Inspection on 15/07/08 for 36 Shooters Avenue

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

36 Shooters Avenue 16/05/07

36 Shooters Avenue 19/01/07

36 Shooters Avenue 25/10/05

36 Shooters Avenue 31/05/05

36 Shooters Avenue 07/01/05

36 Shooters Avenue 19/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 36 Shooters Avenue 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG Lead Inspector Judith Brindle Key Unannounced Inspection 15th July 2008 09:00 36 Shooters Avenue DS0000017578.V365937.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 36 Shooters Avenue DS0000017578.V365937.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. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 36 Shooters Avenue Address 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG 020 8907 8270 020 8427 0458 QSCC1@bt.conig.com 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) Quality Family -Based Community Care Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 16th May 2007 Date of last inspection Brief Description of the Service: 36 Shooters Avenue is a care home providing personal care and accommodation for three people who have a learning disability. The home is owned and run by Quality Family-Based Community Care (QFBCC), a local private and independent care service provider. The home has 24-hour staffing, including one staff member sleeping-over at night. It has been operating since 2001. The home is located within a residential area of Kenton, part of the London Borough of Harrow. The home is close to local shops and bus links, whilst tube links are approximately twenty minutes’ walk away. Parking restrictions do not apply on the road outside the home. The home’s drive can accommodate two vehicles. The house is semi detached and is in keeping with other houses in the locality. Two of the bedrooms are on the first floor, with the other on the ground floor. All are single rooms, fully furnished, with built-in washbasins. The home has one bathroom with an adapted shower facility. There are toilet facilities on each floor. Access to the first floor is by the stairs only. The home has a kitchen, a lounge, and a large rear garden that is shared with the next-door care home, also operated by QFCC. Information/documentation about the service provided by the care home is available. Information about the fees is available from the owner of the care home. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience adequate quality outcomes. The unannounced key inspection took place throughout a day in July 2008. There were no vacancies at the time of the inspection. Two inspectors carried out the inspection. We were pleased to meet, all the people living in the care home. The acting manager was present during all of the inspection. A senior staff member (reviewing officer) was present for part of the inspection. Prior to this unannounced key inspection the Commission for Social Care Inspection (CSCI) sent an Annual Quality Assurance Assessment (AQAA) document to the home to be completed. The AQAA is a self- assessment of the service provided by the care home, and is carried out by the owner and/or manager. It focuses on the quality of the service, and how well outcomes for people using the service are being met by the care home. It also includes information about plans for improvement, and it gives us some numerical information about the service. This document was not completed prior to the inspection. A senior staff member informed us that this documentation had not been received by the home due to problems with the provider’s email system. An AQAA had been completed in 2007 (this was available for inspection). This was discussed with the acting manager and the senior staff member (reviewing officer). The senior staff member said during the inspection that she would supply the CSCI with this completed document. This AQAA document was promptly supplied to the Commission for Social Care Inspection (CSCI) following the key inspection. The acting manager completed this document. Reference to some aspects of this AQAA record will be documented in this report. A number of surveys were supplied to the care home prior to this inspection. These requested feedback from people using the service, relatives/significant others, health and social care professionals, and staff. At the time of writing this report, we had received two completed surveys from people using the service. Other information received by the Commission for Social Care Inspection (CSCI) about the service since the previous key inspection was also looked at. This included what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Also assessed was relevant information from other organisations, and from what other people might have told us about the care home. We spoke with all of the people using the service, one of whom has significant sensory and communication needs, and another who responded to questions 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 6 with gestures and sounds. Observation was a useful and significant tool used during this inspection. Documentation inspected included, all the care plans of people using the service, risk assessments, staff training, and staff personnel records, and some policies and procedures. The inspection included a tour of the premises. Assessment as to whether the requirements from the previous inspection had been met also took place during this inspection. 28 National Minimum Standards for Adults, including Key Standards, were inspected during this inspection. The inspector thanks the people living in the care home, the acting manager and the reviewing officer, for their assistance in the inspection process. What the service does well: What has improved since the last inspection? Since the previous key inspection and prior to a random inspection, which was carried out in February 2008 several areas of the home had improved. These include meeting maintenance requirements, improving quality assurance systems, and providing better meals. But since the random inspection evidence of significant improvement, (generally due to lack of comprehensive record keeping in some areas) was lacking. Documentation supplied to the Commission following the inspection told us that management staff had plans to make several improvements to the service. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 7 Following the inspection documentation supplied to the Commission for Social Care Inspection informed us that staff had received some moving and handling training. 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. The summary of this inspection report can be made available in other formats on request. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 8 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 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information needed to choose a home that will meet their needs. It needs to be evident that people using the service always have their individual aspirations and needs assessed prior to moving into the care home, which makes certain that the home knows about the person, and the support that they need. People using the service have a contract, statement of terms and conditions. EVIDENCE: The care home has documentation, and information about the service provided by the care home. The service user guide is in written/pictorial format. This guide includes detail about the care home, and information about the fees, and of what to do if a person using the service has a complaint. Feedback from two resident surveys informed us that they received enough information about the home before they moved in. Copies of the service user guide were located in the resident’s care plan files. The statement of purpose should be reviewed and updated to include the new contact details of the Commission for Social Care Inspection. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 10 The service user guide could be produced in a format (such as audio, and/or Braille) to help it be more accessible to a person using the service who has significant communication needs. The care home has an admissions procedure/policy. Staff and the statement of purpose documentation, informed us that admissions are not made to the home until a full needs assessment has been undertaken. Since the previous inspection a resident who lived in another of the organisation’s care homes (located next door), has moved into the care home. Staff told us that this resident knew the home well, as he/she had frequently spent time in the home with the people living there, prior to his/her admission. The acting manager told us about the transition process of him/her being admitted to the home. This included an assessment of his/her needs, several visits to the home including overnight stays. A record of this assessment was not available for inspection. It needs to be evident that the person’s needs and aspirations have been assessed prior to the person moving into 36 Shooters Avenue. There was some evidence that his/her care plan had been reviewed, but there should be a comprehensive record of the prospective resident’s transition/admission process prior to moving into the care home. At the time of the inspection he/she was having a trial period in the home prior to confirmation of his/her permanent placement. When asked, he/she indicated to us that he/she was happy living in the home. Observation informed us that he /she knew the other residents, and the staff well, liked their bedroom, and moved freely within the home. Persons living in the home had a recorded statement of terms and conditions in their care plan file. Fees charged (in regard to what the resident pays) are recorded in the service user guide. Placement agreements between the local authority, the service and the resident were filed in the care plan files. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service each have a plan of care. There could be some development in the care plans to ensure that it is evident that they are working documents, and that care plan information be more accessible to people using the service. People using the service are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. EVIDENCE: Each person using the service has a plan of care. All the care plans were inspected. The care plans included profile of each resident, with some description of their varied needs, including cultural and religious needs, dietary needs, behaviour and social needs. The care plans are individualised, and include some recorded resident’s objectives (needs), and action to meet these agreed goals. Each person using the service had signed these plans. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 12 There was some evidence (dates of documentation was not always clear) that the care plans are reviewed (generally six monthly), and that a social worker, relatives, the resident, and staff are invited to these care plan review meetings. There could be development with regard to the format of some of the care plans, to make the information more accessible to those residents who have difficulty reading and/or particular sensory needs. The care plans could indicate more understanding, and assessment of the strands of diversity, including gender, age, and sexual orientation/sexuality. AQAA information provided following the inspection told us that there plans to give residents the opportunity to receive education in ‘sex awareness’, and that referrals for this were being discussed. Though there was some evidence that care plans are reviewed. It was not always evident that agreed resident’s goals had been regularly reviewed to reflect not only changing needs of the residents but documenting the action taken to achieve their long and short term goals/objectives. An example of this was that a resident had an objective to have access to some kitchen equipment to aid her/him with meeting their sensory needs. It was not clear from the records what action had