Inspection on 04/07/07 for 72 Eltham Avenue

This inspection was carried out on 4th July 2007.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 72 Eltham Avenue Cippenham Slough Berks SL1 5UP Lead Inspector Stephen Webb Unannounced Inspection 4th July 2007 10:15 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 72 Eltham Avenue Address Cippenham Slough Berks SL1 5UP 01753 822483 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) ibrooks@adepta.or.uk www.pentahact.org.uk Adepta Mrs Isobel Brooks Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection None Brief Description of the Service: 72 Eltham Avenue is a purpose built home for six residents with a learning disability, some of whom may also have associated physical disabilities. The home is located on a residential housing estate in Cippenham, Slough, and provides accommodation and care for up to six residents of either gender, though at the point of inspection, four residents were present, all of whom were female. A range of specialist adaptations have been made to the home in order to meet the needs of residents with physical disabilities, This was the first inspection of the service under the new providers, Adepta, who took over responsibility for the home on the 19th of March 2007. The home is operated by Adepta, within premises owned by Windsor and Maidenhead Housing Association. The residential care component of the fees, paid for by residents at the time of this inspection was £63.95 per week plus an additional contribution towards the cost of the home’s leased vehicle, from mobility allowance, though the rates for this had yet to be determined. The resident’s local authority provides the balance of fees. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.15am until 6.15pm on the 4th of July 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the manager, some of the staff members on duty during the day, and with one resident. Only one of the residents was able to communicate verbally with the inspector, so time was also spent observing the interactions between residents and staff at various points during the inspection and over lunch with the residents. Written feedback was obtained from the relatives of three of the residents, a GP, and three external healthcare professionals. All who were broadly happy with the service in so far as they felt able to comment, though one felt that staff would benefit from a greater understanding of some of the complex needs of residents and one commented that there was not always a senior member of staff available with whom to discuss a resident. The inspector also toured the premises, and ate lunch with the residents. It was evident that the home was effectively managed on a day-to-day basis by an effective management team, and that the care delivered to residents was appropriate, but a number of issues are identified which are within the remit of the provider to address in order to support and underpin the care practice, and maximise the potential of the unit. What the service does well: The needs and goals of the residents are recorded within their care plans, which also indicate their preferences regarding how they receive any support that is necessary. The residents are enabled and supported to make decisions within their daily lives, and to take appropriate risks as part of enjoying a quality life experience, within the context of appropriate risk assessments. Residents have opportunities to take part in appropriate activities and staff try to engage with them wherever possible. Whilst they do have access to events in the local community, this is limited, at times, by the lack of a dedicated unit vehicle. The rights of residents are supported by the staff, who also encourage them to take part in daily routines and tasks. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 6 An appropriate and varied diet is provided to residents, with alternatives made available if a resident indicates they do not want a particular meal. The healthcare needs of residents are met by the service, and appropriate consultation with external healthcare professionals takes place. The home has an appropriate system to manage the medication on behalf of residents and has offered one resident the opportunity to manage their own medication. Staff are trained and tested on medication administration. The service has an appropriate complaints procedure in place and available within the home. One resident was able to confirm their awareness of the procedure. The training records indicated that all staff had received POVA training updates at some point, during 2006. Residents live in a homely and safe environment, within which adaptations have been made to address the needs of individuals. The home was found to be clean and standards of hygiene were good. The laundry facilities are appropriate to the needs of the service. The needs of residents are met by a core of competent and well-trained staff, supplemented, where necessary, by known agency staff who are familiar with the unit. The provider’s recruitment and vetting system provides protection to residents. Staff have received a good core training under the previous provider, which the new provider will need to continue in order to meet the needs of residents. Observed practice within the unit was good, and the manager demonstrated a clear understanding of appropriate practice in the areas discussed. The health safety and welfare of residents was promoted and protected for the most part. What has improved since the last inspection? Good progress has been made with NVQ and with the recruitment of additional permanent staff to the team. Residents have been enabled to go swimming now that an appropriately equipped local facility has been identified. The manager indicated that menus and diet had been improved by focusing on the provision of more fruit and vegetables. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 7 Some new furniture and equipment has been provided. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents do not currently have the specified information available to them to enable an informed decision about the appropriateness of the service. Though any initial assessments on current residents were likely to have been archived, there was evidence that the current needs and aspirations of existing residents were being addressed, and reviewed, and the provider’s assessment procedure was appropriate to assess the needs of future referrals. Residents did not have contracts or statements of terms and conditions in place relating to the current provider. EVIDENCE: Examination of a sample of resident files indicated the presence of a Core assessment of need in one case, and a discharge summary in another, though all of the residents transferred from the healthcare trust when Adepta took over responsibility for the home, having been admitted to the unit in 2002, (three residents), or 2002, (one resident). Other assessment documentation is likely to have been archived. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 10 Current care documentation satisfactorily reflected the needs and aspirations of individuals. The provider’s assessment and admissions procedure was not initially available for examination in the unit, but a copy was faxed through at the inspector’s request. The procedure described was appropriate, and included a pre-admission assessment visit to the prospective resident, the gathering of information from a range of sources, the allocation of a keyworker and visits to the home. The procedure indicated that any new admission would also be considered in the context of the needs of the existing residents, to try to ensure the minimum of conflicts. The procedure also suggests that the prospective residents brings a familiar item to be left in the home on each visit so that these items might ease the transition and help to convey the message that they are moving home. The assessment document itself was thorough and would enable the home to build up a picture of the needs and wishes of the prospective resident. The manager indicated that a prospective resident for one of the vacant beds had been identified, though this was in the very early stages and the assessment had yet to be undertaken. It is of concern, however, that residents still do not have a service user guide, contract or statement of terms and conditions relating to their care from the current providers, despite Adepta having taken over responsibility for the service in March 2007. A draft contract was shown to the inspector, but the terms and conditions statement, was incomplete in that it did not itemise the specific furniture which the provider supplies within the bedroom, nor detail any specific additional financial contributions expected from the resident’s own funds over and above the basic fees. Mention will also need to be made of any contributions required towards a unit vehicle or other transport costs. It will be necessary, within the required documents to address all of the items within the relevant regulations and standards, including details regarding the specific services and charges which are included and excluded within the fees, since there is some doubt regarding what residents will be expected to fund for themselves under the new provider. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The needs, goals, choices etc. of residents are recorded within their care plans, which also indicate their preferences regarding how they receive any support that is necessary. Residents are enabled and supported to make decisions within their daily lives. Residents are supported to take appropriate risks as part of enjoying a quality life experience, within the context of appropriate risk assessments. EVIDENCE: Examination of a sample of care plans and other care records indicated a good level of detail regarding the needs, wishes, likes and dislikes of the individual residents, within a person-centred plan format. The manager and staff espoused and demonstrated appropriate values in terms of residents right to decision-making and a quality life experience. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 12 Detailed information regarding likes and dislikes was present within a range of formats detailing things that are important for the resident, things they wish the staff to know about them, details of their interests and what they enjoy and of their preferred routines throughout the day, and the level and method of support preferred, including guidance on the use of the sling-hoist. There was a good deal of evidence of residents making choices for themselves within these documents, which were supported by relevant individual risk assessments, which sought to enable, rather than exclude from activities. One resident had signed an agreement for the staff to look after their key to the front door of the whole building after throwing one away, but does have a key to their upstairs flat. Information was also present on how best to respond to specific behaviours, where relevant, to provide a consistent approach. Copies of review minutes were present indicating recent reviews of needs, which addressed skills development, care and support needs as well as ‘cultural’ support. Daily notes recording the activities, and daily life of residents were maintained in bound exercise books. Individual balance sheet records of resident’s finances are maintained and kept secure, and each resident has an individual locked cash tin. The balance is checked and recorded daily, at handover. Individual bankbooks are kept separately and the balances therein, are also checked daily. Examination of a sample of these records indicated appropriate recording and a double-signatory system is operated for any monies in and out. One of the residents is able to sign for money provided to them. Receipts are retained for any expenditure of residents’ funds. These records are audited on a sampling basis during Regulation 26 monitoring visits on behalf of the provider. The costs of necessary staffing support and food within the home are appropriately covered by the home having been included in the fees. The situation when a resident is away on holiday was less clear. The provider should detail these financial aspects within the statement of terms and conditions, which they have been required to produce. One resident lives upstairs in a self-contained flat, where staff support is usually provided only at her request. She does visit the downstairs ‘unit’ but the two spaces are seen as independent of each other for the most part, though she is able to visit the downstairs residents with their agreement. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to take part in appropriate activities and staff try to engage them wherever possible. Whilst they do have access to events in the local community, this is limited, at times, by the lack of a dedicated unit vehicle. Further consideration of the proposed vehicle provision and associated contract, is needed by the provider. Residents have limited family contact and none has a family member who acts in an advocacy capacity. The rights of residents are supported by the staff, who also encourage them to take part in daily routines and tasks. An appropriate and varied diet is provided to residents, with alternatives made available if a resident indicates they do not want a particular meal. Meals are taken in the kitchen/diner, which is very much the hub of the home, except for the resident who lives semi-independently in the upstairs flat. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 14 EVIDENCE: One of the staff is designated as activities coordinator, who takes the lead on planning and arranging for new activities. An information file with leaflets for various local attractions, was available in the office. The known interests and preferred activities of residents are recorded within the various care plan documents. None of the current residents attends college, though one of them used to, and may do so again in the future. Each of the residents has three sessions of day care service per week, amounting to a day and a half each, of various activities. Residents have the choice of whether they wish to attend, though they are encouraged to do so. Residents go swimming weekly and have meals out. They have been to a local farm park, and on a trip to Windsor, and are members of the local library for CD and DVD loans. Residents also visit a local pub and occasionally go to the cinema. An aromatherapist visits for one resident on a monthly basis. During the inspection, residents went out to day services, and one went shopping with a staff member, but the lack of a dedicated house vehicle places limitations on the level of community access by residents. At present the service has use of an adapted vehicle, which is shared with another local home, necessitating advanced booking to ensure its availability, which reduces the options for impromptu outings. One resident uses a bus pass and some taxis are also used to supplement the available transport. There were three available drivers for the vehicle in the team, at the time of inspection. The home also makes use of a local transport service but this is limited to local trips and also has to be booked in advance. Given the level of specialist need of residents within this service, serious consideration needs to be given to the provision of a dedicated suitably adapted vehicle for the exclusive use of the home, in order to maximise the level and quality of community accessibility for the residents. In many homes part funding of such a vehicle is achieved by contributions taken from residents’ mobility allowance at source. The provider has developed a draft lease vehicle agreement, which is being considered for use with residents, but this is understood still to be for a vehicle that will be shared between this unit and another. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 15 It is not really appropriate to expect residents to contribute financially to a unit vehicle when their access to it will be significantly limited by the fact of it being shared with another home, particularly at the contribution levels under consideration. Within the draft agreement it is also an expectation that the residents additionally pay a share of the petrol costs and would be responsible for paying any excess should an insurance claim need to be made. These additional elements also appear inappropriate once the resident has paid a significant contribution towards the vehicle itself, and in any event, holding residents responsible for any insurance excess would be inappropriate as it is unlikely that the claim would result from any direct action of the residents if properly supervised. It may also be inappropriate to increase the monthly contributions of residents where a resident moves out, since occupancy levels are not within their control, and are the responsibility of the provider. The provider should reconsider the most appropriate financial and contractual arrangements, perhaps in consultation with an external advocacy service, on behalf of the residents. Whatever arrangements are decided upon, they should be demonstrably even handed between the residents, and proportionate to their level of usage. The home has a collective record of activities, though it is not always completed by staff, when an activity takes place. Often these are recorded within the handover book instead. It is suggested that consideration be given to the maintenance of individualised records of activities and community access, as part of the care history for each resident. Such a record would make it easier to establish the level of activities provision for monitoring purposes. The current residents are all of white UK origin but their individual ‘cultural’ needs are recorded and addressed when identified. Support is provided to enable residents to remain in control of their own behaviour within the context of their surroundings and activity. Wider cultural diversity is also celebrated. The staff have previously organised Italian and African themed nights, and were in the process of preparing for a West Indian themed night the following day. This included making carnival costumes and flags for staff and residents as well as examples of West Indian cuisine. Residents were involved in trying on the costumes during the process. The success of the previous theme nights was indicated by the framed photomontages of these events, which were displayed. