Inspection on 21/12/05 for Albemarle Road, 33

This inspection was carried out on 21st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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 11/09/06

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 21st December 2005 02:00 Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 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.V273424.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 7 Adults with a Mental Disorder Date of last inspection 1 June 2005 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 can be used by residents who do not smoke. The home is part of the Community Options group, who manage the facility whilst Hyde Housing owns 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. 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. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an unannounced visit. The inspector met with the manager and two staff members and a number of residents. The home provides care for up to seven residents. At the time of the inspection there were six male and one female. The age range was between 44 and 57. There have been no new admissions since January 2005. A limited tour of the facility was undertaken as five of the bedrooms were locked by the residents themselves. Two new staff members met with the inspector and the manager facilitated the inspection. The manager has changed since the previous inspection. This change of manager will need to be incorporated within the Statement of Purpose and all documentation, which includes information relating to the staff. Arising out of this inspection were five requirements, two of which are repeated. Two recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: Care plan information was poor and not reflective of needs in those viewed. The interventions section was limited in content and detail and from this information it would be difficult to provide the support that the residents require. This is particularly true when there are new staff who rely on the documents to address the care. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 6 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.V273424.R01.S.doc Version 5.0 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.V273424.R01.S.doc Version 5.0 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): EVIDENCE: No standards were assessed in this section. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. Care plans are not sufficiently detailed to reflect residents’ needs, therefore this does not provide the information that staff need to address care in a consistent manner. EVIDENCE: The care plan of one resident was inspected; he is on enhanced levels of the Care Programme Approach (CPA). This resident has had periods of disturbed behaviour during recent months. The CPA care plan was in place with reviews conducted under the CPA, May and August 05. The in-house support plan was limited both in the identified needs and interventions to address the problem. The last review was dated as 2 January 2005. One problem had no intervention detailed. Generally the documentation was insufficient and incomplete in content and detail. Risk assessments covering those issues specific to the residents and general daily living topics were in place. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 10 The second care plan inspected was again lacking in detail. More specifically this resident was spending long periods away from the home although there was no specific care plan in respect of this. Care plans and supporting risk assessments need to be comprehensive in content, reflective of the identified needs, and kept under review. Please see repeated requirement 1. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards were assessed in this section. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 12 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): 20 The majority of medication procedures are robust enough to safeguard residents with the exception of homely remedies, which needs revising. EVIDENCE: The medication systems were inspected. Medications received into the home and those disposed of are recorded. Medication charts had photographs of residents in place and the allergies recorded. One resident receives depot injection medication, which is administered by the Community Psychiatric Nurse on a three weekly basis. Five residents are on a staged process of self-administration of medication, one is fully self-medicating. Those residents who self medicate are assessed and have risk assessments in place to confirm their ability and compliance with the procedures. Staff regularly monitor residents who are undertaking selfmedication. The records for homely remedies had first names recorded, this needs to be full names. In addition, there needs to be instructions to detail the reason for administration of the homely remedies medication, the maximum dose and duration. Please see requirement 2. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 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 the following standard(s): 22,23 Avenues for making complaints are available. Complaints are investigated and taken seriously. EVIDENCE: There have been no complaints made to the CSCI regarding this service. The home has its own complaints procedure and supporting documentation. The documentation needs to be amended slightly to include details of whether the complainant was satisfied with the outcome. This was actioned immediately by Gabriel Lau through the head office. Community Options have their own procedures in dealing with allegations of abuse. One investigation had been undertaken this year in relation to alleged abuse. This investigation was conducted by senior management of Community Options. Mr Lau, the manager, confirmed that he had received training in respect of abuse in September 2005. The two newly appointed staff had received information relating to abuse during their induction period. There was no evidence that other staff had received any updated training on this topic. All staff must be trained in abuse and receive up dates. Please see requirement 3. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 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 the following standard(s): 24,25,28. The home is maintained and managed in a domestic manner, however some areas were not maintained to a satisfactory standard. EVIDENCE: The communal areas were satisfactory except for the smoking lounge, which has suffered staining to the carpet and to the furniture. There is an extractor fan to reduce the smoke in this room, although it remains smoky. There was evidence of Christmas decorations and a tree. The kitchen and dining areas were both clean and tidy. The hot water was running cool in those outlets tested. Five bedrooms were locked therefore not inspected. Two bedrooms were inspected one very presentable clean and tidy, whilst the other bedroom was very untidy and hazardous with items on the floor. Staff must ensure that all areas are maintained in a clean and hygienic manner. The payphone is located on the first floor and it was in working order. Please see requirement 4. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 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 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 Staff are provided with induction and ongoing training to adequately address the work that they undertake. EVIDENCE: Currently the home has a full complement of staff except for one full time vacancy for a support worker. Two support workers were appointed October 2005. The inspector met with the two new staff. They both confirmed a fourday company induction and a further orientation period in the home itself. Topics covered included manual handling, abuse and fire procedures. The training files of three long-term staff were inspected. They contained a number of training certificates relating to mandatory training and specific to mental health issues. It was evident that the manual handling training had lapsed. This must be addressed. The manager is an NVQ assessor in the care component although to date there are no staff who have completed NVQ. This needs to be actioned. Supervision of staff has lapsed. This needs to be recommenced. Staff personnel files had been inspected November 2005 at the Community Options head office and found to be to a satisfactory standard. Please see requirement 3. Please see recommendations 1 and 2. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 16 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): 39,41,42,43. Residents and staff are involved in the day-to-day operations of the home, which is well managed by a competent manager and supported by senior staff. EVIDENCE: Residents in this home all have a key worker who co-ordinates their care. Residents’ meetings are held and minutes kept. The last residents’ meeting had been held in October 2005. Residents are actively involved in all aspects of their care as far as they are able. Any developments in the home, such as redecoration, holidays etc, would be discussed with the residents. Community Options are part of The Investors in People, quality assurance system. Staff meetings are held regularly, although a gap of six months was evident in the records seen. An annual staff survey is conducted by Community Options and the results related back to the staff. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 17 Residents’ finances were checked and found to be correct with supporting receipts and staff/residents’ signatures to confirm the transaction. The manager is seeking an independent financial advocate for one resident who has poor finances and is unable to address this. The Business Plan covers all aspects of the operations of Community Options and has a specific section for each home. It covers the period 2004-2006. Policies and procedures are generated through Community Options head office in a standard format. These are available to staff and located in the office. Fire drills had been conducted, however’ there were none detailed since October 2005. Residents and staff attend these. All staff and residents must have adequate training in fire prevention methods. Please see requirement 5. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 X 2 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albemarle Road, 33 Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 X 2 DS0000006881.V273424.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement The Manager must ensure care plans are comprehensive in content and detail all actions to be taken. Previous time frame for action 30/08/05. This is now outstanding. The Manager must ensure all information is recorded relating to homely remedies. The Manager must ensure that all statutory training and other relevant training are current. Previous time frame for action 31/3/05. This is now outstanding. The Manager must ensure that all areas of the home are maintained. The Manager must ensure that all staff have two fire drills annually. Timescale for action 30/03/06 2. 3. YA20 YA32 13 18 30/03/06 30/08/06 4 5 YA2424 YA42 16 23 30/01/06 30/01/06 Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 20 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 YA32 YA36 Good Practice Recommendations The Manager should ensure that NVQ training is addressed. The Manager should ensure supervision is conducted six times a year and covers all aspects of this standard. Albemarle Road, 33 DS0000006881.V273424.R01.S.doc Version 5.0 Page 21 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. 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