been taken to achieve this goal. There should be more evidence that the care plans are up to date ‘working’ tools that all resident’s changes in need and goals (short term as well as long term), are clearly documented. The last record of residents ‘daily’ progress documentation was on the 6th June 2008. The registered person should ensure that these records and the care plans are more regularly up dated to show that people using the service are receiving the care and the support that they need each day. The acting manager confirmed that these records would be completed. Feedback from completed surveys from people using the service confirmed that they felt that they could make decisions about what to do each day. The home has a resident’s financial procedure. The people using the service receive varying levels of support from staff with the management of their monies. One resident has their finances managed by a solicitor. Another manages his/her own money with minimal support from staff. We viewed residents’ financial records, including bank statements. These were up to date and included records of expenditure and bank withdrawals. The acting manager told us that she carries out ongoing monitoring of each person’s finances, and that there are also monthly checks of these records. Records, and staff confirmed that the acting manager ensures that ‘spending money’ is accessible to all people using the service. The acting manager is not acting as an appointee for the people using the service. There was evidence from records, and staff that each resident has risks that have been assessed. These included possible health and safety risks, such as kitchen safety and road safety. It was not evident from much of the documentation inspected, that these had been reviewed regularly. Some of 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 13 the risk assessments were not dated. There needs to be evidence that all assessed risk to residents are regularly reviewed, and so up dated to meet changing needs of people using the service, and to ensure that risk to their safety is minimal. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13, 14,15, 16 and 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle, and are supported to develop their life skills. The visiting arrangements are flexible and meet the needs of visitors and residents, so as to ensure that residents have the opportunity to develop and maintain important relationships. People using the service are supported to make choices. Meals provided are varied, and people who use the services can choose what to eat, but records of food eaten need to be available. EVIDENCE: Records confirmed that each resident has an activity programme. It was not evident from one programme dated November 2007 that this had been updated to remove information about activities that the resident no longer participated in. Residents’ individual activity programmes should be reviewed 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 15 and updated as and when there are changes in the leisure pursuits that are chosen and participated in by each person using the service. Feedback from completed surveys from people using the service confirmed that they felt that they could make decisions about what to do each day. Two residents attended day resource centres during the inspection. A resident told us that he/she attends the day centre for three days a week and he/she spoke of enjoying the facility. He/she told us about friends that also attended the day resource centres. Another resident indicated that he/she enjoyed attending a day resource centre. Another resident did some knitting and reading during the inspection. One of the people using the service is visually impaired and we were told that literature in Braille is provided for this person regularly. This resident was seen to be reading documentation in Braille during the inspection. A staff member told us that a number of activities are available to people using the service. At weekends we were told, residents regularly go out to restaurants for meals. The acting manager told us that she had recently accompanied the residents for a meal at a local Chinese restaurant, which they all seemed to enjoy. A resident regularly attends an Irish club. It was not clear due to the lack of recent ‘daily’ records the number and variety of activities that residents had actually participated in (see previous section). AQAA information told us that there were plans to support a resident in accessing more opportunities to meet more friends, and that there were plans for residents to have an annual holiday of their choice. During the inspection people using the service were observed to move around the care home freely, and chose whether to be on his or her own, or to socialise with others. A person using the service spoke of being involved in household duties. These duties include, tidying their own bedroom, assisting in the laundering of their own clothes, and washing dishes. A resident spoke of tidying his bedroom, and of sometimes participating in making snacks and meals. Residents were observed to clear their breakfast crockery, and cutlery following breakfast. Staff told us of the involvement that residents have in the preparation of their meals, and said that one resident often participates in peeling potatoes for meals. A person using the service told us about the contact that he had with his/her family. He/she spoke of having recently received a telephone call from a relative, and told us about this relative visiting him/her. We observed that residents use the transport facilities of dial a ride to access some community amenities 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 16 We were told that other activities that residents participate in include community based activities such as shopping, going to restaurants, and going to the local bank. Staff told us that a resident has some voluntary employment at a church. Records informed us that