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 16 Residents go on holidays, annually but are having to pay for their own holiday accommodation as the funding authority do not fund holidays. All have sufficient funds to enable this. There was some doubt about whether residents also had to pay the costs of the staff entrance fees etc. when on holiday with support staff. The provider needs to clearly state what expenses residents are expected to be responsible for, within the new terms and conditions document, as this information was not available within the unit. (Requirement made under Standard 5). The current residents were said to have very limited or no family contact and none were considered as having a family member available to act in an advocacy capacity. However, the manager was clear that the home would support and encourage family contact, where appropriate. However, three relatives did complete and return inspection comment cards, and expressed satisfaction with the care provided at the home, in so far as they were aware of it. Residents are given various household tasks to undertake with support according to their interest and ability to take part, but may just be expected to be present with the staff member while they undertake the task, and the staff member will chat to them and involve them thus. One resident does a lot of her own shopping and meal preparation and cooking with staff available to offer support when she requests it. She is also largely responsible for planning her weekly menu with some support from staff to address healthy eating considerations. The level of disabilities of the other residents limits the degree to which they can be actively involved in shopping and cooking but they are involved in the process as much as possible by being present, perhaps putting on aprons and enjoying the aromas and flavours of the meals being prepared, and being engaged by the staff while the cooking is done. This was observed during the inspection while West Indian meals were being cooked in preparation for the following days West Indian evening. Three of the residents were present in the kitchen-diner, which is very much the hub of the home, to which everyone gravitates. Staff are aware of the food likes and dislikes of the residents, and menus are planned based on these within a twelve-week cycle. Three of the residents were said to be able to make only limited menu choices in advance. However an alternative is always offered at the time where anyone indicates they do not like the meal offered. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 17 The staff are aware of how individuals indicate their like or dislike of food, and this is also recorded within care plans. Meals were said to be prepared mainly from fresh ingredients and this was evident during the inspection. Homemade cakes were also in evidence. One resident needs their meals to be liquidised and this is done separately to the various elements in order to preserve some variety in taste and texture. Main meals are served in dishes on the table and each resident is asked whether they would like the various items. Adapted cutlery and crockery is also available where appropriate, to maximise the independence of residents and to try to ensure that hot meals remain hot throughout the meal. Meals are taken in the kitchen/diner, which is the hub of the home, to which the ground floor residents gravitate, though as already noted, one resident lives semi-independently in the first floor flat, and tends to eat her meals there, with staff company if she wishes. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support is provided to residents according to their stated or indicated preferences and their needs. Individuals’ preferences are recorded in detail. The healthcare needs of residents are met by the service, and appropriate consultation with external healthcare professionals takes place. A healthcare review for all residents should be considered, as this last took place in 2005. The home has an appropriate system to manage the medication on behalf of residents and has offered one resident the opportunity to manage their own medication. Staff are trained and tested on medication administration, but need an update to their training on epilepsy, which was last provided in 2003. EVIDENCE: As already noted the care plans provide considerable detail regarding the needs and individual preferences of residents with regard to their care and support. They reflect an appropriate level of consultation, where possible, and interpretation, based on experience and knowledge of the communication 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 19 methods of individuals, in identifying their likes and dislikes. There was specific information on how individuals communicate various emotions non-verbally. The advice of a speech and language therapist had previously been sought. Residents still retain the opportunity to make choices and to indicate different preferences at times, and observation during the inspection, indicated that these were accommodated by staff. Where necessary, guidance was in place to indicate the appropriate response to specific behaviours in order to provide a consistent approach, though it was said that these had rarely been needed in the recent past. The new provider has in house behavioural psychology support available if required, who is scheduled to visit in August to review the existing guidelines. One resident said she was happy that staff supported her when she wanted, and