Inspection on 25/10/05 for 36 Shooters Avenue

This inspection was carried out on 25th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

36 Shooters Avenue 15/07/08

36 Shooters Avenue 16/05/07

36 Shooters Avenue 19/01/07

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 08/07/2008.

CARE HOME ADULTS 18-65 36 Shooters Avenue 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG Lead Inspector Clive Heidrich Unannounced Inspection 25th October 2005 08:35 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 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.V260543.R01.S.doc Version 5.0 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.V260543.R01.S.doc Version 5.0 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 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No admissions until requirements met as per Notice dated 24th June 2005. That no more service users are admitted to the home, until such time as the registered person can demonstrate that requirements imposed on the home by the Commission for Social Care Inspection have been met or are being met satisfactorily as deemed by the Commission. Date of last inspection 31st May 2005 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. There were no vacancies in the home at the time of the inspection. The home is owned and run by QFCC, a local private and independent care service provider. The home has 24-hour staffing, including one staff sleepingover at night. It has been operating since 2001. The home is located within a residential area of Kenton, part of the borough of Harrow. It is close to local shops and bus links, whilst tube links are around twenty minutes’ walk away. Parking restrictions do not apply on the road outside the home. The home’s drive can accommodate two vehicles. The premises is an adapted two-storey building. Two of the bedrooms are on the first floor, with the other on the ground floor. All are single rooms, fully furnished, and with built-in sinks. The home has one bathroom with adapted shower facility, and toilets on each floor. Access to the first floor is by the stairs only. The home has a kitchen, a lounge, and a reasonably-sized garden that was undergoing redevelopment work at the time of the inspection. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. References to the owner in the text of this report are about Ms Fox. References to Ms Squire are about the registered manager of 34 Shooters Avenue, the sister-home next door. References to management refer to both of these people. This is the first full inspection of the home since 31/5/05. On 2/8/05, the CSCI completed the imposition of a condition on the registration of the home preventing any further service user admissions. This was imposed due to concerns about the care in the home and due to ongoing non-compliance including with an enforcement notice of 11/2/05. An additional inspection visit then took place on 8/9/05 to consider the progress being made with addressing the reasons behind the imposed condition and with the noncompliance issues. There remained a number of issues for the home to address at that stage. Concurrent to this, the application by the owner to be registered as the manager of the home, as initially made in April 2004, has been coming to a conclusion. This inspection took place across a cool day in late October. It finished at 4:55pm. Its focus was both on compliance with previous requirements and notices, and on assessing the core standards that were not inspected during the May 2005 inspection. Consequently, the inspector met with all service users, some staff, the owner, and the registered manager of the sister-home next door. The inspection included the consideration of the home’s environment, the records available, and the observations of the care being provided. This inspection also incorporated the investigation of an anonymous complaint about recruitment practices. The complaint was unresolved through a lack of sufficient evidence. The inspector thanks all involved in the home for the patience and helpfulness during the inspection. What the service does well: The service provides security and a sense of belonging to its service users. Positive relationships were observed between staff and service users. There continues to be improved access to community health professionals for service users. Service users receive personal support relative to their needs. Service users were appropriately dressed and groomed throughout the inspection. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 6 Service users are supported to stay in touch with family and friends. What has improved since the last inspection? What they could do better: Despite the noted improvements, there are a number of areas where standards are insufficient and which must be promptly addressed. Of these, there are six issues that have been highlighted both within the enforcement notice served on the organisation on 11/2/05 and through the imposition of a condition on the home’s registration on 2/8/05. These are in summary about: • providing sufficient individual care plans for service users, • providing all staff with sufficient training about how to operate the home’s complaints procedure, • providing a suitable and updated procedure in the home about protecting service users from abuse, • ensuring that the garden is made fully safe for service users through removal of all broken and discarded items, • providing the home with a training and development plan and budget, & • providing the CSCI with a copy of the accounts for the home from previous years. There are additionally requirements that were only contained on the former notice, about ensuring that the home is suitably risk assessed, and about securing an occupational therapy assessment for the home, that have yet to be completed. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 7 The CSCI is considering the further enforcement action necessary to ensure that these issues are addressed. A number of other issues must also be fully addressed promptly. An immediate requirement notice was given to management at the end of the inspection. Two of the points, about providing a summary care plan for one new service user, and about providing suitable staff recruitment details in specific areas for two staff, have been promptly addressed. The third, about providing a working tumble drier in the home, was not fully addressed at the time of the drafting of the report. It is important that formal review meetings are convened for two service users in the home so that their care provision can be considered by involved parties. This must then take place for all service users on an ongoing basis every six months. This process would, for instance, enable the current lack of weekday activities for one service user, for which a plan is now drawn up, to be considered for effectiveness. The owner must ensure that there is always sufficient staffing to enable service users to go out at weekends. Current provision of one staff member working at any one time across the weekend does not allow for individual community pursuits to be followed. The owner must ensure that medication practice is improved upon. Medications for service users must not be left lying around as was found during the visit, and administration records must be kept up-to-date. There are some maintenance and cleanliness issues that must be addressed to uphold hygiene and décor standards. For instance, the areas of the kitchen effected by past flooding must have their redecoration properly completed. The practice of leaving the waste bin outside must be changed, as there was evidence that it is attracting vermin. The owner must ensure that staff complete the NVQ courses that they have signed up to. She must also ensure that other required courses are attended, either through the NVQ process or other training options, so that staff receive sufficient formal training to support service users more effectively. Finally, a system of regular reviewing, reporting on, and improving, the quality of care provided at the home, remains be set up. The combination of a range of areas where improvements must be made, and of non-compliance with previous requirements and notices, is putting service users at risk and is preventing the home from meeting the national minimum standards. The owner must promptly address this. 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 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 8 contacting your local CSCI office. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 9 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.V260543.R01.S.doc Version 5.0 Page 10 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): 2, 3 and 4. Prospective service users are enabled to visit the home before deciding about moving in. Prospective service users’ social workers may assess their needs before agreeing placement into this home, but there was no evidence of the home’s management undertaking their own assessments before enabling new service users to move in. Consequently the needs of such service users may not be addressed until a later date. EVIDENCE: The feedback of one of the two service users who have moved in during the summer was very positive, saying that they had settled in fine and that they had viewed the home before moving in. The other service user provided no negative feedback in this respect. There were no pre-admission assessments available for the two newest service users. Ms Squire said that none had been undertaken by the organisation, although social services had been involved in checks prior to the moves. Records of were seen in support of this. Whilst both service users moved from another of the organisation’s homes, and so their needs were reasonably wellknown to the organisation, some re-assessments were necessary. In particular, re-assessments were needed in terms of judging whether this new home, its environment, and its staff team, for instance, could meet the needs of these new service users before they moved in. Any future admissions must include a full assessment of the prospective service users’ needs by the home’s management. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 11 Some aspects of this report, such as the lack of day provision and poor dental care for one new service user, suggest that an assessment of needs by the home’s management would have enabled plans to have been set up to deal with the individual issues much quicker. It is encouraging that there was clear evidence on this inspection of work by staff and management to address some of the new service users’ individual needs. It was however clear that the home was not meeting the needs of one new service user fully, which must be addressed as soon as possible (see also standard 6). 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 12 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, 9 and 10. The individual plans of the service users were insufficient in a number of areas, in terms of providing plans of support that addressed individual needs. The plans also varied in quality, with one identified by the inspector for immediate remedial action from the home’s management due to some of the service user’s key individual needs being unaddressed both in practice and in writing. The whole planning and reviewing process, whilst somewhat improved on since the last inspection visit, needs to become consistent and suitably detailed. Whilst service users may take risks within their lives, there is little written evidence of assessment to minimise hazards affecting individuals. This increases the chances of accidents and incidents, which management must address. Service users’ personal information can be left available in communal areas of the house. This allows private information to become available to unauthorised people, which management must address. EVIDENCE: 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 13 The two newest service user’s files were inspected on this occasion. One gave a reasonably clear indication of the needs of the service user and how staff should address the needs, although it suffered as