a resident had had a holiday in 2007. The home has a menu. Staff informed us that this menu is not in use, and residents are asked on a daily basis, what they wish to eat. If the menu is not being followed in the home it should be discarded as its information could be misleading to people using the service. AQAA information informed us that fresh food is provided to people using the service. Meals eaten by people using the service are not recorded. The registered person must ensure that all food eaten by residents is documented, to ensure that there is monitoring of healthy, and nutritious food being provided to people using the service. Also this information is needed for tracking what someone has eaten if a person or persons becomes unwell following eating a meal. AQAA information told us that recording of meals is planned. We observed people using the service having breakfast. Residents confirmed that they chose what to eat. Breakfast looked appetising, and was healthy consisting of wholemeal cereal, brown toast and fruit. Residents told us that they are happy with the food provided, and confirmed that fresh meals are cooked daily. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, but health records could be better. The principles of respect, dignity and privacy are put into practice. Systems are in place to ensure that medication is stored and administered safely to people using the service. EVIDENCE: Records informed us that residents receive care and treatment from the dentist, optician, chiropodist; last recorded visits were in 2007. It was not clear from the records inspected whether people had attended any appointments this year (see previous sections with regard to record keeping). AQAA information told us that people using the service ‘see their GP’s, chiropodists, and other healthcare support regularly’. Care plans indicated that the individual health and personal care needs of people using the service were assessed. Residents confirmed that they felt well. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 18 One resident was wearing glasses. We noted that the frames of these glasses were bent, and the lenses were not clean. The acting manager said that these were reading glasses, and that the resident did not need to wear them during the day. The registered person needs to ensure that the resident has an opportunity to attend an optician appointment for an up to date check up, and if needed to get the glasses repaired. Staff should assess whether resident’s need support with cleaning their glasses. Staff respected residents privacy, and dignity during the inspection, and were sensitive when supporting and assisting residents with meeting their needs. Residents told us, and indicated that they liked the staff. Residents freely approached staff, and interacted with them in a positive manner. The home has a medication policy. Medication is stored securely. All medication administration record sheets were in order. Records are maintained of disposal of medication. The acting manager told us that all staff administering medication to people using the service have received medication training from a pharmacist. Records inspected during the previous key inspection confirmed that staff receive an ‘in house’ assessment of their competency with regard to their knowledge and handling of medication prior to administrating it to people using the service. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to an effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The care home has a complaints policy, which includes timescales, and recording procedures. During the previous key inspection we noted that the care home has a copy of the complaints procedure in Braille, which a resident could access. The format of the written complaints procedure could be improved and developed (possibly include pictures, and/or audio format) to make it more accessible to residents who may have difficulty in reading. The home has a complaints record book. There were no complaints documented. It was recommended following the previous key inspection that that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and so that it is evident that any ‘concerns’ are responded to as required. It was not evident from records and from talking to the acting manager that this had commenced. The acting manager spoke of developing these records. AQAA information told us that the care home had ‘introduced a communication book between the day centre and our home to monitor and record resident’s behaviour’. Feedback from two resident surveys informed us that the residents know who to speak to if they are not happy, and that they know how to make a complaint. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 20 The care home has a safeguarding adults policy/procedure. Records and staff told us that staff had received safeguarding adults training, so that they knew what action that they need to take if there is an allegation or suspicion of abuse. There are procedures in place for ensuring that accidents/incidents are recorded and reported appropriately. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24, 26 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, warm, and comfortable, but some aspects of the décor could be improved. The premises are suitable for the care home’s stated purpose. Resident’s bedrooms, meet their individual needs, and are individually personalised. EVIDENCE: 36 Shooters Avenue is a semi-detached property located in Kenton close to Harrow. The doorbell was not working at the time of the inspection. Though there was a door knocker, the doorbell should be fixed. The acting manager told us that she would ensure that it was repaired. There is parking available for two vehicles on the forecourt of the property. The inspection included a tour of the premises. The forecourt/entrance area of the home looked unattractive, flowerbeds on the forecourt contained numerous 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 