left her to it, when she did not want support. She also indicated that the staff checked back with her regularly, to see she was still managing alright. This resident’s independence, privacy and dignity were also addressed by the provision of her own door key to her first floor flat in the home. Observation during the inspection indicated that staff were aware of the individual approaches to residents and understood their communication, and they were seen to try to engage individuals in whatever was going on. Relationships between staff and residents were friendly and there was evidence of warmth and humour. Information was also present detailing how to keep individual residents safe, on healthy eating guidance for one resident, and an individual exercise programme, and regarding residents’ individual preferences about how to take their medication. The home has various adaptations in place to assist in meeting the needs of the ground floor residents, in relation to physical disabilities, including a mobile hoist and tracking hoists in bathrooms, and a height-adjustable bath. However, consideration should be given to the possible benefits of additional overhead tracking hoists in two of the bedrooms, in consultation with an Occupational Therapist. This is discussed further within the premises section of this report. Healthcare records are made within a typed format to guide their completion with the necessary information. Owing to archival of the records under the previous provider, it was not always possible to identify the dates of the most recent appointments, and it is suggested that these dates should be brought forward and indicated within the new system to enable effective monitoring. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 20 The files examined did contain copies of old healthcare checklists dating from 2005, and consideration should be given to undertaking a new comprehensive healthcare review to bring these records up to date. The manager and deputy both have the assessor and verifier NVQ units and are accredited trainers for medication. All staff receive their medication training from them, undertake a written medication assessment and are observed, prior to administering medication themselves. The home uses a monitored dosage system and an audit trail, including records of medication quantities received and returned, is maintained to enable monitoring. A double signatory system is used to record administration. However, one resident is prescribed anti-epilepsy medication and staff last received training on epilepsy in 2003. The manager must arrange for staff to receive an update of this training from an appropriately qualified trainer. One resident has been asked whether she would like to administer her own medication, but has declined. Her medication is stored in a small medication cabinet in her flat, and is administered from there. None of the other residents would be able to self-administer. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has an appropriate complaints procedure in place and available within the home. One resident was able to confirm their awareness of the procedure. It was not possible to locate copies of the policies/procedures on whistle blowing and the protection of vulnerable adults within the home, in order to evaluate these documents, and ensure that they afford appropriate protection to residents. The provider must make these documents readily available in the unit to all staff. However, the training records indicated that all staff had received POVA training updates at some point, during 2006. EVIDENCE: The home has an appropriate complaints procedure in place, and a version in text and picture format, which would support its explanation to residents. The manager indicated that the procedure is explained to residents but it is not always possible to gauge whether this has been understood. It was felt that the residents would all be able to express their unhappiness about something, but this would depend on interpretation by staff of their nonverbal communication, in the case of three of the residents. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 22 One resident would be able to make a verbal complaint, and she confirmed to the inspector that she would go to the manager or staff if she was unhappy. Examination of the complaints log indicated that there had been no entries to date, so it was not possible to evaluate the procedure in action. The staff guidance on the complaints procedure does allude to their potential advocacy role in bringing a complaint on behalf of a resident who is unable to do so themselves, which is good practice. The Commission has not received any complaints for referral to the service since the last inspection, under the previous providers. The manager said that the service had appropriate policies/procedures on the protection of vulnerable adults, and whistle-blowing, but these were not available in the unit or easily located on the unit’s computer. The local multi-agency POVA guidance was available in the office, together with the DoH guidance, and the contact phone numbers regarding POVA issues were posted in the office. One staff member indicated their awareness of appropriate practice in terms of adult protection and knew the extent of their role and to whom they should report any concern. The provider must ensure that copies of the POVA and whistle blowing policies/procedures are readily available to staff within the unit. It is suggested that paper copies be retained since they remain available to staff should the computer copy not be accessible. POVA training was provided to all staff under the previous provider, over a range of dates between February and December 2006, and should be regularly updated henceforth by the current provider. As previously noted, appropriate systems are in place within the unit to protect residents funds from abuse, though further clarification of financial responsibilities in some areas, is needed within the required statement of terms and conditions or contract. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and safe environment, within which adaptations have been made to address the needs of individuals. Consideration should, however, be given to further developments as described, to maximise the appropriateness of the equipment provided. The home was found to be clean and standards of hygiene were good. The laundry facilities are appropriate to the needs of the service. EVIDENCE: The home’s décor was attractive and homely, with lots of pictures and photos of residents enjoying past events. Corridors were wide and well lit. There are five ground floor bedrooms and a first floor self-contained flat. There is a pleasant communal lounge and a large kitchen/diner, which is the real hub of the home. One of the resident’s has her favourite armchair sited there so she can be where everyone tends to gravitate. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 24 There is an adapted bathroom with a height-adjustable bath and adjustable shower table, and also an adapted level entry shower room with a further shower table. Both are equipped with appropriate locking devices. In order to meet the needs of the residents with complex physical disabilities, ceiling tracking hoists have been installed in the two bathrooms to assist with transfers to and from the residents’ individually adapted wheelchairs. It is recommended that an occupational therapist be consulted regarding the potential benefits of providing a similar ceiling tracking hoist system within each of the residents’ bedrooms to assist with transfers there. The home does have a mobile hoist available but this is not always the most appropriate method for resident and staff wellbeing. The bedrooms were homely and personalised to reflect the interests of their occupant. Each resident has a single bedroom. One resident had been involved in the repainting of her bedroom. The home has begun to develop a sensory room, which is enjoyed, by one resident in particular. There is scope for further development of this facility. One resident, who has greater independent living skills, lives upstairs in the self-contained flat, with her own bathroom, kitchen, lounge and bedroom, to which she has a front door key. The home has an attractive, enclosed rear garden, though it is affected by the noise from the nearby motorway. A pergola provides shade from the sun, and the level paved pathways and patio, ensure the garden is fully accessible to residents, though some require staff support to use the area. At the time of inspection there were building works being undertaken in the road outside the home, as part of extensions of the housing estate, but the contractors had provided a level pathway around the works for wheelchair access to the unit, although the parking area at the front of the building was not currently accessible. It is understood that works will also be done to ensure that there is a suitable transition between the home’s frontage and the new roadway on completion of the works, to enable easy access. The laundry is appropriately equipped to meet the needs of the residents, though most would be able to have little direct involvement in undertaking their own laundry. Observed standards of hygiene in the home, were good and there were no residual odours, suggesting that continence issues are well managed. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are met by a core of competent and well-trained staff, supplemented, where necessary, by known agency staff who are familiar with the unit. Good progress is being made with NVQ. Good progress is being made with the recruitment of additional permanent staff to the team. The provider’s recruitment and vetting system provides protection to residents, but the necessary evidence of this process must be available for inspection within the unit. Staff have received a good core training under the previous provider, which the new provider will need to continue in order to meet the needs of residents. EVIDENCE: The staff on duty on the day of inspection were motivated, keen and actively engaged the residents in the day-to-day tasks and events in the home, at whatever level they wished to be involved. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 26 One staff member stayed on duty after their shift ended to help colleagues complete some of the preparations for the West Indian evening the following day and staff had also contributed items toward the event. They demonstrated an understanding of the individual needs, communication and preferences of the residents, which was reflected in the care plans etc. The standard staffing for the unit is four staff on the early shift and four on the late shift with one waking night and a sleep-in staff nightly. However, with two vacant beds, this has been reduced to three during the day at present, which appears to be sufficient to meet the needs of existing residents. The policy of the new provider is to retain all staff recruitment records at head office, which made it impossible to verify the appropriateness of the recruitment and vetting process. Copies of CRB check confirmation, references and ID confirmation were requested and were faxed through to the unit to enable this to be checked. The records sampled indicated an appropriate vetting process, and the manager confirmed that the process was in accordance with the standards and regulations. If the provider is to continue holding these records at head office only, then a fully completed checklist of the required items, signed off by an appropriate person, should be supplied to the unit and filed for inspection. This should include confirmation that a satisfactory CRB check at enhanced level was returned, The CRB reference number and confirmation that a POVA check was also requested also need to be provided. The provider could alternatively retain copies of the required documents and evidence of recruitment and vetting securely within the unit, for inspection. In addition