at the previous visit from some areas lacking clear and individual plans and from a lack of regular reviewing. That service user had also had a formal review meeting since moving into the home, which had appropriately identified key goals to work towards. The other new service user’s file showed that there had been no formal review meeting since they had moved into the home. Their file showed much less evidence of their individual needs having been assessed and planned for, as for instance there was no indication of the significant health need of this person nor of planning for resumption of their day services or other weekday activities. An immediate action notice was therefore left for management at the end of the inspection, for them to set-up an individual care plan for this person, so that it could be clear as to how staff and management would be supporting the service user to have their individual needs addressed. A reasonable plan has consequently been forwarded to the inspector. A check of the third service user’s last formal review meeting found it to have been from over six months ago. Therefore two of the service users are in need of formal review meetings, to ensure that their needs are being addressed and that goals are set where appropriate. The owner must address this. Risk assessments within the individual files checked were insufficient. They lacked reference to some of the key hazards that individual service users may face, or may cause. For instance, the key health need of one service user was not referred to within the risk assessments for that person’s objectives in their file. The inspector observed one practical hazard for this person, in terms of the difficulty of people getting past that person’s feet when sat in their chair in the lounge, which could cause injury to anyone involved. This was pointed out to Ms Squire, who has since reported that furnishings have been re-arranged in the lounge to address the risk. It is however necessary for all service users’ risk assessments to be reviewed and updated in writing, to ensure that hazards are identified and risks from these minimised. The inspector observed that all three service users’ files were left on the table in the lounge at the start of the inspection. They remained there until the inspector requested to inspect them. There were also documents openly available in the entrance hall, such as the communication book and the staff meeting minutes, that included reference to service users’ needs and histories. Service users’ personal information is consequently not being kept sufficiently confidential. These issues must be addressed to uphold sufficient standards of confidentiality in the home. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Service users are enabled to have an involved and healthy diet that they enjoy. They are supported to upkeep good family and friends’ contacts. They are provided with appropriate leisure activities in the home. Service users are generally provided with appropriate support to be part of the local community and to take part in activities appropriate to their needs. Shortfalls in this respect for one service user are starting to be addressed. There also needs to be sufficient staffing working at weekends to support with community activities. Service users’ rights and responsibilities are generally well-recognised in the home. There was reasonable evidence of service users being supported to be independent in the home. Support for skills development, whilst improved, needs to be better evidenced. There also needs to be a better recognition of the home’s boundaries relative to the sister home next door, so that service users can feel secure with what their rights in these respects are. EVIDENCE: 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 15 The service users spoke positively about the food provided in the home. They confirmed that they get enough food and that they are involved in planning the weekly menus. One service user noted that everyone mucks in with preparing the food. Breakfasts were seen to be taken at times that suited each service user. There was a plentiful supply of value tinned food, salad and dairy items, and bread, in the kitchen. The menus and the records of food individually eaten were generally sufficient. The service users spoke positively about the service in the home enabling them to uphold good links with their families. They noted that their families are welcomed into the home by staff. Records confirmed that family members do visit, that there are regular phone calls to and from family members, and that family members can and do attend formal review meetings. One service user also has the support of a befriender. Service users were seen to have the freedom of the home. They could make their own decisions. For instance, one service user kindly made the inspector a cup of tea, which was appreciated. Another stayed in their room until much later in the morning, as they had no morning appointment to attend. The service users confirmed that they have keys to the house and to their rooms. The inspector was concerned with the freedom of the house that staff from the home next door had. On three occasions during the morning, staff from the sister-house next door entered this home through the back door. Whilst they greeted anyone they met, there appeared to be no sense of boundary between the two homes from the staff members’ points of views. One service user noted that they are sometimes reminded to return to their home when in the other home, which they felt compromised about because they were having to use the tumble-drier in that home due to the drier in their own home being out-of-action. The owner must ensure that there are clear boundaries agreed between the two homes, and that staff and service users ordinarily respect these boundaries. There was verbal and written evidence, including from service users, that the service users have become much more involved in cooking since the last inspection. This encourages independence, which is appropriate. The owner