Inspection on 31/05/05 for 36 Shooters Avenue

This inspection was carried out on 31st May 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 25/10/05

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 31 May 2005, at 12:45hrs st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 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 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 CRH PC Care Home Only 3 Category(ies) of LD Learning Disability registration, with number of places 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7/1/05 Brief Description of the Service: 36 Shooters Avenue is a care home providing personal care and accommodation for up to 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 sleeping-over 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 G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across almost 8 hours of a warm May afternoon. Its focus was in particular on the work undertaken by the registered person (the owner, Ms Lorna Fox) in addressing the large number of requirements of the previous inspection. This included consideration of progress in addressing a statutory enforcement notice about 23 issues of ongoing non-compliance from previous inspections. This notice was issued to the owner on 11/2/05 with timescales for implementation of 6/5/05. It was found that 6 of these issues had been addressed, but that the majority had little or no progress since the last inspection. The CSCI is considering further enforcement options. The only other regulatory activity to have been undertaken since the last inspection was a CSCI pharmacy inspection on 31/1/05. Medication standards were found to have improved at that visit, with only two issues requiring further action from the owner. The home was, at the time of the inspection, running in conjunction with the sister home at #34, as per recently-withdrawn plans submitted to the CSCI to merge the two homes. The owner confirmed during this visit that the plans are to re-establish the homes as separate units. During this visit, the inspector could only gain access to this home through ringing on the sister home’s (#34’s) doorbell, as no-one was answering #36’s doorbell. The residents of both homes were about to have lunch at the start of the inspection. The inspector spent time talking privately with each of this home’s residents. Discussions also took place with the staff present and the owner. A tour of the premises took place, and a number of documents were checked. The owner received feedback throughout the inspection. She also accepted an immediate requirement form at the end of the inspection, to address the broken washing machine in the kitchen, a broken man-hole cover in the garden, and complete the furniture-moving of the newest resident from another QFCC home. This was confirmed by letter on 1/6/05. There has been no written response at the time of writing, although the inspector has received verbal confirmation by phone of the issues having been addressed. What the service does well: The service provides security and a sense of belonging to its residents, as good relationships were observed between some staff and residents. Residents from the home and the sister home at #34 spend a lot of positive time in each others’ company. There is potential for the current system of individual planning and monitoring to be effectively used within the home. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 Prospective residents are able to view the home and make a choice about whether to move in. EVIDENCE: The one resident to have moved into the home since the last inspection noted that they had had choice about the process. He noted that, although his room is fully furnished, he did not yet have all the furnishings that belong to him brought over from the pervious home, another QFCC home, since his move in January 2005. This was put to the owner, both verbally and in writing, to address within a week of this inspection. Phone calls to the home since the inspection have clarified that this requirement has been partially achieved. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9. Individual plans of residents were found to lack guidance in most cases where needs are identified. The plans did not recognise all needs. The monitoring of identified needs was patchy. This provided for a directionless service in some areas, and makes monitoring and reviewing of the service provided to residents more difficult. Risks relating to residents are considered in practice, but are only recorded for challenging behaviours. What is recorded is not always practiced. EVIDENCE: The files of two residents were checked through during this inspection. A useful system of planning for and monitoring developments under 30 key areas has been set-up. It was however not being implemented in many areas, in terms of either no guidance as to how to address each resident’s need and/or no monitoring of progress in this respect. The owner said that training for staff in drawing up these systems has been done, and that it is up to the staff now to ensure that the systems are used. The inspector is of the opinion that the ultimate responsibility, for ensuring that individual plans of some form are in place and being followed, is with the owner. The plans are necessary, to guide staff and residents about what each residents’ needs are and how staff are expected to support them. Monitoring records are needed in all areas to measure and review progress. The owner must ensure, as previously stated 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 10 within inspection reports dating back to 2003, that individual plans are fully in place for each resident. She must also ensure that relevant information about residents in relation to these plans, and any other significant information, is recorded about within their files. The residents’ files only contained information about risks in relation to potentially challenging behaviours. This guides staff and clarifies to residents about how staff will support them, and so is useful. There also needs to be an assessment of other risks that each resident may be subject to, outside of what is considered behaviours of theirs that challenge, such as risks to health from activities, and how these risks can be handled where possible. Discussion took place with staff and the owner about which residents can be left alone in the house when staff are temporarily at #34. The practice for one resident, who appeared to be alone in the house at the start of the inspection, did not tie-up with the agreed expectation that a staff member should have been present. The owner noted that, as previously required, residents have had formal review meetings within the last six months. Professional feedback has been received to confirm this in some cases. Discussions took place with residents and the owner about residents’ lookedafter money. Residents raised no concerns about how their money is looked after. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, and 16. Residents are partially supported to have a community presence. Records and feedback noted areas where improvements are needed, particularly in terms of college and temple attendance. Staffing levels do not always allow residents to go out when they want to. EVIDENCE: Residents’ views about whether they get sufficient support with going out varied. They listed day centres, college, and going out shopping, as community activities. One person noted that there are sometimes two staff working, which makes going out difficult. Staff explained that lunch out on the day of the inspection had been planned for, but due to the sickness of the third staff member with no replacement, and then because not all residents wished to go out, lunch was being served at home. It was baked potatoes with tuna and sweetcorn. Records provided little evidence of residents going out much, including no college or temple attendance since the end of April for the two residents checked, and of residents recently requesting more activities within their residents’ meeting minutes. Local walks were however a semi-regular occurrence. Feedback from staff and the owner was that activities generally occur. The owner must therefore ensure that that records clearly show the activities that residents have been involved in, that there is always sufficient 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 12 staffing to enable residents to go out (a minimum three people working at some stage, for the duration of a shift, each day), and that college and temple visits are always supported to take place. Previous requirements in this area were partially addressed. There was now a toaster and kettle available to residents in the kitchen, although the kitchen itself was judged as not being kept sufficiently clean to safely prepare food and drinks. Residents generally use the kitchen of #34 however. Residents reported still not having front door keys, but have bedroom keys and locks. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. The service is providing improved access to community health professionals, enabling residents’ health needs to be pursued or addressed. Clothing was identified as needing labelling, to help everyone to ensure that there are no disagreements about whom any piece of clothing belongs to. EVIDENCE: The inspector asked residents about accessing and attending health appointments such as with the GP. No concerns were raised, and two residents could clearly state that they get support to attend appointments. The owner noted that in the recent past, staff have double-booked appointments but that this has now been addressed. One resident was supported to attend an appointment during the inspection. Records showed attendance with a number of health professionals, including for specialist needs in some cases. The owner explained how the health needs of one resident were being pursued. A positive conclusion was about to be reached. One resident was also complimentary about staff’s understanding of his health needs. A couple of residents noted that another resident sometimes wears their trousers. The owner explained that this wasn’t the case, directly to one of these residents, but conceded that clothing needs clear labelling. She must ensure that this is promptly addressed. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There was little evidence of residents feeling listened to about concerns or complaints, or of these being acted on. The complaints processes in the home are not working, which prevents residents from changing the service for the better, and puts them at risk of mistreatment. There is guidance for staff, from management and records, about how to positively work with residents who challenge the service. Staff require formal external training due to the nature and range of challenges faced, and the adult protection policy must be reviewed and updated, for there to be sufficient pro-active abuse prevention strategies. EVIDENCE: All three residents noted some degrees of dissatisfaction with the service. Feedback included being unclear what the outcomes of raised complaints are, of not having complaint processes explained, and about staff and the owner not listening to concerns. One resident complained to the inspector about staffing issues during the inspection. This was put to the owner verbally during the inspection, and confirmed in writing to both parties afterwards. At the time of writing this report, there was no reply from the owner. Issues within the last residents’ meeting minutes were found to be unaddressed. Complaint records were not available. The owner said that they exist, and she cited investigations that she has undertaken in the past. This includes one investigation into an anonymous complaint about care and staffing issues raised with the CSCI since the last inspection, which the owner did not uphold. The inspector explained that records of residents raising concerns, such as missing CDs and trousers, and not going out to specific places as per the residents’ meeting minutes, must be both kept and show the actions taken to address the issues. The owner must additionally address previous requirements about complaints, as stated within the requirements list at the end of this report. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 15 Residents and staff explained that residents can challenge verbally but not physically. Staff said that they have had good training in this respect from the owner, and that issues are considered at fortnightly staff meetings. Guidelines were available to staff about how to positively address each residents’ challenging behaviours. Staff could appropriately explain what to do with an allegation of abuse. There were some occasional records of residents’ challenging behaviour. It remains for the adult protection policy to be reviewed and updated. The owner must also ensure that all staff receive, or have recently had, external training on challenging behaviour and adult protection, due to the nature and range of challenges faced, to help ensure that residents are treated appropriately in such circumstances. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29, and 30. Residents do not live in a fully safe and independence-enhancing environment. The kitchen was not sufficiently clean. The garden had a number of health and safety hazards due to ongoing refurbishment work. The bathroom lacks a working shower despite the shower being installed in recent months. Residents have to spend too much time relying on facilities in the sister home at #34 instead of having them provided in this home. Safety work has taken place to prevent injury due to scalding. EVIDENCE: The home was is a poor state of repair in some areas. The kitchen was spoilt by a severely ripped lino, insufficient cleanliness including within cupboard areas, and the start of a build-up of clothing awaiting washing (mostly in bags, but also two pairs of trousers on the floor). There were also a number of tiedup bags in the garden. This build up was caused by the washing machine being broken. One resident clarified that it had been like this for three days, although the day of the inspection was the first working day since then. The owner said that a professional came to repair the washing machine during the inspection, as seen by the inspector, but they left as they could not get access to the home (as experienced by the inspector at the start of the inspection). The 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 17 issue of fixing the washing machine was made an immediate requirement. It was addressed shortly afterwards. The broken drain cover in the garden was similarly addressed through this method. Other areas in a poor state of repair include the grubby stairway carpet, the items stored in the garden (for both disposal and re-use, including broken chairs around a garden table that were judged as dangerous to sit on), and the shower attachment that one resident pointed out as not working. There is a complete list of requirements in this respect at the end of the report. The owner noted that all hot water taps in the home have recently had temperature control valves fitted. The bath tap was checked and found to be at a suitably safe temperature. Similarly, all radiators now have covers for safety purposes. The lounge was available for use on this occasion, improving on the last inspection. Facilities within one resident’s bedroom had been improved on. Redecoration work now made the bathroom and the downstairs toilet more pleasant and private. There remained an odour control issue within one room in the home. This was discussed with the owner, and must be addressed. The CSCI received correspondence from the local environmental health department in April 2005 noting significant improvements in complying with their previous requirements. . 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, and 35. Staff at the home lack appropriate training. This can prevent them from meeting residents’ needs most effectively. Staffing levels in the home are sometimes too low to meet residents’ needs. EVIDENCE: There were two staff attending to the needs of the six residents of the two homes, upon entry to house #34 (see standards 37-43 below). As explained under standards 11-17, a staff member was sick but no replacement was found, which prevented some residents going out for lunch. One resident complained to the inspector about staffing issues during the inspection (see standards 22-23). Another resident noted that there are sometimes only two staff working, which stops people going out. The owner noted that she cannot afford extra staff, but that normal staffing levels are sufficient according to a staffing model. A staffing level analysis by the inspector, from the rotas supplied for 18/4/05 to 1/5/05, showed an average of 180 hours per week across both homes, down 46 hours per week from the previous inspection. From that roster, only 24 hours of the possible 196 day hours were covered by three or more staff. There were also five occasions across those 14 days when there was only one staff sleeping-in rostered instead of the required two. The owner is again required to provide written proof of how staffing levels, based on residents’ 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 19 needs, are calculated. She must also ensure that 3 staff work together for the majority of each day, to enable residents to pursue community activities and have sufficient staff support, and that two staff always sleep-over at night for similar support reasons. The owner said that staff have been asked to provide certificates for training that they have done. She is liaising with a learning skills council for training courses. Training packs were seen. The owner has yet to use them with staff. Staff spoken with stated that the owner provides individual training. The owner must ensure that, as previously required, a number of requirements around training of staff are addressed, so that staff have sufficient knowledge to provide appropriate care for the residents. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42, and 43. Residents’ views do not always underpin the reviewing and development of the home. There were no formal systems of quality auditing. Improvements are needed in some areas of record keeping to ensure that these records safeguard residents’ best interests. Some aspects of the home and of how it is operated compromise residents’ health and safety. There is no open and accountable management of the service. EVIDENCE: The inspector failed to gain direct access to the home at the start of the inspection. After 15 minutes of trying to gain access via the home’s front door, to no response except for one resident being seen at an upstairs window, the inspector rang at house #34 and gained entry for this unannounced inspection indirectly. A visitor also failed to gain entry to the home during the inspection. The owner must ensure that any visitors are enabled to enter the home unless there are good reasons to prevent this. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 21 It remains for all records to be available for inspection. On this occasion, complaint records and electrical certificates were not available. It has also been required over a number of inspections for the owner to provide audited accounts for the home. These issues must be addressed. The owner appropriately notified the CSCI about an incident involving one resident in January 2005. She must ensure that this is followed-up in writing. There were no other issues requiring notification, she stated. The man-hole cover outside the back door of the home was noted to be cracked, partially exposing the drain underneath. This caused a risk of accident and injury to anyone who stepped on it. The owner was required to make this safe, by immediate action form at the end of the inspection. Verbal feedback stated that this had been achieved. Some risk assessments for the home have been written for some appropriate hazards. The owner must ensure that the process is completed for relevant risks around the home, and that the fire safety risk assessment consider the needs of each resident. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 2 x Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 2 2 1 2 1 Standard No 11 12 13 14 15 16 17 x 2 2 x x 2 x Standard No 31 32 33 34 35 36 Score x 2 1 x 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 36 Shooters Avenue Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 1 1 G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 4 Regulation 12, 16(2)(d) Requirement The furnishings that belong to the resident who moved in in January 2005, but which remain at his old house in Barnway, (including an adapted chair), must be promptly delivered to him. Individual service user plans must show how each need of the service user will be met by the home staff (as guided by Standard 2.3) (timescale of 31/8/03 not met). Individual service user’s communication needs, and how staff are to meet these, must be recorded within their care plan (timescale of 1/5/03 not met). The owner must ensure that relevant information about residents in relation to individual plans, and any other significant information, is recorded about within their files, for monitoring and reviewing purposes. 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 (timescale of 1/3/04 not met). Timescale for action 7/6/05 Now completed. 2. 6 15 31/8/03 3. 6 17(1)(a) schedule 3 3(l) 17(1)(a) schedule 3 1/5/03 4. 6 1/9/05 5. 7 15 1/3/04 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 24 6. 9 13(4) 7. 9 13(4), 18(1)(a) 8. 12 16(2)(m, n) 9. 13 18(1)(a) 10. 13 17(1)(a) schedule 3 12(4), 18(1)(a) 11. 16 12. 16 12(4, 5) 13. 14. 18 22 12(4), 16(2)(f) 17(2) schedule 4 part 11 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 (timescale of 1/8/04 not met). The owner must ensure that expectations on staff about being present in house #36 when any dependant residents are present must be documented on applicable residents files. The expectation must then be practiced. The owner must ensure that college and temple visits are always supported to take place where any resident wishes to attend these. The owner must ensure that there is always sufficient staffing to enable residents to go out (a minimum three people working at some stage, for the duration of a shift, each day). The owner must ensure that records clearly show the activities that residents have been involved in. The owner must ensure that there is sufficient staffing present so as to enable service users to always be able to access their rooms without causing undue hazards (timescale of 15/2/05 not met). The owner must ensure that, unless there are clear and recorded reasons, all residents have a front door key. The owner must ensure that residents clothing is clearly labelled. Records must be kept of residents raising concerns. Records of actions and outcomes of these must also be kept. 1/8/04 1/8/05 1/8/05 1/8/05 1/9/05 1/8/05 1/9/05 1/8/05 1/8/05 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 25 15. 22 12(3) and (5), 22 16. 22 22 17. 22 22 The owner must ensure that service users are able to communicate about any aspect of the home that bothers them, and that she and staff take reasonable actions to address the issues (timescales of 1/5/04 not met). The owner must ensure that all people working in the home are clear on how the complaints system works, and that this is also clearly explained to service users (timescale of 15/3/05 not met). The home’s complaints policy sets up the following: · a central complaints book, · a named complaints manager for the home, · that staff will receive inhouse training on the policy at least annually, · that the policy and any complaints will be reviewed by the manager at least sixmonthly. These must be implemented. The policy must also clarify about the records that will be made of complaints and of actions taken in response. 1/5/04 1/9/05 1/5/04 18. 22 17(2) schedule 4 part 11 12, 13(6) 19. 23 (timescales of 1/5/04 not met in all cases) There were no complaint records 1/8/05 available for viewing, which must be addressed (timescale of 6/5/05 not met). The adult protection policy was 1/4/04 not sufficiently clear about what to do with an allegation. This must be addressed, including for when to notify funding authorities and the CSCI, for ensuring the protection of the all the people involved, and for use Version 1.30 Page 26 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc 20. 