observation of practice showed that residents chose whether to be alone or in company. Two of the residents spent a great deal of time going in and out of the office where they clearly felt comfortable, while the other resident chose not to join in. Residents participated in practical tasks in the home, for example laying the table, taking the milk in, opening the door, raking the grass etc. It was discussed with the manager that the care plans could better show the choices that are offered to residents, for example in choosing their clothes each day. A resident spoken with was able to say what they were going to have for dinner that night and the next night. Two of the residents were able to indicate that they liked the food and had had a nice lunch. Residents were seen to be offered a choice of drinks and snacks, and to feel confident to make choices and express likes and dislikes. Staff and residents were just leaving to go shopping at the start of the site visit and returned with ample food stocks. The menu is planned each week with resident input and known likes and dislikes. Staff confirmed that an alternative would be offered should a resident decide they did not want a specific meal. Records indicated a cooked breakfast each weekend, a weekly take-away meal as well as meals out. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Resident health-care needs were effectively managed and supported. The home operates an efficient medication system but evidence of training for all staff involved in medication practice would better protect residents. EVIDENCE: The registered manager advised that all residents are mobile and none require any assistance with mobility or transfers. The care plan indicated where the resident needed prompting and support for personal hygiene, and identified that same gender staff undertook intimate personal care. The home has a key worker system that staff were clear about. The service user’s health-care needs, both in relation to physical and mental well-being were identified within the care plan. Records indicated routine health care screenings, as well as regular checks with, for example, the dentist. Residents were able to indicate, through photographs, that they knew who the chiropodist was. They were also able to demonstrate that he looked after their feet and fingernails. The registered manager confirmed and evidence was seen on file that annual multidisciplinary reviews had been undertaken in the past. The registered manager advised that the social worker allocated to residents has now left. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 15 They have not been advised of a replacement and reviews are due. Discussion took place about contacting either the team leader or service manager in the relevant social service office to request dates for resident reviews. No omissions were noted on the medication recording record (MAR). A record was maintained of medications received and returned. A record was maintained of sample staff signatures. None of the residents at home at this time received PRN (as required) medications or the invasive procedure of rectal diazepam. A copy of Estuarys medication policies and procedures were readily available, and known to staff. A copy of the Royal Pharmaceutical Society guidelines for the Administration and Control of Medications in Care Homes was also readily available. Discussion with staff and records confirmed that staff had arranged for a resident to have liquid medications, where this change was appropriate. The manager advised that staff undertake initial medication training and then have an annual competence assessment undertaken by himself. Competence assessments were seen to be in place for some agency staff but not for others who administer medication. The registered manager confirmed that he had no evidence that those staff had had appropriate medication training. This needs to be addressed. Care plans showed that thought had been given to residents’ end of life care and practices. An advocate had provided their views on much of what should happen in relation to the resident whose care filed was tracked. In relation to another resident, relatives were consulted and would act for the resident. One resident is currently in hospital due to deterioration in their health. Discussion with staff, comments from residents and inspection of the records show that the residents who remain at home have been taken by staff to visit the resident in hospital, who is a person that they have lived with for a number of the of years. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The home had endeavoured to support residents to be aware of how to raise any concerns. Arrangements for protecting residents were generally satisfactory but would be supported by better access to information. EVIDENCE: The registered manager confirmed that no complaints had been received by the home to the last inspection. The Commission for Social Care Inspection had received no complaints about the home. The home has a service user-friendly version of the complaints procedure, which contained large print and a pictorial format. A copy of this was seen on the back of each residents bedroom door. It was also included in the Service User Guide. Estuary also has a formal complaints procedure. The manager provided two customer feedback records received since the last inspection. One of these stated that the person was pleased with the care received by their relative at the home, and also that the manager took time to explain things to them. The other came from another relative who expressed a view that staff at Central Avenue have, for many years, always worked hard to make sure that the resident was always well cared for and healthy. The registered manager advised that he would report any concerns regarding protection of vulnerable adults (POVA) to the service manager. When provided with a scenario, he could have been clearer on who needed to be informed, and advice was provided. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 17 Estuary has its own policy and procedure on POVA. The home had a copy of the local POVA protocol/guidelines from another area funding authority. A copy of the local POVA protocol/guidelines and booklets for staff were not available in the home. Advice was provided on accessing these. For some time, Estuary has been recommended in inspection reports to produce a user-friendly version of their whistleblowing policy and procedure for staff. This is still awaited. At the time of this inspection there was no whistleblowing policy or procedure available in the home. A copy of the original version was sourced on the intranet by the registered manager and printed off for inclusion in the homes policies and procedures folder. Not all staff had had up-to-date training on POVA. A member of staff advised that they had been due to undertake POVA training last week but that it had been cancelled at the last minute without a further date yet being arranged. Another member of staff had training planned for the week following the site visit. It was not possible to inspect and fully audit all records relating to resident’s money. Records were available of resident’s weekly expenditure and a group rolling float. Receipts were sent Estuary each week and therefore could not be confirmed. A log is kept in a bound book that explains what each transaction/ withdrawal is actually used for, for each resident. Records were not available of residents bank/savings accounts. Records sampled indicated that residents money was being used appropriately, with the exceptions relating to the television installation and residents purchasing their incontinence pads, which is inappropriate. Inappropriate use of residents’ money at Central Avenue has been raised previously with the registered person who advised they had introduced appropriate policies and procedures to protect residents. This clearly needs to be reviewed. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Central Avenue provided the residents with homely and comfortable surroundings, but some aspects of safety, cleanliness and maintenance need attention to ensure the best living environment for residents. EVIDENCE: Overall the premises presented as pleasant and homely. Maintenance issues needed attention, for example a curtain rail falling off the wall or no working bulbs in the central light in the lounge. Residents had ample communal space, including a lounge, a large kitchen dining room and a pleasant garden. All residents have a single bedroom, none of which are ensuite. It was noted positively that the laundry area has now been refurbished, with cleanable wall and floor surfaces and hand washing sink. Additionally one resident’s bedroom, the lounge and the office have been decorated recently. An appropriate lock had been fitted to the bathroom door that allowed residents to have privacy, and respected their dignity. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 19 The manager advised that none of the current residents needed any specialist equipment. Residents have the choice of a bath or a shower. The registered manager said that no residents have a bath and they all choose to have a shower. Records demonstrated that bath water had been tested regularly as being between 35°C and 36°C, which is barely warm. The registered manager confirmed that records of checks of the shower temperature water or cleaning of the shower heads had not been undertaken for some time. Resident bedrooms were personalised and individually decorated. A key was hung on the back of each residents door. In one case the key did not work in the lock. Additionally it was brought to the managers attention that the type of lock being used may not be safe in an emergency if locked from the inside. One resident confirmed that they liked their bedroom. Residents chose to spend time in their room, which gave an indication that they felt comfortable there. The managers attention was drawn to areas that were in need of a good clean, for example items in residents bedrooms, walls and skirting boards or the interior of the fridge. The managers attention was also drawn to areas in the home where hazardous items (C0SHH) were not safely stored and were within residents reach. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The lack of records showing safe recruitment practices and appropriate training for agency staff, and in some cases permanent staff, did not best protect residents. EVIDENCE: Job descriptions were seen on the staff files sampled. A member of staff on duty advised that they had very recently restarted NVQ training. The home is running with the equivalent of almost 2 full time staff vacancies. The manager advised that he has had recruitment training recently and a plan is in place to allow managers in an area to advertise, shortlist, interview and appoint staff, where this was previously undertaken by Estuary. To cover the vacancies and annual leave etc the home uses a number of agency staff each week, some of whom are regulars. They have been no new staff appointed at the home since the last inspection. At that time it was identified that there was no evidence of identity on file for one staff member. It was disappointing to note that this had not been addressed. Where a photograph is required to be kept of each staff member, unclear photocopies were all that were available on some files. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 21 The registered manager provided original copies of CRB checks for all permanent staff that had recently been redone. There was no evidence from the agency for each agency staff member that confirmed appropriate references and checks had been completed and the date that this had occurred. Agency staff training records contained a CRB number but no supporting evidence. Agency staff training records did not always contain confirmation from the agency (by use of a stamp) that the training had occurred. The records identified to date the training needed to be updated. Many of these had expired and there was no record as to whether staff had completed additional or updated training. Training records for permanent staff were contained in a training plan and an individual programme for each person. The training plan identified dates that training should occur. As identified with staff during the inspection, the training on POVA recorded on the training plan had not actually occurred. The registered manager confirmed that his update on moving and handling had been outstanding for almost a year, but was booked for later this month. He also confirmed that health and safety training, which included fire safety and infection control, was out of date for several staff. The registered manager demonstrated that he had e-mailed Estuary on a number of issues to advise that of dates were due or overdue and requesting training for his staff. He also advised that evidence of training, what once it is completed, is not always sent from head office, who organise the training. Current certificates were seen on some files, including for a few regular agency staff. A schedule of dates for supervision was available. The registered manager advised that supervision had not occurred regularly while he had been absent and that appraisals had not been completed in time. Consent was obtained from a member of staff to view their supervision records and this and discussion confirmed that supervision had otherwise been undertaken regularly during the year. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents appear to have a good relationship with the registered manager. Some aspects of the homes management, both in-house and corporate, are positive and benefit residents. Others aspects, for example the safety and welfare of residents and staff are not always promoted and protected. The home has devised and implemented a quality assurance system to seek residents and their representatives’ views. EVIDENCE: The registered manager had been on leave for at least 12 weeks very recently. The registered provider had failed to notify the Commission as required by Regulation of this event and the arrangements made for the management of the home in his absence. The registered manager stated that he had completed the NVQ4 and two of the four units of the Registered Managers Award, which is ongoing. He was aware Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 23 of current developments for example in relation to changes to CSCI inspections, judgments and KLORA, and was advised of recent changes, and further planned changes to the Regulations. Staff spoken with confirmed that the manager is approachable and that they can go to him for support and advice. Residents also freely approached the manager, interacted and spent time with him in the office. A resident from Central Avenue is participating in Estuarys Quality Network, as a social secretary, supported by a member of staff. The report from Estuarys previous Quality Network identified that leisure, work and fulfilling activities were areas that the homes needed to improve on. The registered manager confirmed that he does not undertake any audits, for example of the medication or other systems and practices in the home to reassure himself of every day quality monitoring. Residents meetings are held and relatives invited. A satisfaction survey was available that had been undertaken with residents last year. It was in pictorial format, which is positive, with yes and no answers and signed by all residents. The manager was recommended to include more reference to activities and that questions on targeted areas could be more specific to gain more accurate information of residents’ views. The monthly visits and reports, required to be undertaken by the person registered and sent to the Commission, have been sporadic. Records sampled and found to be satisfactory included accident records, roster, record of visitors and menus. Other records have been referred to in this report. The homes own expenditure record confirmed that they pay for take-away meals and formal meals out, which is positive. Estuary have corporate policies and procedures in place and a folder containing these was available at the home. Information in the pre-inspection questionnaire indicated that these are reviewed. An accident procedure could not be found. As stated earlier, the whistleblowing procedure was recommended to be reviewed and written in plain language. Current inspection certificates were available in relation to the gas, electrical fixed wiring, fire equipment, emergency lighting and fire alarm. Risk assessments were available in relation to safe working practices. Records were kept of checks within the home of fire doors and other fire equipment. Fire drills were recorded as occurring regularly which is positive. The registered manager was advised to audit the fire drill records to ensure that all staff are included regularly in drills. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 24 A fire risk assessment had been completed in February 2006. This identified a need for fire doors no longer to be wedged open and to be fitted with acoustic door closures and for additional and emergency lighting points to be fitted. This had not been actioned. Risk assessments were not in place relating to the temperature of the hot water in both the kitchen and laundry. The registered manager was also recommended to consider a risk assessment in relation to access to the washing powder etc in the laundry, particularly as one resident is known to eat inappropriate items. A current certificate of liability insurance was displayed. From observations during this inspection and discussion with the manager and staff there was nothing to indicate that the home is anything other than financially viable. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 3 2 2 3 1 3 Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 26 YES 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 YA12 Regulation 16(2)(m) Requirement The person registered must ensure that residents are enabled to engage in age and peer appropriate activities. Outstanding from the last inspection. The person registered must ensure that residents are enabled to engage in community activities. Outstanding from the last inspection. The person registered must ensure that residents are enabled to engage in appropriate social and leisure activities. Outstanding from the last inspection. Evidence of medication training/competence assessments must be available for all staff involved in medication systems, once completed. Outstanding from the last Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 27 Timescale for action 01/08/06 2. YA13 16(2)(m) 01/08/06 3. YA14 16(2)(m) 01/08/06 4. YA20 13(2) 01/08/06 inspection 5. YA23 13(6) The person registered must 01/08/06 ensure that residents’ money is not used inappropriately. The Commission require a separate written confirmation from Estuary of the actions taken in relation to this issue. The registered provider must 01/08/06 ensure of the home is well maintained and repairs carried out in a timely manner. I The registered provider must ensure at the home is maintained free from hazards for residents this refers to save storage of COSHH items. The person registered must ensure the safety of service users. This refers to have an appropriate and safe locks on bedroom doors. The person registered must ensure the home is clean. The person registered must ensure staff employed at the home have the skills to meet residents needs. This refers only to ensuring staff on duty are able to drive residents to their appropriate activities or to provide alternative safe arrangements. Outstanding from the last inspection. 11. YA34 18,19, Sch 2 &4 The person registered must ensure that Criminal Record Bureau checks are carried out for all agency staff working in the home. (Previous timescales of Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 28 6. YA24 23(2)(d) 7. YA24 13(4)(a) 01/08/06 8. YA26 13(4)(a) 01/08/06 9. 10. YA30 YA33 23(2)(d) 18(1)a,b & c 01/08/06 01/08/06 01/08/06 01/02/05, 20/07/05 and 05/12/05 not met). 12. YA34 Sch 2 & 4 The person registered must provide evidence of the identity of all staff working at the care home. Outstanding from the last inspection 13. YA35 18(1) The registered person must ensure that all staff have been provided with training appropriate to the work they are to perform. This includes evidence of up-to-date training for agency staff. The person registered must notify the Commission of those issues identified by Regulation. 01/08/06 01/08/06 14. YA37 38(2) 01/08/06 15. YA39 24 16. YA42 23(4) The registered person must 01/08/06 ensure that visits are undertaken monthly, as required by Regulation, and copies made available in the home and sent to the Commission. The registered person must 01/09/06 ensure the safety of service users by implementing the findings of the fire risk assessment. This refers to not awaiting open fire doors, fitting them with acoustic automatic closures and the fitting of additional emergency lighting points. Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 29 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 YA2 Good Practice Recommendations The procedure for admissions should identify the stage at which prospective residents and ordered their representatives are provided with a copy of the Service User Guide and Statement of Purpose. The care plan should more clearly demonstrate the choices offered to residents. Staff should be more careful of the language used in relation to residents and show respect for them as adults. Risk assessments are recommended to be undertaken in relation to residents leaving the premises unsupervised. The manager is recommended to access local protocols and guidelines in relation to POVA. He is also recommended to ensure that both he and all staff are provided with the opportunity to read these. The whistleblowing policy and procedure should be written in clearer language. Outstanding from the last inspection. A planned programme of maintenance for all works within the home should be available for inspection. Outstanding from the last inspection. The bath water temperature should be set at a safe level and be warm enough for residents to use should they choose to do so. 50 of care staff should achieve NVQ training Outstanding from the last inspection The registered manager to achieve NVQ4 in Care and Management. Outstanding from the last inspection The registered person should introduce a procedure for DS0000018072.V304138.R01.S.doc Version 5.2 Page 30 2. 3. 4. 6. YA6 YA6 YA9 YA23 7. YA23 8. YA24 9. YA27 10. 11. YA32 YA37 12. YA40 Central Avenue (2) staff to follow in the event of accidents. 13. YA40 The registered manager is recommended to audit the fire drill record to ensure that all staff are included on a regular basis. The registered manager is recommended to undertake risk assessment in relation to the hot water in the kitchen and laundry and also resident access to the washing powder. 14. YA40 Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Central Avenue (2) DS0000018072.V304138.R01.S.doc Version 5.2 Page 32 - 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. 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