however acknowledged that further improvements on supporting service users with skills development improvements are needed, essentially through broadening and individualising the skills and through better records of developments. Some service users spoke of the activities they are supported with and the services that they attend. It was clear that staff support is provided, that both local transport and taxicards are used, and that church attendance is supported to the service users’ satisfaction. The owner noted also that there 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 16 are house vehicles available for use. One service user noted that their choice about no longer wishing to attend a day service is being respected. One service user went out to their day centre during the morning of the inspection. Another went out with staff for shopping, whilst the third stayed at home. Ms Squire explained that a placement had been re-established for this latter service user at a day service that reflected their culture, with it due to restart in mid-November. Management must ensure that this placement, and other occupational activities that are being planned for the service user for the rest of the week, are supported to be successfully undertaken. The inspector was on this occasion confident that there are records of all activities undertaken by service users. The owner noted that she is planning on increasing staffing levels outside of college term-time, as the service users would need this to enable them to have a one-to-one staff-supported activity each day of the week. Rosters generally showed that there is support to enable this during college week. However, there was a lack of staffing at weekends, when a second staff member must be assigned to the house for a period of hours on each day to enable individual service users to go out by themselves or have one-to-one staffing support in the home. There was written evidence of holidays being requested by service users, but no outcome for this. It is recommended that some form of holiday in 2005 be pursued for each service user based on their needs and wishes. The facilities seen in the lounge, and in one service user’s bedroom, suggest that reasonable leisure activities are available to service users within the home. Ms Squire noted also that one service user has had a talking newspaper service acquired for them, which is evidence of an individual need being addressed. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users receive personal support relative to their needs. Service users were appropriately dressed and groomed throughout the inspection. Service users’ health needs are generally well-met, through both staff and externalprofessional support, although one improvement around dental care is needed. There are policies in place for handling the medications of service users. There needs to be improvements made to ensure that the procedures are followed and risks of medication mis-management are minimised. EVIDENCE: One service user confirmed to the inspector that their clothing is looked after well by staff. All service users were seen to be dressed in reasonable and individual clothing, both for in the home and for going out. They were also all reasonably well-groomed. The staff member present at the start of the inspection attended to one service user’s support needs with a bath at the start of the visit, and generally oversaw any personal support that service users needed. Communication book records showed that staff leave messages in support of upholding appropriate standards of personal and health care for service users. There had been much support of service users attending check-ups with health 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 18 professionals in recent months according to records seen, such as for optician, dentist, dietician, and chiropodist support as applicable. The dental care of one service user was highlighted well within their file following a check-up. The inspector noted that the service user’s care plan objectives did not specifically cover dental care, and were generalized personal care objectives that were not specific to the individual service user’s needs. This was a factor in the immediate requirement for a review and updating of the service user’s care plan, as detailed under standard 7. The owner must ensure that a plan of the necessary staff support with dental care, appropriate to the individual needs of each service user, is now provided to all service users. None of the service users in the home self-medicate. The home uses a pharmacy-supplied blistered-dosette system of medication. There were records of medicines being signed in on delivery from the pharmacy. Whilst staff had signed for the administration of many of the prescribed medicines, there were six gaps in the signing for two service users across the previous three days prior to the inspection. The owner must ensure that all medications are signed for upon administration. A check of the medication cupboard found a couple of prescribed medications for a service user from the sister home next door, including one that was beyond its expiry date by a month. The owner must ensure that only medications for the service users of this home are stored in the medication cupboard. A day’s worth of one service user’s tablets were left unattended for a period of around five minutes, in a container, in the kitchen during the early morning. This puts service users at risk of taking the wrong medication, or of their medication being misplaced or forgotten. The owner must ensure that staff administer medications to service users at the time of dispensing, and that they look after the dispensed medications securely until the service user agrees to take the medication. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Complaint processes have been clarified to service users, and are in the process of being clarified to staff. Service users should therefore shortly be able to have good confidence in the complaint process. There are significant risks that service users would not be protected from abuse, due to a lack of sufficient procedure in the prevention of abuse, and due to a lack of suitable training of staff. EVIDENCE: The complaints book was empty. Service users said that they have had the complaints procedure recently explained to them. There were records of this. One service user was able to express confidence in the procedure. There was a consensus that house meetings are useful for getting issues addressed. One service user noted that they are all asked if they have any concerns. Ms Squire noted that the complaint procedure has been made available to all service users in their rooms, and that a Braille version has been ordered for the applicable service user. She has started discussing the procedure with staff in supervision sessions. When these issues are completed, service users should be able to have good confidence in the systems. There were no recorded accidents or incidents since the last inspection visit to the home. The procedure for how to handle any allegations or concerns of abuse had not been updated as previously required. Staff had similarly not received any formal training on such allegations, or on how to handle challenging behaviour. Management must ensure that these issues are attended to, to minimise the risk of actual abuse occurring. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 20 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, 27, 29 and 30. The home is adequate to live in, and is in many ways kept suitably clean. Management are starting to address a number of issues in the home that compromise the homeliness and comfort of the home. Some fine-tuning of cleaning systems is needed to ensure that hygiene standards are upheld. A working tumble-drier is also needed, as advised to the home’s management by immediate requirement notice. The home has sufficient toilets and bathrooms that meet service users’ needs. It lacks an occupational therapy assessment to ensure that service users’ minor mobility needs are addressed. EVIDENCE: The home’s tumble-drier was not working. Service users and staff confirmed that it has not been working for a number of weeks, one person saying that it is two months like this now. As per standard 16, this has caused some inconvenience for some service users. It was made an immediate requirement that a suitably-working drier be promptly installed. There were a number of maintenance and repair issues arising from the last inspection. On this visit, it was found that the fixing of a leaking pipe in one 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 21 service user’s room had been addressed. A maintenance worker was working throughout the inspection, and hence it was clear that water-damage issues to the walls and some kitchen cupboards, and the installing of a railing in a bathroom for one service user, had started to be addressed. The garden also had only a few discarded items needing to be removed. It needed weeding and trimming however, and it would benefit from a storage area. The waste system needed reviewing as it is not acceptable for the bin to be stored outside, as there was evidence of it attracting vermin, including through feedback from one service user. The owner noted that following discussions with service users, the garden will return to being separated between this and the home next door. The following issues remained essentially unaddressed: • The back door of the kitchen needing a key. • The back of the garden needing risk assessment and action due to hazards from overgrowth and building work. • The stairway needing to be cleared of dirt and stains. • The house having an occupational therapy assessment. The house was found to be reasonably clean from the start of the inspection. The service users reported that the home is kept clean enough. The staff member present undertook cleaning tasks earlier on. The kitchen was generally clean but needed wiping over on the tops of such things as the fridge and the stove where it was greasy and dusty. There was evidence of effort being put into cleaning recently, both from feedback and records, which is encouraging. It is recommended that the cleaning schedule file be restarted, so as to keep a record to show that cleaning has taken place. The upstairs toilet had an offensive odour both during the morning and later in the afternoon. Most communal sinks lacked working soap, though most had empty soap dispensers. This was explained to Ms Squire, who agreed to address the issues. One service user noted that their TV, video and DVD equipment was unsteady balanced. They wished for a shelf for some of the equipment to minimise risks. Ms Squire agreed to attend to this. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 22 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): 33, 34 and 35. Service users are mostly supported by an effective staff team. There were however insufficient staffing levels at the weekends. The home’s recruitment records were found to lack some necessary checks under the legislation, which might have put service users at risk. However this issue was addressed fully following an immediate requirement notice. Management are starting to address the training needs shortfalls of the staff team. EVIDENCE: The recruitment files of two current staff members were checked through. There were significant gaps in each of the records, in terms of identification and work eligibility, which was put to management in an immediate requirement notice. Copies of documents were consequently sent after the inspection to address the issues. Other recruitment checks found that CRBs were suitably in place where needed, and that both staff members had contracts on file. Discussions with the person in charge of recruitment for the organisation found that they had clear and appropriate systems mostly in place. Following the investigation of a complaint about recruitment practices during this inspection, feedback was provided to the owner and the personnel 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 23 manager. The recruitment policy was slightly altered to take into account the recent changes in legislation concerning references. The inspector was informed by management that NVQ courses at level 2 or 3 had started at a local college for four staff. Written evidence was supplied in support of this. There was similar evidence that all staff had recently attended fire training by a suitable professional, as previously required. The owner noted that she has started a training plan for the home in conjunction with a local training provider, and is due to finish it soon. As per standard 13, there must be additional staffing supplied at the weekends to enable service users to undertake community activities. It also remains for the owner to provide a written staffing-levels review for the home, to justify how the needs of service users are met through the staffing levels supplied. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 24 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): All of them. Service users benefit from a reasonably well-led home and from the efforts of staff to uphold standards. The manager must however undertake suitable NVQ training to demonstrate suitable expertise. There remains a significant shortfall in terms of management formally auditing the views of involved people in the home, reporting on the process, and planning to address identified shortfalls. It remains for there to be evidence of staff reading and understanding the policies of the home. There have been improvements to the record-keeping in the home, with only minor shortfalls still to address. There have been improvements to the practice of health and safety in the home. A number of shortfalls were however identified which could put service users and staff at risk of accident. There remains a lack of transparency about the home’s business and financial processes. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 25 EVIDENCE: The registered owner took over as manager of this home, in line with her application to the CSCI to manage both homes, at the end of April 2004. The application process is coming to a conclusion. The owner used to manage the sister home a number of years ago, and has a number of years’ experience in a management and business role. The owner came across with clarity, at this inspection, about how the home is expected to operate and about the changes that will take place to support this. One service user said that the manager of the home is Ms Squire, because she is the senior person in the home throughout the week. They noted that the owner comes into the home occasionally, such as for meetings. It is recommended that the position of manager of the home by clarified and explained to service users. Management stated that they missed out on NVQ level 4 places at the local college used for staff members’ NVQs. Alternative arrangements for the new year have been pursued. The owner must ensure that the manager of the home becomes suitably qualified. Staff meeting minutes showed that they are being held monthly. Ms Squire is generally the senior figure present at them. She advises staff of the standards expected. The handover file itself was rarely being used. A communication book was however being used well by staff and management to inform of appointments for service users, and to remind staff to uphold individual service user goals. Responsibility sheets, to guide staff for key responsibilities, were also on display in the home. It is therefore clear that management are making leading the staff in terms of their expectations of the service, and that staff are in many ways responding. The inspector identified that there was a lack of summary details and contacts for each service user. This information is needed to ensure that quick contact can be made when needed. Ms Squire noted that they have information from the service users’ previous homes, and that she is currently updating the information. She acknowledged that inventories of possessions are also needed for each service user relative to this home. There were records, dated from the day of this inspection, which considered any significant hazards around the home and what needs to be done to minimise their risks. Whilst they show that consideration of hazards is undertaken, the work must be completed, and must be undertaken or checked by a suitably trained person. For instance, it was stated that there are no concerns with electrical safety, however it was identified by the inspector that 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 26 the home needs to update its professional portable appliance and electrical wiring tests. There was evidence of suitable fridge and freezer checks, of regular house health and safety checks that addressed hazards, and of smoke detector checks by staff. There were also checks of the fire extinguishers and the gas systems by suitable professionals. Shortfalls in terms of quality assurance practices were explained to Ms Squire. An annual audit of all involved people’s perspectives on the care supplied in the home is required, with a report and action plans from the audit being made available. It remains for the owner to supply the CSCI with details of the financial accounts of the home. It was also pointed out to the owner that the revised CSCI certificate must be displayed. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 2 3 X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 X 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X 3 X 1 1 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X X 2 2 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 36 Shooters Avenue Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 1 2 2 1 1 DS0000017578.V260543.R01.S.doc Version 5.0 Page 28 Are there any outstanding requirements from the last inspection? Yes 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. Standard Regulation Requirement Any future admissions must include a full assessment of the prospective service users’ needs by the home’s management. Pre-admission assessment processes by the home must enable there to be a plan of action set-up to address how the new service user’s needs will be addressed once they move into the home. The owner must ensure that a summary and individualised care plan is developed for one specific service user, with appropriate involvement of the service user and/or their representatives as applicable. The plan must show what the service user’s key individual needs are, areas of significant risk, and how staff will support the service user to address the needs. A copy of the plan must be supplied to the CSCI and must be made available to staff from that stage onwards. Individual service user plans must show how each need of the service user will be met by the DS0000017578.V260543.R01.S.doc Timescale for action 01/01/06 1 YA2 14 2 YA3 15 01/01/06 3 YA6 15 08/11/05 4 YA6 15 31/08/03 36 Shooters Avenue Version 5.0 Page 29 home staff (as guided by Standard 2.3) Previous timescales of 31/8/03 partially met. The owner must ensure that for each service user’s individual objectives, a plan to meet the objective that is individual to the service user exists. Previous timescale of 15/10/05 partially met. Savings plans and any restrictions in access to money such as a limit of £5 per week must be available as part of the individual service user’s plan. Previous timescales of 1/3/04 not met. The owner must ensure that, as per the policy on service users’ objectives, monthly reviews of key objectives take place and are recorded. Previous timescale of 15/10/05 partially met. The owner must audit when the last formal review meeting was for each service user and ensure that these reviews are undertaken at least every 6 months. Summary records of the meetings must also be kept. Previous timescale of 15/10/05 partially met. The owner must ensure that service users’ money is stored securely at all times, including through keeping the cabinet locked. Previous timescale of 1/10/05 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 30 5 YA6 15 15/12/05 6 YA6 15 01/03/04 7 YA6 15(2) 15/12/05 8 YA6 15 15/12/05 9 YA7 16(2)(l) 01/12/05 not met. Risk assessments for the new service users must be updated in writing, to reflect the change of environment and service. Previous timescale of 1/10/05 partially met. Service user risk assessments must be updated where out-ofdate or not reflecting current practice. They must be written and implemented where new areas of risk are evident. Previous timescale of 1/8/04 partially addressed. Service users’ personal information must be kept confidential. Files that contain such information must therefore be stored securely when not in use. There were few recorded entries within service users’ files that showed emphasis on the maintenance or development of their skills. This must be addressed. Previous timescale of 15/10/05 partially addressed. Management must ensure that the re-established day service placement, and other appropriate occupational activities, that are being planned for one of the new service users, are supported to be successfully undertaken. The owner must ensure that there is always sufficient staffing to enable service users to go out (a minimum three people working at some stage, for the duration of a shift, each day). Previous timescale of 1/8/05 DS0000017578.V260543.R01.S.doc 10 YA9 13(4) 15/12/05 11 YA9 13(4) 01/08/04 12 YA10 12(4), 17(1)(b) 01/12/05 13 YA11 17(1)(a) s3 pt 3(m) 15/12/05 14 YA12 12(1), 16(2)(m) 01/12/05 15 YA13 18(1)(a) 15/12/05 36 Shooters Avenue Version 5.0 Page 31 16 YA16 12(4) 17 YA19 15 18 YA20 13(2) 19 YA20 13(2) 20 YA20 13(2) 21 YA22 22 achieved for weekdays but not weekends. The owner must ensure that there are clear boundaries agreed between the two homes, and that staff and service users ordinarily respect these boundaries. The owner must ensure that a plan of the necessary staff support with dental care, appropriate to the individual needs of each service user, is now provided to all service users. The owner must ensure that all medications are signed for upon administration. The owner must ensure that only medications for the service users of this home are stored in the medication cupboard. The owner must ensure that staff administer medications to service users at the time of dispensing, and that they look after the dispensed medications securely until the service user agrees to take the medication. The owner must ensure that all people working in the home are clear on how the complaints system works. Previous timescales of 15/3/05 and 1/9/05 not fully met. Service users must be provided with a copy of the complaints process within their rooms (in Braille where necessary). Timescale of 15/10/05 partially met. The adult protection policy was not sufficiently clear about what to do with an allegation. This must be addressed, including for when to notify funding DS0000017578.V260543.R01.S.doc 15/01/06 15/12/05 01/12/05 01/12/05 01/12/05 01/09/05 22 YA22 22(2, 5, 6) 15/12/05 23 YA23 12, 13(6) 01/04/04 36 Shooters Avenue Version 5.0 Page 32 authorities and the CSCI, for ensuring the protection of the all the people involved, and for use of the applicable authority’s adult protection procedures. Previous timescales of 1/4/04 not met. The owner must ensure that all staff receive, or have recently had, external training on challenging behaviour and adult protection. Previous timescale of 1/10/05 not met. All excess, waste, and broken items must be disposed of or removed out of communal areas of the home [including the garden]. Previous timescales of 15/2/05 and 1/8/05 partially met. The cupboard underneath and to the right of the main sink in the kitchen has a warped bottom shelf and lack a door. These issues must be addressed. Previous timescale of 15/10/05 partially addressed. There was an obvious amount of mould and mildew in one corner of the ceiling and surrounding walls in the kitchen. This issue must be permanently rectified. Previous timescale of 15/10/05 partially addressed. The back door in the kitchen requires a key so as to enable it to be locked. Previous timescale of 15/10/05 not addressed. The