23 18(1)(c) 21. 24 13(4), 23(2)(c) 22. 24 23(2)(o) 23. 26 12, 23(2)(f) 24. 27 23(2)(c, d, j) 25. 27 12(1)(a), 13(4)(c) 26. 28 16(2)(j), 23(2)(b) 13(1), 23(2)(n) 27. 29 of the applicable authority’s adult protection procedures (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. All broken chairs in the accessible area of the garden must be made safe or disposed of (timescales of 15/6/04 not met). All excess, waste, and broken items must be disposed of or removed out of communal areas of the home (timescale of 15/2/05 not met). The owner must ensure that each service user is provided with a useable lockable storage space within their bedrooms, to which override keys would only be available to employees in prerecorded emergency scenarios (timescales of 1/4/04 not met). The bathroom must have the shower made fully working, as it is not suitable for service users to have to go through the garden to reach the shower in house #34 (timescale of 22/2/05 not met). The lock in the downstairs toilet must be replaced with one that can be over-ridden in case of emergency (timescale of 1/5/05 not met). The kitchen lino must be replaced due to extensive wear and tear (original replacement timescale of 1/6/04 not met). 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 (timescales of 1/7/04 not met). 1/10/05 15/6/04 1/8/05 1/4/04 15/7/05 1/9/05 1/6/04 1/7/04 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 27 28. 30 29. 30 30. 30 31. 30 32. 30 33. 34. 30 32 35. 33 36. 33 The kitchen, now being used only for laundry, must be thoroughly cleaned, to remove of old and ingrained marks and stains such as old food stains (timescale of 10/2/05 not met) including within cupboards. 12(4) and (Further) Action must be taken 16(2)(k) to both address the smell, and the cause of the smell, in the room with an offensive odour so that the odour is permanently removed (timescales of 1/5/04 not met). 16(2)(j) The owner must ensure that soap is always available in communal area toilets. It was missing from the downstairs toilet on this occasion (timescale of 1/2/05 not met). 23(2)(c) There was no working washing machine available for service users of the home. The machine must be fixed or replaced. 12(4), The owner must ensure that all 16(2)(e, f, clothing awaiting washing is j) hygienically stored, not left in a pile on the kitchen floor as on this inspection. 23(2)(d) The grubby stairway carpet must be thoroughly cleaned or replaced. 18(1)(c) At least 50 of staff have must have achieved the NVQ level 2 in care award by 2005 (timescale of 1/1/05 not met). 18(1)(a) The owner must explain why there was no-one rostered between the hours of 10am and 5pm on 6th January 2005 (timescale of 22/2/05 not met). 18(1)(a) The owner must provide explanations about how the rosters provide sufficient staffing to meet the needs of service users (timescale of 22/2/05 not met). G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc 16(2)(j) 15/7/05 1/5/04 1/8/05 3/6/05 Now completed. 15/7/05 1/8/05 1/1/05 1/8/05 1/8/05 36 Shooters Avenue Version 1.30 Page 28 37. 33 12(1), 18(1)(a) 18(1)(c) 38. 35 39. 35 18(1)(c) 40. 39 24 41. 41 17(3)(b) 42. 41 37 43. 42 12(1), 13(4), 23(2)(o) The owner must ensure that two staff always sleep-over at night, and that roster records confirm this. The owner noted that most staff need to attend a number of mandatory training courses. They must attend to this within suitable timescales (timescale of 1/6/05 not met). As per the new policies,: · individual staff must have recorded needs assessments annually; · new staff must be trained in accordance to the learning disability awards framework (LDAF); and the home must have a training and development plan with a designated training budget. (timescales of 1/6/04 not met) A system of regular reviewing, and improving, the quality of care provided at the home, 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 (timescales of 1/9/03 not met). All records required under legislation must be available for inspection. They must also be available for use by applicable people (timescales of 1/7/04 not met). The owner appropriately notified the CSCI about an incident involving one resident in January 2005. She must ensure that this is followed-up in writing. The man-hole cover outside the back door of the home was noted to be cracked, partially 15/7/05 1/9/05 1/6/04 1/9/03 1/7/04 1/8/05 1/8/05 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 29 44. 42 18(1), 23(4)(d) 45. 42 23(4) 46. 42 10(1), 12(1), 13(4), 16(2)(j) 47. 43 25 48. 43 10(1), 18(1) exposing the drain underneath. It must first be made safe, and must then be fixed. Staff must have formal fire safety training, with follow-up training within the home on a regular basis (timescales of 1/7/03 not met). The fire-safety risk assessment must be improved upon, as it was seen to miss a number of potential hazards (timescale of 1/9/04 not met) including the needs of each resident. General health and safety assessments for the systems in the home must be undertaken and recorded (timescale of 1/4/04 partially met but the process must be completed for all relevant risks around the home). A copy of the accounts for the financial year, 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 (timescales of 2/6/03 not met). The owner must ensure that any visitors are enabled to enter the home unless there are good reasons to prevent this. 1/7/03 1/9/04 1/4/04 2/6/03 15/7/05 49. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 30 36 Shooters Avenue Standard 1. 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 31 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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. Extracts may not be used or reproduced without the express permission of CSCI 36 Shooters Avenue G62-G11 S17578 36 Shooters Avenue V230332 310505 Stage 4.doc Version 1.30 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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