Inspection on 11/09/06 for Albemarle Road, 33

This inspection was carried out on 11th September 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albemarle Road, 33 27/09/07

Albemarle Road, 33 21/12/05

Albemarle Road, 33 01/06/05

Albemarle Road, 33 15/12/04

Albemarle Road, 33 02/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Albemarle Road, 33 33 Albemarle Road Beckenham Kent BR3 5HL Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 11th September 2006 12.15p Albemarle Road, 33 DS0000006881.V305296.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 Albemarle Road, 33 DS0000006881.V305296.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. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albemarle Road, 33 Address 33 Albemarle Road Beckenham Kent BR3 5HL 020 8663 6225 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) 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, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 7 Adults with a Mental Disorder Date of last inspection 21/12/05 Brief Description of the Service: The home is an adapted building located in residential area of Beckenham. The house is located 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 is used by residents. There is a pleasant garden to the rear of the building and parking to the front of the building The home is part of the Community Options group, who manage the facility whilst Hyde Housing own the building. The home provides accommodation for up to seven residents in the category of mental disorder. The residents in this home are all under the Care Programme Approach. At the time of the inspection there were no vacancies. The Manager has changed since the last inspection. Mr Gabriel Lau has returned from another of the Community Options facilities. Mr Lau has managed this home previously and knows the residents well. The staff group have two full time vacancies currently. Community Options operate a night support telephone line out of this home. This is staffed separately from the home, and primarily functions as an advice line for mental health users. The take up of this service has so far been limited. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In preparation for the inspection the pre-inspection questionnaire was returned. Three comment cards were received, one from a resident and two from visiting professionals to the home. Positive comments were related with them. The inspection was conducted over two periods, one afternoon and one evening. The purpose of this was to meet with residents and different members of staff on duty. The inspector met with several residents over the course of the two visits and four staff members; three were permanent and one a bank staff. A tour of the premises was undertaken, including two bedrooms and all of the communal areas. At the time of the visits the home had seven residents all on enhanced levels of Care Programme Approach. The inspector viewed records relating to the residents and those pertaining to the home’s maintenance including health and safety aspects. What the service does well: What has improved since the last inspection? Some communal areas had undergone redecoration since the last inspection. The colour scheme was chosen by residents to encourage more participation and ownership of the home. Residents’ meetings seem to have improved not only in frequency, but attendance, from the minutes seen. The annual staff survey has been collated and the results published. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 6 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, 33 DS0000006881.V305296.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 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 the following standard(s): 2 The quality rating in this section is adequate. This is based on all of the information including the site visit. Assessments are conducted prior to placement and information provided prior to admission however this was not fully evidenced within the resident’s file. EVIDENCE: The inspector viewed one resident’s assessment documentation from the most recent admission, which was 5/1/05. Other admission assessments had been inspected on previous visits hence these were not re-inspected. The resident was under the enhanced level of The Care Programme Approach (CPA) as are all of the residents in this home. Within the assessment and pre admission information there was a summary assessment, which contained information on medical, drug and alcohol issues as well as mental health needs. Areas within this were limited in content. There was a letter confirming the placement as well as terms and conditions of residency and a licence agreement. Copies of some of the CPA information were available within the file. There was no information relating to trial visits or records of what information the resident had been provided with prior to his admission. The home has a Statement of Purpose and Service Users Guide that will need to be amended to reflect the change of Manager. It was unclear if these documents had been provided individually to residents prior to admission or Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 9 were available for general use in the home. Residents themselves were unable to respond to the question. Please see requirement 1. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. The quality rating in this section is adequate. This is based on all of the information including the site visit. Care plans and risk assessments are in place for the individual residents although they do not fully reflect the physical, psychological and social needs of residents. EVIDENCE: The care plan of the last resident admitted to the home was inspected as well as two others. Community Options have in place support plans, which includes information and self-assessment by residents. The first support plan contained three problems including personal hygiene, shopping and cooking. The intervention section was better completed. The generation date was February 2006. These were due for six-month review although this had not been conducted having been due August 2006. The support plan contained nothing which reflected the mental health of the resident or information for staff in respect of a deterioration in this. In addition, there was a typed outline care plan that identified a number of areas which needed intervention although three only were referenced in the Community Options support plan. The CPA care plan had been reviewed 13/7/06. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 11 There was a general risk assessment giving an overview of risk although this was not dated or signed. There was an individual missing persons risk assessment dated February 2005, signed by staff and the resident. Other identified risk areas had assessments in place. There was a list of health care appointments provided through the Primary Care Trust. The second support plan identified seven areas of need relating to the resident and her assessed rehabilitation needs. This resident met with the inspector and advised that she consumes a lot of coffee and is incontinent. She said that this had happened on occasions, although this was not included in her support plan. Staff stated this happened infrequently although were aware it did occur. There was no further investigation or action in relation to the issue. Supporting risk assessments were in place dated 26 January 2006. The third care plan was inspected because the resident had presented on the first day of inspection inebriated, displaying verbal aggression, was argumentative, banging cupboard doors and items of furniture. The inspector had witnessed this. The inspector was advised that he displays these types of behaviour on a number of occasions at least weekly. Within his care notes, referenced several times, was his use of alcohol and behaviours that this precipitated. Nowhere did it have a specific plan of care of advise on the type of approach for staff to employ when he displayed aggression. The support plan had last been reviewed April 2005 and the problem areas were relating to personal hygiene, weight gain and finances. In the event that residents display any form of aggression a specific plan of care must be in place to advise staff of the interventions that they need to take. In addition staff need to be trained if they use any restraint techniques. The care plan must be reflective of all needs, behaviours and any issue, which requires the intervention or assistance of staff or other health professionals. Please see requirement 2. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. The quality rating in this section is adequate. This is based on all of the information including the site visit. Choice and independence are facilitated within the home. There is flexibility around routines - rising, retiring etc. Active rehabilitation is difficult with this type of resident and requires a consistent approach by staff. EVIDENCE: Residents within this home have enduring mental health problems, several of whom have been in mental health care for many years. This type of resident group can be hard to motivate and engage. Staff need to take a consistent approach working with support plans and liaising with other members of the multi disciplinary team. The main focus of the support is rehabilitation to enable residents to live more independently. Residents are supported and encouraged to maintain their own bedrooms and have specific chores to address in the main house. Five of the residents, shop and cook for themselves, with varying levels of staff support. Two residents need more staff assistance in these matters. Healthy eating is encouraged, however, resident’s choice prevails. At the last environmental health inspection July 2005, it was recommended that all staff complete the Basic Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 13 Food Hygiene course. Due to the nature of the work, staff do on a regular basis prepare and cook food. From the training information provided, three staff were overdue an update, with no date yet set for this. Three of the residents attend MIND in Beckenham, and two attend Stepping Stones. Two residents were attending MIND on the first day of the inspection. There is a holiday planned for the 23 September to the Isle of Wight, which Community Options are funding. The inspector attempted to engage with residents individually and as a group on both of the visits. This was difficult and only limited information was obtained. Staff with whom the inspector met described the difficulty of engaging residents with activities and rehabilitation programmes. Some residents, they felt, because of the level of choice and independence that they had did what they wanted and it was difficult to do any positive work. Examples of this was residents going out for long periods avoiding any rehabilitation programme, whilst another resident was said to waste his money on alcohol depleting his funds for essential items such as clothing/food. This meant that aspects such as shopping/budgeting, which is part of rehabilitation, could not be undertaken with him, although Community Options did provide all essential items for him in the absence of funds. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The quality rating in this section is good. This is based on all of the information including the site visit. Healthcare provision is accessed as needed by the resident population through the local provision. Medications were well managed with staff trained specifically on procedures before they undertake administration. EVIDENCE: Residents are supported to access all healthcare through the local community provision, which for rehabilitation purposes is appropriate. This encourages residents to be part of the local community. Records relating to health care appointments were in place except where residents access these services independently without staff knowledge. In those cases it is impossible for staff to obtain the information, unless the resident relays this. Services including the GP, dentist and optician are all accessed locally. Accident records are retained and Regulation 37 reports forwarded to the CSCI. Residents in this home are fully mobile and hence there is no specialist equipment required or in use. All of the residents are under Care Programme Approach and therefore have on going monitoring through the mental health teams and reviews undertaken. CPA procedures generate care plan and identify potential risks. These are kept Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 15 under review by members of the multi disciplinary team and key workers in the home. CPA also provides a support mechanism in the event that resident‘s mental health should deteriorate and a hospital admission is required. A support worker took the inspector through the medication systems. The medications were inspected; these are located in a cupboard within the ground floor staff office. The cupboard was clean and tidy with no overstocking present. There are no controlled drugs in use currently. On the medication administration charts photographs of residents were in place. Medications received and those returned are recorded on separate forms. Hand transcribed medications had two staff initials in place to confirm the accuracy of the information recorded. Of the two staff on duty that afternoon, one had taken her medication proficiency test, and therefore was able to administer drugs; the second staff was currently in the process of this. One resident is self-medicating. Confirmation by the GP was in place, the resident themselves would go through a phased process with ongoing assessments before they were able to fully self-administer medications. One anomaly which the inspector noted, was that in a book headed “Homely remedies“ there were details of medications administered to residents, which were not homely remedies i.e. Lorazepam and Haloperidol. It is perhaps that this book has been used for another purpose other than homely remedies. All records relating to medications must be clear, with ”as required “, medications recorded on the individual resident’s administration chart. Please see recommendation 1. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality rating in this section is adequate. This is based on all of the information including the site visit. Information and avenues by which to make a complaint are available. Staff demonstrated a limited knowledge of adult protection measures and the reporting mechanisms for such. EVIDENCE: The home has on display in the hall the complaints procedure, which includes details and contact numbers of external bodies including the CSCI. There is a complaints procedure operated through Community Options. Information on how make a complaint so also available in the Service User Guide. There is a complaints file, which has in place the forms to complete in the event that a complaint is made. In addition there is a complaints’ log to reference and audit all complaints made. There have been no complaints since the last inspection. Community Options have in place policies to cover complaints, whistle blowing and abuse. From the training records it was noted that five staff have done POVA training, two of these attended in 2004. The POVA training also included whistle blowing. The inspector met with staff throughout the two visits and questions on dealing with abuse and whistle blowing were raised. One staff member had not, he said, received any training on abuse or whistle blowing not even on the Company Induction. He demonstrated a limited knowledge in relation to dealing with abuse. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 17 A second staff had received training in this topic through Age Concern training services, although again had a limited knowledge and did not state the need to report such matters. All staff must be familiar with the policies and procedures and the appropriate action to take when abuse is suspected. Please see requirement 3. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The quality rating in this section is adequate. This is based on all of the information including the site visit. The home is maintained in a domestic manner. Communal areas were satisfactory as were toilets and bathrooms. EVIDENCE: The entrance hall stairs and landing had been redecorated in an orange colour, which the inspector was advised was the choice of the residents. It was clean and odour free. Residents are encouraged to become involved with aspects of the home to encourage a sense of ownership and belonging. The main sitting area is also the smoking room. This, as always, was smoky, even though ventilation systems are in operation. This was maintained in a domestic fashion with sofas and easy chairs. The dining area was pleasant and is retained as a no smoking area. The kitchen has deteriorated over recent months. Many of the fronts of drawers and cupboards were missing. The garden was pleasant laid with grass, with a fishpond at one end. Garden seating was available. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 19 The inspector was only able to access two bedrooms during the visits undertaken. This was because residents were out on both occasions, or that they did not want the inspector to view their bedrooms. The two bedrooms were very different, one tidy clean and well organised, whilst the other was untidy cluttered and hazardous. Whilst the inspector appreciates the difficulty of engaging residents to maintain their own bedrooms more effort must be made to address this with some residents. This should be included as part of their rehabilitation on a regular basis. The first floor shower room was out of order on the first visit; it was waiting for Hyde Housing to repair it. The hot water was cool; temperature checks were available to ensure they were within safe limits. Radiators have risk assessments in place, as they are not covered. Window restrictors are in operation. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 The quality rating in this section is adequate. This is based on all of the information including the site visit. Staff are provided in sufficient numbers although this can be affected due to covering another establishment. EVIDENCE: The home employs nine staff including the manager. Currently there are two vacancies for full time staff. Vacancies are covered by staff working overtime and, bank or agency workers. The Manager confirmed that one staff had completed NVQ 2, whist another was working towards it. One staff had completed NVQ 3 and another working towards it. The inspector met with four staff over the two visits and the Manager facilitated the inspection on the first day. Staff who had been recruited by Community Options and not transferred under TUPE arrangements, confirmed recruitment procedures including application form, interview, CRB clearance and two references. The inspector will inspect the recruitment procedures when she visits the Head Office of Community Options. The personnel files, are not retained in any of the individual homes. Staff confirmed that they had attended the company induction, which lasted five days. One staff did not start until he had completed this, as he had had no previous experience with mental health residents. This had been two years previous when he was appointed to the bank. This had covered health and Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 21 safety, introduction to mental health, although he could not recall adult abuse having been covered. He was waiting to attend further training topics which he identified, were those that he needed, to address his work. A second staff had lots of experience having worked thirty years with mental health residents. She confirmed updates in statutory topics and was waiting to attend NVQ level two training. Another staff provided information relating to induction and ongoing training including challenging behaviour and an introduction to mental health. All of the staff expressed their concern regarding the staffing cover for another Community Options facility that has deregistered. Staff advised the inspector that on occasions there was no cover for either the morning or the afternoon at this facility. Staffing is provided with the use of bank staff some