far end of the garden was somewhat overgrown and DS0000017578.V260543.R01.S.doc 24 YA23 18(1)(c) 01/02/06 25 YA24 23(2)(o) 01/08/05 26 YA24 23(2)(b) 01/12/05 27 YA24 23(2)(b, d) 01/12/05 28 YA24 23(2)(c) 15/11/05 29 YA24 13(4), 23(2)(o) 01/12/05 Page 33 36 Shooters Avenue Version 5.0 potentially dangerous to unsupervised service users. This must be risk assessed and appropriate action must be taken. Previous timescale of 1/10/05 partially addressed. Consideration, in conjunction with service users, must be given to whether the shared garden is appropriate now that the two homes are no longer to merge. There must be evidence available of this consultation. Previous timescale of 15/10/05 partially addressed. The TV, video and DVD equipment in one service user’s bedroom must be made secure, such as through the use of a shelf. The owner must secure an occupational therapy assessment of the home, to ensure that the needs of service users in this respect will be met. Previous timescales of 1/7/04 not met. The grubby stairway carpet must be thoroughly cleaned or replaced. Previous timescales of 1/8/05 and 1/10/05 not met. The toilets in the home must have soap available, and must have systems to remove of offensive odours promptly. The kitchen was generally clean but needed wiping over on the tops of such things as the fridge and the stove where it was greasy and dusty. The waste system must be reviewed as it is not acceptable DS0000017578.V260543.R01.S.doc 30 YA24 12, 23(2)(o) 15/12/05 31 YA24 13(4) 15/12/05 32 YA29 13(1), 23(2)(n) 01/07/04 33 YA30 23(2)(d) 01/10/05 34 YA30 12(4) 16(2)(j, k) 15/12/05 35 YA30 16(2)(j) 13(4), 16(2)(j) 15/11/05 36 YA30 01/12/05 Page 34 36 Shooters Avenue Version 5.0 37 YA30 16(2)(e), 23(2)(c) 38 YA33 18(1)(a) for the bin to be stored outside, as there was evidence of it attracting vermin. The owner must ensure that there is a tumble-drier in place in the home, and which dries clothes appropriately. The owner must provide explanations about how the rosters provide sufficient staffing to meet the needs of service users throughout the week. 28/10/05 01/08/05 39 YA34 17(2) s4, 19 s2 pt 1 40 YA35 18(1)(c) Previous timescales of 22/2/05 and 1/8/05 not met. The owner was required to provide a copy of photographic identification for one staff member, and a copy of proof that another staff member is 01/11/05 entitled to work in the UK, to the inspector, as these documents were missing from the respective files. Most staff need to attend a number of mandatory training courses. They must attend to this within suitable timescales. 01/09/05 Previous timescales of 1/6/05 and 1/9/05 partially met. The home must have a training and development plan with a designated training budget. Previous timescales of 1/6/04 not met. The owner must ensure that the manager of the home becomes suitably qualified at NVQ level 4 in management and care. A written plan for this must be part of the home’s general training plan. A system of regular reviewing, and improving, the quality of care provided at the home, DS0000017578.V260543.R01.S.doc 41 YA35 18(1)(c) 01/06/04 42 YA37 10(3) 01/12/05 43 YA39 21, 24 01/09/03 36 Shooters Avenue Version 5.0 Page 35 including through consultation with service users and their representatives, must be set up. Reports of such reviews must then be supplied to service users and their representatives, and the CSCI. Previous timescales of 1/9/03 not met. The owner must ensure that there is documentation to show that staff have read the home’s policies. Service users’ files must include the summary information about themselves and their contacts (such as family, GP etc). Previous timescale of 15/10/05 not met. An inventory of possessions is needed for each service user living in the home. General health and safety assessments for the systems in the home must be undertaken and recorded. Previous timescales of 1/4/04 and 6/5/05 partially met but the process must be completed for all relevant risks around the home. The fire-safety risk assessment must be improved upon, as it was seen to miss a number of potential hazards including the needs of each service user. Previous timescales of 1/9/04 not met. The owner must ensure that the professional portable appliance and electrical wiring tests are suitable updated. A copy of the accounts for the financial year [02/03 and DS0000017578.V260543.R01.S.doc 44 YA40 18(1)(c), (2) 01/12/05 45 YA41 17(1)(a) s3 pt 3 15/12/05 46 YA41 17(2) s4 pt 10 01/02/06 47 YA42 10(1), 12(1), 13(4) 06/05/05 48 YA42 23(4) 01/09/04 49 50 YA42 YA43 13(4), 23(2)(c) 25 15/01/06 02/06/03 Page 36 36 Shooters Avenue Version 5.0 03/04], including details of the running costs of the home, rent, payments under a mortgage, and expenditure on food, heating and staff wages, must be sent to the CSCI. A copy of the business and financial plans for the home must additionally be kept at the home. Previous timescales of 2/6/03 not met. The certificate of registration for the home, that contains the imposed condition on the registration of no further Care Stds admissions of service users, was Act s28(1) not on display in the home. This must be rectified. Previous timescale of 1/10/05 not met. 51 YA43 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA14 YA30 YA37 YA38 YA40 Good Practice Recommendations It is recommended that some form of holiday in 2005 be pursued for each service user based on their needs and wishes. It is recommended that the cleaning schedule file be restarted, so as to keep a record to show that cleaning has taken place. It is recommended that the position of manager of the home by clarified and explained to service users. It is recommended that the handover file be restarted, to enable better communication between outgoing and incoming staff. It is recommended that a signature sheet, similar to those used with service users’ objectives, be used by staff who read each policy of the home. 36 Shooters Avenue DS0000017578.V260543.R01.S.doc Version 5.0 Page 37 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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