to the usual checks, the provider expects candidates to demonstrate their literacy and numeracy, in written tests. The manager indicated that un-covered shifts are staffed either from existing staff members or known agency staff who have been used previously and are familiar to and with the residents and their needs, in order to maximise consistency and continuity. The manager confirmed that she checks that agency staff have received the basic training and have the right to work the hours in question, before they are first used. Two long-term agency staff have recently been recruited onto the permanent team and were due to become permanent staff in the near future. A further new staff member had been recruited externally and was awaiting pre72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 27 employment checks, and a new bank staff had also been appointed. The unit will still have two vacant posts within its staff complement after this. Two staff had recently completed their fast-track NVQ, one at level 2 and one at level 3, so there were three support staff with NVQ. The manager and deputy both have NVQ level 4 and their Registered Manager’s Award, and one other staff is a part-time student nurse, and another is leaving. New staff will commence their NVQ after their induction and foundation training. One staff member described her induction, which took place over four days, (under the previous provider), when she started working at the home, which appeared to have been thorough, and the core training she had attended. She had also completed her NVQ level 3. Staff have previously received the required core training and individual staff training record sheets are maintained. Staff have received SCIP training on managing challenging behaviour, which focuses mainly on preventive and deescalation techniques. A cycle of clinical updates was undertaken in late 2006, to address any gaps in the core training. The new provider will need to maintain the necessary training levels via regular updates and ensure that new recruits receive the required induction and core training. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40 and 42: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home at the unit level, though the provider needs to ensure that required documents, policies, procedures and systems are put in place, where these are absent, in order to guide practice and ensure consistency. The provider has adopted a quality assurance system for seeking the views of residents and others, but this has yet to be actioned within the unit. Required monthly monitoring visits must be undertaken monthly and the resulting reports copied to the manager. Observed practice within the unit was good, and the manager demonstrated a clear understanding of appropriate practice in the areas discussed. However, the absence of a number of required policies and procedures, within the unit, and of a comprehensive set of guidance for staff, could compromise the rights and best interests of residents. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 29 The health safety and welfare of residents was promoted and protected for the most part, though the absence of a written procedure for accident reporting and the lack of evidence of the required electrical testing having been undertaken, could compromise this. EVIDENCE: The manager is appropriately experienced and qualified. She has thirteen years care experience and has attained her NVQ Level 4 and Registered Manager’s Award. She also has a Degree in Health and Social Studies. The manager also attends regular training courses to update her knowledge and practice. The deputy manager is a nurse who has also attained her NVQ Level 4 and the RMA. The management team are effective in their role and the home is well-run on a day-to-day basis, with staff having clear leadership and expectations from the management within the unit. The provider has introduced the ISAQ (international Standards for Assuring Quality) system to measure and review the quality of their service, but a quality assurance cycle has yet to be undertaken within the unit and the manager was not aware of a proposed date for this, though she understood it to be an annual process. Under the previous provider quality assurance was addressed as an ongoing rolling programme, which was last undertaken in 2006. However, the new provider should undertake a quality assurance review to establish a baseline for the current performance of the service. Since they became responsible for the service, the provider has only undertaken Regulation 26 monitoring visits in May, (2nd of May), and June, 7th of June), though these were in fact labelled as April and May’s reports. The report should relate to the month in which the visit was undertaken, and visits must be undertaken within each calendar month. There was no evidence that a monitoring visit had taken place in April. The reports for the two visits that had taken place were not initially available in the unit for inspection, but were emailed through during the inspection. The manager cannot address the issues within Regulation 26 reports if they are not provided with a copy within a reasonable timescale after each visit. The provider must ensure that visits take place monthly and that copies of the resulting reports are forwarded promptly, to the unit for action on any issues therein, and filing for subsequent inspection. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 30 A number of required policies and procedures could not be located during the inspection, and there did not appear to be a procedures manual, where all of the key policies and procedures were held together for ease of access by staff. The provider should ensure that all of the policies and procedures required under Standard 40 and Appendix 2 of the National Minimum Standards are available within the unit. It is suggested that to rely solely on a computer based set of policies and procedures is not sufficient, since they may be rendered unavailable for a variety of reasons, and paper copies are strongly recommended in addition to any computerised resource. It is also recommended that the policies and procedures documents are held collectively within an indexed folder to enable them to be found easily. The provision of signature sheets for staff to sign to confirm they have read and understood the policies and procedures, provides a degree of accountability, and is also good practice. The home has the recommended tear-off accident recording pad, but there had been no accidents to residents since the new provider took over responsibility for the unit in March 2007. A RIDDOR report pad was also available for use when appropriate. The manager indicated that the provider also has an in-house accident record which has to be completed in addition to the legal format, which seems to be an unnecessary duplication, which could potentially lead to confusion. However, it was not possible to locate a copy of a current accident reporting procedure under the new provider, to clarify their expectations with respect to the filing of the accident forms. There is a requirement for a collective accident record for the unit, for monitoring purposes, and in addition, an individual record of accidents to a resident must be made within their case record. This is most simply achieved by copying the completed statutory accident form so that a copy is placed in both the collective record and within the relevant resident’s case record. In order to ensure consistent accident recording practice the provider must provide a written procedure. Examination of a sample of health and safety-related service certification indicated that required servicing had been undertaken within appropriate timescales with the exception of the five-yearly testing of the electrical installation, of which no evidence could be located. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 31 The provider should arrange for this testing to be done if evidence cannot be produced that it has been undertaken within the last five years. A copy of the certification should be provided to the unit for filing with other certificates. Fire drill records were detailed and indicated recent drills in September 2006 and February 2007, and the unit fire risk assessment had been reviewed in March 2007. Individual fire risk assessments were also in place, which had been agreed with the fire authority. 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 2 X 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? NO 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 YA1 Regulation 5 Requirement A service user guide must be produced by the provider, which addresses Standard 1, and Regulation 5. Timescale for action 04/09/07 2 YA5 3 YA20 4 YA23 5 YA34 The document should be in a suitable format to support its explanation to residents, where this is possible. 4& A written contract/statement of 5(1)(b)&(c) terms and conditions, must be produced by the provider, which fully addresses Standard 5 and Regulation 4 and 5. 13(2) & 18 The manager must arrange for an update to the epilepsy training for all staff to ensure they have up-to-date knowledge relating to this condition. 12(1)(a) & The provider must make copies 13(6) of the whistle blowing and vulnerable adults protection, policies/procedures available to staff within the unit, to enable staff to make reference to these if required. 17(2) & The provider must ensure that Schedule 4 evidence of the required recruitment and vetting process for any staff recruited since it DS0000069482.V345171.R01.S.doc 04/09/07 04/10/07 04/08/07 04/09/07 72 Eltham Avenue Version 5.2 Page 34 took responsibility for the service, is available for inspection within the unit. Evidence of the required process must also be available for any future appointments. The provider must ensure that 04/08/07 Regulation 26 monitoring visits take place on a monthly basis and copies of the resulting reports must be provided to the manager, for action, and for filing within the unit. The provider must ensure that 04/08/07 an appropriate procedure for the recording of accidents to residents is instigated. A copy of the procedure should also be made available within the unit. 6 YA39 26 7 YA42 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA13 Good Practice Recommendations The provider should give further consideration to the proposed vehicle provision for the unit, and the contracting thereof, to ensure that residents have ready access to appropriate transport in order to maximise their community access, within an appropriate contractual arrangement, which respects their rights. The manager should consider a healthcare review for each resident as these were last undertaken in 2005 The provider should consider consulting with an OT with regard to the potential benefits of installing ceiling tracking hoists within the identified residents’ bedrooms to facilitate transfers to and from the residents’ beds. The provider should consider the benefits of undertaking an early quality assurance survey to establish a baseline for the performance of the service. DS0000069482.V345171.R01.S.doc Version 5.2 Page 35 2 3 YA19 YA24 4 YA39 72 Eltham Avenue 5 YA40 The provider should ensure that all of the required policies and procedures are readily available to staff within the unit, in order to ensure consistent and appropriate practice by staff. It is strongly recommended that they be held within an indexed Policies and Procedures file, which includes a system of staff countersignature, to confirm their familiarity with the documents, since this provides for a degree of accountability on the part of the staff. The provider should ensure that the required five-yearly electrical installation testing has been carried out and that a copy of a current certificate is available for inspection within the unit records. 6 YA42 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 72 Eltham Avenue DS0000069482.V345171.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!