22 weeds, and the door mat should be replaced. The registered person should endeavour to improve the appearance of the front area of the home. This was discussed with the acting manager and the senior member of staff (reviewing officer). Potted plants could be an attractive feature, and something that residents might enjoy being involved in caring for. Some areas of the interior of the home could be ‘freshened up’, be more pleasing to people using the service. Paintwork on some skirting boards, and in bathrooms could be repainted to contribute in making the environment more attractive. The seats of the dining chairs should be cleaned. Areas of the home that are ‘dusty’, for example the bathroom lamp, and several ornaments in the sitting room could be cleaned. The stained stair carpet should be cleaned or replaced. The There is a large garden (shared by the next door care home that is owned by the provider) with raised vegetable beds. The garden was very ‘weedy’, and should be better maintained. This was discussed with the acting manager, and reviewing officer, who confirmed that they would review the environment with the residents, and make some changes for the better. AQAA documentation told us that improvements to the interior and exterior of the home were planned. The home has one bedroom on the ground floor and two located upstairs. A resident kindly showed us his/her bedroom. It was individually personalised. He/she indicated that he was happy with his bedroom. Other bedrooms looked similarly furnished, and included a variety of personal possessions. There was several items of equipment on the landing of the stairs, including some office equipment. If these items are not in use they should be removed. AQAA information told us that handrails and frames had been placed in the bathroom for use by a resident who has sensory needs. The laundering facilities are located away from the food preparation area in the home. Suitable hand washing facilities are located throughout the home. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment practices generally promote the safety and welfare of the clients. A staff development and training plan would assure clients that training supports the aims and objectives of the service and new legislative requirements. People using the service would benefit from staff being appropriately monitored and supervised. EVIDENCE: An up to date staff rota was displayed. The home has currently four staff employed. The acting manager confirmed that there was flexibility in staffing to meet the changing needs of the people who use the service, and to ensure that staffing rotas take into account the needs and routines of people using the service. Feedback from two resident surveys informed us that the care staff listen and act on what the people using the service say. Staff have varied qualifications, with one holding their National Vocational Qualification (NVQ) in Care level 2 and one working towards achieving her NVQ 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 24 Level 4 qualification. AQAA information told us that ‘75 of our staff team are trained in or are attending NVQ care courses’. We looked at all four staffing files during this inspection; all staff have an up to date enhanced Criminal Records Bureau check (a check to ascertain whether a prospective staff member has a criminal record), in place. We noted that three out of four staff doesn’t have the required two references in place. The review manager informed us that this is due to being a family run business and the three staff in question are family members, have worked in the home for several years, and all related to the responsible individual. The responsible person should obtain references for every body employed even if it is family; this is to ensure that there is evidence that people using the service are protected. None of the files assessed by us had a current training and development plan in place. The registered person must ensure that all staff have an up to date training and development plan and training analysis in place, to ensure it is evident that staff are adequately trained, and residents are supported by skilled staff. We found a number of certificates, with the majority of staff having attending Safeguarding adults, Health and Safety, Food Hygiene and First Aid training. One of the staff employed has only attended Food Hygiene training. We spoke to one member of staff who informed us that she did not receive any training since the last key inspection, which was in May 2007. We previously required for all staff to attend manual handling training. Due to the present needs of the people living at the home, none of the residents needs any support around their mobility; we discussed this with the reviewing officer. She agreed to ensure that all staff would promptly receive some refresher training/education in basic manual handling. Following the inspection the reviewing officer promptly supplied the Commission for Social Care Inspection with evidence that moving and handling training was planned and that each staff member had carried out a moving and handling assessment. The registered person needs to ensure that it is evident that all staff receive refresher statutory training (including safeguarding adults, manual Handling, food and hygiene, First Aid and health and safety training), to ensure that people using the service are protected and safe living in Shooters Avenue. It should be evident that all staff receive at least five paid training and development days (pro rata) per year to ensure that all people using the service are supported by qualified and skilled staff, and that resident’s needs can be met fully met by them. AQAA information told us that there were plans for staff to receive training in Makaton, so develop their skills in communicating with residents who have communication needs. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 25 We looked at supervision records during this inspection; none of the records looked at, had recent supervisions in place. Staff spoken to confirmed this, by not being able to tell they inspectors when they last had recorded staff supervision. Staff told us that they speak regularly to the proprietor, so receive informal staff supervision, but records of this contact was not available. The registered person shall ensure that persons working at the care home are appropriately supervised. Recorded staff supervision meetings should take place at least six times a year. We found two annual performance reviews in two different staffing files; this staff has been working with the organisation since before 2000. Staff should receive an annual appraisal to ensure that the progress of their knowledge and skills is monitored and developed so that quality care and support is provided to people using the service. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39, 41, and 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has some quality assurance systems, which ensures that a quality service is provided to people using the service. Record keeping could be better to ensure that it is evident that resident’s rights and best interests are safeguarded. So far as reasonably practicable the health, safety and welfare of people using the service is promoted and protected. EVIDENCE: The home does not have a registered manager. This was required following the previous key inspection. There is an acting manager who is registered for the now non-operational care home (owned by the same providers) located next door. The acting manager is supported by a senior member of staff 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 27 (reviewing officer). The acting manager told us during a previous inspection that she has achieved her National Vocational Qualification in Care Level 3 and an advanced course in Care Management. The acting manager told us that she had considered applying for manager registration with the Commission, but due to the probability of imminent changes to the service, possible changes to her employment, and the care home’s planned deregistration, she had decided that she would not go ahead with the process. The owners have applied to de-register this care home and have plans for the property to be a supported tenancy with care and support being provided by a domiciliary care agency (the process of registering this with the Commission for Social Care Inspection has commenced). The registered person needs to ensure that a manager is registered with the Commission for Social Care Inspection promptly if the decision is made to maintain the registration of 36 Shooters Avenue. It was evident that the acting manager has the necessary experience to run the home, and that she knows the residents very well, and that she works hard to provide them with the care and support that they need. But the acting manager and the reviewing officer are aware that there are significant areas (including record keeping and staff training) where the home needs to improve, particularly with regard to recording, staff training, and improving the attractiveness of the interior and exterior of the care home. Record keeping could be significantly better (see in other sections of the report) to ensure that it is evident that resident’s rights and best interests are safeguarded. The home has a quality assurance policy/procedure. Talking to staff and inspection of records confirmed that the home has some systems in place to improve and monitor the quality of the service provided to people using the service. It was not evident from records provided that an annual development plan of the service had been completed. AQAA information told us that people using the service have the opportunity to attend and participate in resident meetings. We were told by staff and AQAA documentation that the home provides stakeholders, (including social workers, GP’s and resident’s representatives) with feedback surveys to obtain their views of the quality of the service provided to people using the service. AQAA information told us that the care home ‘will introduce questionnaires for service users’, and ensure that these questionnaires are ‘clear and available in different formats according to their needs’. This should be actioned. Information from AQAA documentation told us that policies/procedures had been reviewed in 2006. The home has a health and safety policy, and risk assessment. No health and safety issues were noted during the inspection. AQAA information told us that the home does ‘ regular health and safety checks in the home’ Records confirmed that required service checks of gas and electrical systems in the home are carried out and are up to date. Fire safety systems are monitored closely. Regular fire drills take place. AQAA documentation told us 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 28 that the home would include a staff ‘training element in our records of fire drills’. Fridge/freezer temperatures are monitored. Hot water temperatures are also monitored. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 29 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X 2 3 X 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 30 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 YA2 Regulation 14 (1) Requirement There needs to be evidence that peoples needs are comprehensively assessed (with involvement from the person and/or their representative) by a suitably qualified/trained person prior to the prospective resident moving into the home. It needs to be evident that agreed resident’s goals are regularly reviewed to reflect not only changing needs of the residents but also the action taken to achieve their long and short term goals/objectives. There needs to be evidence that all assessed risk to residents is regularly reviewed and so up dated to ensure that any risk to people using the service is minimal. The registered person must ensure that all food eaten by residents is recorded. This would ensure that there is monitoring that healthy, and nutritious food is being provided to people using the service, and also is needed for tracking what someone has eaten if that DS0000017578.V365937.R01.S.doc Timescale for action 01/09/08 2 YA6 15(2)(b) 01/09/08 3 YA9 13(4) 01/09/08 4 YA17 16(2)(i) 17(2) Sched 4 (13) 01/09/08 36 Shooters Avenue Version 5.2 Page 31 5 YA19 6 YA35 7 YA35 8 YA36 9 YA39 10 YA37 11 YA41 person or persons becomes unwell following eating a meal. 12(1) The registered person needs to 13(1) ensure that a resident has an opportunity to attend an optician appointment for an up to date check up, and if needed to get their glasses repaired. 