Inspection on 01/06/05 for Albemarle Road, 33

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Albemarle Road, 33 27/09/07

Albemarle Road, 33 11/09/06

Albemarle Road, 33 21/12/05

Albemarle Road, 33 15/12/04

Albemarle Road, 33 02/08/04

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

CARE HOME ADULTS 18-65 Albemarle Road 33 Albemarle Road Beckenham Kent BR3 5HL Lead Inspector Rosemary Blenkinsopp Announced 1 June 2005 09.45 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. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Albemarle Road Address 33 Albemarle Road, Beckenham, Kent BR3 5HL 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) 020 8663 6225 Community Options Limited Vacant Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 7 Adults with a Mental disorder. Date of last inspection 15/12/04 Brief Description of the Service: The home is an adapted building located in residential area of Beckenham. The house is over two floors accessed by stairs. All communal accommodation is on the ground floor, with the smoking area located in the living room. The dining area is a no smoking area and this also provides seating, which can be used by service users who do not smoke. The home is part of the Community Options group, who manage the facility whilst the building is owned by Hyde Housing. The home provides accommodation for up to seven service users in the category of mental disorder. The service users in this home are all under the Care Programme Approach. The acting manager of this facility had been in post since September 2004, having previously been based at another Community Options home. Mr Ligory, the acting manager, has now been appointed to the position permanently. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an announced of which the home had been notified several weeks in advance. In preparation for the inspection the preinspection questionnaire had been completed and four relatives’ comment cards were received. The manager, Mr Anton Ligory, facilitated the inspection. During the inspection all of the residents and one staff member met with the inspector. A selection of records were viewed and the communal areas toured. What the service does well: 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. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 6 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 Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 7 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) 1,2,3,4,5 The residents are provided with good information on which they can base their decision on whether they want to live in the home. EVIDENCE: The inspector viewed the recently updated Statement of Purpose, which was reflective of the service and staff. The Service User’s Guide is comprehensive in content with good information on key worker systems, care plans, local facilities and other relevant topics. The most recently admitted resident had detailed assessment information including that received under the Care Programme Approach (CPA). He had spent half a day at the home prior to admission. Confirmation of his placement was on file. The terms and conditions of placement included the room to be occupied. This document was signed by the manager and the resident. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 8 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) 6,7,8,9,10. The care plans contain good supporting documentation although more detail is needed under the interventions section to indicate the actions to be taken to address the problem. EVIDENCE: Two care plans were viewed. They had good information relating to risk assessment including individual missing persons procedures. Residents are risk assessed in relation to their ability to self medicate although no formal care plan is in place to support this assessment. The focus of the care plans is rehabilitation, incorporating activities of daily living. The care plans detail the support that the residents need to maximise their level of functioning in this area. Care plans are developed as part of CPA and reviewed at six monthly intervals. Within the “Actions to be taken “ section, the information was limited and needed more detail to address the problem stated. The manager showed the inspector a revised care plan and this was more comprehensive in content. Daily records are retained on each resident were reflective of the resident’s day. Please see requirement 1. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 9 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) 11,12,13,14,15,16,17. Residents are supported in all activities of daily living and use the service provided in the local community. EVIDENCE: Each resident has a weekly activity plan, which outlines how they intend to spend their time. Residents are free to have visitors when they wish. Residents can choose from a variety of activities including local leisure centres, MIND, Stepping Stones Club as well as all local facilities. Two residents were at MIND as the inspector arrived. Currently there are no residents who are in paid employment or attending adult education classes. Resident’s meetings are held monthly and minutes kept. All aspects of the running of the home are discussed at these meetings. Residents had decided that the annual holiday would be in Bognor Regis this year. There is no forum for relatives to meet regularly, although staff are available at all times. This is something which should be explored. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 10 All residents do their own shopping and, with assistance, some cooking. Menus are therfore decided individually. Allocated fridge/ freezer and storage space is provided for each resident. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 11 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) 18,19,20,21. Residents are provided with the support that they require and access local health services as part of integration into the community. EVIDENCE: Within the care plans there is a contact sheet which details what health care the resident has accessed. This sheet provides a good audit tool for monitoring health care and access. Services such as the GP, optician, dentist, and chiropody are all accessed through the local provision. The CPN was in visiting during the inspection, although this was his first visit to the home and was unable to comment on the services provided. The home has a policy covering death and dying. Residents are supported to self-medicate and this is a staged process. One resident is fully self-medicating whilst the other five are still at an earlier stage in the process. In the medication file there was good information for each medication in use and its side effects. Staff have proficiency tests conducted on medication procedures, however this needs to be conducted at regular intervals to confirm ongoing safe practices. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 12 Generally, information was completed with the exception of two charts which had no allergies recorded. Hand transcriptions of medication should have two staff signatures in place to reduce the margin for error. The medication cabinet contained three items, which had expired. More auditing needs to be introduced to prevent this reoccurring. Please see Requirement 2 and Recommendation 1. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 13 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) 22,23. The systems for raising complaints and concerns offer protection to residents EVIDENCE: The complaints procedure was on display. Supporting policies are in place to be used by staff, residents or visitors. Staff were aware of what to do in the event that a complaint is raised. One complaint had been raised in the home and investigated by senior management from Community Options head office. The complaint was unsubstantiated. The finances of two residents were checked and found to be correct. Two staff and the resident’s initials were in place. One resident has his finances dealt with through an appointee. All residents have bank accounts. One resident needs considerable assistance with her finances and staff have worked hard to manage this. Policies covering Data Protection, Confidentiality, and Whistle blowing were available. Staff were aware of what constitutes abuse although one staff had not received training on this topic. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 14 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) EVIDENCE: No standards in this section were assessed. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 15 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) 32,33,35,36. The staff team are able to meet the needs of residents although more formalised supervision is needed in order to achieve the objectives of the home. EVIDENCE: The personal files are retained at Community Options head office and no information in respect of recruitment was available to inspect. Staff did confirm that they had job descriptions and a contract. Of the two support workers on duty, one had met with the inspector previously, therefore the other had discussion with the inspector. She confirmed that training was provided covering statutory and mental health issues. She had completed NVQ 2, as had two others in the home. She stated that there was always good support provided either from the manager or via the out of hours on call system. The training certificates were viewed and some of the statutory topics needed to be updated, including manual handling. Five staff are due to do abuse training. Community Options are investigating training relating to learning disability as previously recommended by the CSCI. Please see requirement 3. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 16 All staff do internal rotation between day and night duty. Vacancies are covered by regular agency. Supervision is conducted although the content of the supervision notes was limited and did not meet the criteria for standard 36.4. Please see recommendation 2. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 17 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) 37,38,42. The home promotes safe working practices for the residents and staff. EVIDENCE: Mr Ligory has been appointed as the permanent manager to this home. He has applied to the CSCI to complete this process. Staff were happy at his appointment as he has worked with Community Options for many years and knows the residents. They felt that he was supportive and the fact that he works on different shifts was a benefit. Mr Ligory is a trained nurse currently on the register. A selection of health and safety records were viewed and found to be satisfactory with the exception of fire training. Fire training is conducted regularly approximately every three – four months although it was evident that not all staff are receiving training at appropriate intervals. Staff must receive fire training twice a year for those on day duty. Please see requirement 4. Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 18 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albemarle Road Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 19 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 6 Regulation 15 Requirement The Manager must ensure care plans are comprehensive in content and detail all actions to be taken The Manager must ensure all information is recorded on medication charts and regular audits of medication are undertaken The Manager must ensure that all statutory training is current. Previous time-frame for action 31/3/05 The Manager must ensure that all staff have two fire drills annually Timescale for action 30/8/05 2. 20 13 30/7/05 3. 32 18 30/8/05 4. 42 23 30/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 20 36 Good Practice Recommendations The Manager should ensure that hand transcriptions of medications have two staff signatures in place. The Manager should ensure supervision is conducted six times a year and covers all asects of this standard. G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 20 Albemarle Road Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH 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 Albemarle Road G51-G01 s6881 Albemarle Rd AI v221610 010605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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