of whom were said to be unreliable, cancelling at the last moment. The inspector herself noted that on the first visit by 16.15 the staff covering the other home had not attended and in fact rang to say that they would be delayed for 20/30 minutes. In addition, the inspector was advised, that when the staff compliment at Albemarle Road includes a bank worker, it is the permanent staff who then provides the cover to the other facility. The reason for this was that only permanent staff can administer medications, which needs to be done at the deregistered facility. The off duty rota indicated gaps in cover and parts of the off duty could not be read due to the number of amendments. Staffing at Albemarle Road must not be compromised to cover another home, particularly as the resident population at Albemarle Road is far more volatile and vulnerable than those at the deregistered premises. On the first afternoon the inspector observed that one resident returned to the home inebriated, he was shouting, banging doors and displaying aggression both verbally and physically. The staff stated that this happens when he has got the money to spend on alcohol. Another staff member stated that recently another resident had been aggressive to a point where she was so concerned that she locked herself in the office and phoned the police. She was in the home on her own at that point. The management of such situations requires sufficient skill, training and knowledge not only of the procedures but also of the individual resident. Some staff were unable to confirm training in areas such as management of violence and aggression, although they did have knowledge of individual residents. Clear guidelines, plans of care, intervention strategies and risk assessments must provide specific guidance to staff in the management of such situations. This must be supported by ongoing management presence and support. Please see requirements 4 and 5. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. The quality rating in this section is adequate. This is based on all of the information including the site visit. The change of Manager and the way the management cover is provided needs to be reviewed. Quality assurance measures are in place which include information from staff and residents. Health and safety aspects are well addressed in this home. EVIDENCE: The Manager in this house has again changed since the last inspection. Mr Lau has been back in the house for a few weeks. He has previously managed Albemarle Road although has moved around within Community Options homes. The movement of managers is something that the CSCI had discussed with the providers who proposed that this would happen less in future. Mr Lau is a qualified nurse in mental health and remains on the live NMC register. He has completed the Certificate in Management Studies. He is also an NVQ assessor. Mr Lau has applied to the CSCI to become the Registered Manager for this facility. There is a Deputy Manager also in this home. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 23 It was noted from the staff off duty rota that Mr Lau and his Deputy both work mainly early duties. It was only very occasionally that a late duty or a weekend was included as part of their working week. This was confirmed by staff in the home. The management arrangements within a home should be in place to provide maximum cover to provide staff support particularly with this resident group. Residents’ monies are checked regularly three times a day by staff on duty. Any discrepancy would be reported and an investigation undertaken. One balance sheet and money was checked and found to be satisfactory with supporting receipts in place. Residents, as well as staff signatures, were in place to confirm the transaction. Care plans included those to deal with finances for residents who needed them. One resident has an appointee who deals with his finances. All residents have bank accounts the inspector was advised. The inspector saw the minutes of residents meetings, which had been held August 06, April 06 and February 06. The topics discussed related to the home and a good attendance was indicated. Minutes of the staff meetings held July 06, April 06 and December and November 2005 were available. Community Options conduct an annual staff survey and the results of this are collated and published. Staff have an annual staff appraisal. Reports from Regulation 26 visits were available although not monthly. The reports seen were dated July 06, June 06 April 06 and December 05. Regulation 26 visits must be conducted monthly unannounced and a report of the findings left. Service certificates were in place for electrical including the five-year inspection and portable appliances and the gas installation. The insurance certificate was current. The fire installation had been inspected 6 June 2006 and two recommendations were made. Mr Lau advised the inspector that these had been referred to Hyde Housing for action. Fire drills had been conducted February, July and September with staff and residents attending. Weekly fire alarm testing and regular checks on emergency lights were recorded. Please see requirement 6. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 24 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14 Requirement Timescale for action 30/12/06 2. YA6 15 The Manager must ensure that all information relating to assessments procedures is recorded and available. The Manager must ensure care 30/12/06 plans are comprehensive in content and detail all actions to be taken covering physical mental and social needs. Previous time frame for action 30/08/05. This is now outstanding. The Manager must ensure that all staff are knowledgeable on adult protection procedures and the appropriate action to take. The Manager must ensure that there are sufficient staff in Albemarle to maintain safety of staff and residents and to address residents needs. The Manager must ensure that all staff are suitably trained for the work that they undertake. The Registered Provider must ensure that Regulation 26 visits are conducted unannounced and a report on the findings left. DS0000006881.V305296.R01.S.doc 3. YA23 13 30/12/06 4. YA33 18 30/10/06 5. YA32 18 30/12/06 6. YA39 26 30/10/06 Albemarle Road, 33 Version 5.2 Page 26 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 YA20 Refer to Standard Good Practice Recommendations The Manager should ensure medications are recorded in the appropriate books or documents. Albemarle Road, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office 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, 33 DS0000006881.V305296.R01.S.doc Version 5.2 Page 28 - 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. 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