18(1)(c) The registered person must ensure that all staff have an up to date training and development plan and that there is training analysis in place, to ensure staff are adequately trained and skilled to provide support and care to people using the service. 18(1)(c)(i) The responsible person must ensure that all staff receive training appropriate to the work that they perform (including up to date statutory training), to ensure that it is evident that all residents are supported, safe and protected by qualified and skilled staff. 18(2) The registered person shall ensure that persons working at the care home are appropriately supervised. 24(1)(2) There needs to be evidence that the home has completed annual development plan of the service which provides evidence that the service provided to residents is reviewed/monitored at appropriate intervals, and that there are systems in place to improve and develop it. 8 Care The registered person needs to Standards ensure that a manager is Act part II registered with the Commission (11) for Social Care Inspection promptly if the decision is made to maintain the registration of 36 Shooters Avenue. 17(1)(2)(3) Record keeping needs to be DS0000017578.V365937.R01.S.doc 01/09/08 01/09/08 01/11/08 01/09/08 01/10/08 30/11/08 01/09/08 Page 32 36 Shooters Avenue Version 5.2 better to ensure that it is evident that resident’s rights and best interests are safeguarded. 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 2 Refer to Standard YA1 YA1 Good Practice Recommendations The statement of purpose should be reviewed and updated to include the new contact details of the Commission for Social Care Inspection. The service user guide could be produced in a format (such as audio and/or Braille) to help it be more accessible to a person using the service who has significant communication needs. There should be a comprehensive record of prospective resident’s transition/admission process prior to moving into the care home. There could be development with regard to the format of some of the care plans, to make the information more accessible to those residents who have difficulty reading and/or particular sensory needs. The care plans could indicate more understanding and assessment of the strands of diversity, including gender, age, and sexual orientation. There should be more evidence that the care plans are up to date ‘working’ tools so document all resident’s changes in need and goals (short term as well as long term) promptly. The registered person should ensure that ‘daily’ progress records are documented to provide recorded evidence that residents are receiving the care and the support that they need everyday. Risk assessments (and all other documentation) should be dated. Residents’ individual activity programmes should be reviewed and updated as and when there are changes in the leisure pursuits that are chosen and participated in by each person using the service. DS0000017578.V365937.R01.S.doc Version 5.2 Page 33 3 4 YA2 YA6 5 YA6 6 7 YA9 YA14 36 Shooters Avenue 8 9 10 YA17 YA18 YA22 If the menu is not being followed in the home it should be discarded as its information could be misleading to people using the service. Staff should assess whether resident’s need support with cleaning their glasses. It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. Previous recommendation. The format of the complaints procedure could be improved and developed to possibly include pictures to make it more accessible to residents who may have difficulty in reading. The front doorbell should be repaired. The forecourt area of the home could be improved to develop the attractiveness of the entrance to the home. The garden at the rear of the property should be better maintained. The items of ‘office’ equipment should be removed if they are not in use. As they could be a hazard to residents particularly with sensory needs. Paintwork on some skirting boards, and in bathrooms could be repainted. The stair carpet is very stained and should be cleaned or replaced. Areas of the home that are ‘dusty’, for example the bathroom lamp, and several ornaments in the sitting room could be cleaned. 9 YA24 10 YA24 11 YA34 12 YA35 13 YA36 The seats of the dining chairs should be cleaned. The responsible person should obtain references for every body employed even if it is family; this is to ensure that there is evidence that people using the service are protected. It should be evident that all staff receive at least five paid training and development days (pro rata) per year to ensure that all people using the service are supported by qualified and skilled staff and needs can be met fully met. Recorded staff supervision meetings should take place at least six times a year. Staff should receive an annual appraisal to ensure that the progress of their knowledge and skills is monitored and developed so that quality care and support is provided to DS0000017578.V365937.R01.S.doc Version 5.2 Page 34 36 Shooters Avenue 14 YA39 people using the service. Residents should have the opportunity to complete feedback surveys to express their views about the quality of the service provided by the care home. 36 Shooters Avenue DS0000017578.V365937.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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