Inspection on 27/09/07 for Albemarle Road, 33

This inspection was carried out on 27th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albemarle Road, 33 11/09/06

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 Rosemary Blenkinsopp Unannounced Inspection 27th September and 19th October 2007 08:35 Albemarle Road, 33 DS0000006881.V344505.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.V344505.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.V344505.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 Gabriel Toe Wan Lau Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 7 Adults with a Mental Disorder Date of last inspection 11th September 2006 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 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. At the time of the inspection there were no vacancies. The Manager has changed since the last inspection. Mr Gabriel Lau has retired and a new Manager from another of the Community Options facility has taken over. The on call support line, which was operational out of Albemarle Road, had been discontinued. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a day period with feedback provided to the mange on a separate visit .The AQAA had been completed and forwarded to the CSCI office. The site visit was conducted unannounced, and at the time of this visit the Manager was on annual leave. A second visit a therefore arranged to provide feedback on the findings to the Manager. At the time of the inspection there were seven residents in the home, which included one in hospital. Two residents were case tracked and members of the multi disciplinary team contacted to obtain comment regarding the service provide in the home. There was feedback received from members of the multidisciplinary team and two comment cards from residents. The inspector viewed a selection of records and documentation relating to residents including assessments ad care plans as well as, health and safety records. The personnel files are retained at Community Options head office, these are not held in the home. This had been an agreement some years previously with the NCSC .The inspector will attend the Head Office to randomly select and inspect a selection of personnel files to evidence if satisfactory recruitment checks are in place. In previous visits to inspect personnel files they were found to be to a good standard. What the service does well: The service deals with those residents who have enduring mental health problems many of whom have been in psychiatric services for some time .The home is a supportive environment which enables rehabilitation in to less supported accommodation and within this it has been successful. Staff are provided with good training opportunities from Community Options who have their own training coordinator. The home is supported by Community Options management and this incorporates support from other homes in the group and that provided through staff at Head Office. Community Options operates an open policy wher residents can go to Head Office with issues and they are actively encouraged to attend Board meetings. The daily records were to a good standard. Medication records were well completed with supporting information to ensure safe systems are in operation. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albemarle Road, 33 DS0000006881.V344505.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.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are conducted by staff in the home, which provides an outline of support that they require. Supporting information is received by members of the multidisciplinary team which provides further information and overall a comprehensive picture of needs. EVIDENCE: Two residents were case tracked as part of the inspection this included viewing of their admission information and their supporting care plans and records. Resident’s information files included individual licence agreements as well as terms and conditions of residency. These documents had the resident’s signature in place. In the file of a recently admitted resident there was an assessment conducted by staff in the home. The information provided general information on the resident, an over view of care required, medication, information and activities of daily living guidance. This resident had been transferred from Croydon Road and he confirmed that he had spent one day in Albemarle prior to his admission. Information was provided from Croydon Road prior to his transfer, which included their care plan .A CPA care plan was on file dated 8/6/07 this included good information on the resident needs. A risk assessment conducted under CPA procedures conducted by the CPN was on file review date 21/2/07. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 9 Within the two residents comment cards one stated that he had viewed the home prior to moving into it. Staff advised the inspector that residents were encouraged to visit the home to meet staff and other residents. The Statement of Purpose has been amended to reflect the management changes. The residents are provided with a file of information, which includes information on the service as well as support services and resources. The registration certificate will need to be changed once the Manager has completed the CSCI registration process and at his point the Responsible Individual needs to be amended to Chris Mansie. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Support plans are in place for residents although not fully reflective of needs and reliant on residents input. The care plans would not provide staff with sufficient information on which to address appropriate and consistent care . EVIDENCE: The home allocates a key worker to every resident on admission. Residents were aware of who their key worker was and that they co coordinate their care within the home. All of the residents in this home are male therefore it is important to consider gender care issues in the staffing of the home. Two care plans were inspected of those residents involved in the case tracking. In the first care plan there was personal information and the resident’s photograph. The support plan was set out on a standard format. This basic support plan included physical health, mental health, diet and the resident’s medicine regime. The section covering mental health needs, under the interventions required to address the problem, information was limited. The review date for this care plan was set for 12/10/07. The information contained Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 11 details of the resident’s preference for their funeral arrangements. A further support plan, dated 25/9/07 was more detailed in content and included the resident’s signature and review dates. The resident had an overview of potential risks recorded including individual missing person’s information. This had the resident’s signature in place. Other risks included use of kitchen equipment i.e. kettle and use of cleaning materials. These were dated April 07. Risk assessments were also in place for individual problem areas, which pose a potential risk to the resident and/or others. All of the information relating to identified risks had action specified to reduce the risk and the signature of the key worker, resident and Manager. The daily records were to a good standard and gave a detailed picture of the resident’s day. There was further information in respect of the resident’s financial situation. A second care plan was inspected it too contained risk assessments both general and those specific to the residents needs. The support plan was limited to one problem that of attending a training course. Other issues were not included. Staff advised the inspector that this was the only issue the resident had requested assistance with. This resident had been admitted back to hospital due to deterioration in his mental health. There was information relating to this admission 25/9/07. The inspector discussed care planning with the Manager and advised that residents, who are in residential accommodation, need support and assistance with daily living issues and these should have been incorporated along with any other mental health problems identified during assessment, and during their stay in the home. Residents themselves may not have the insight into their problems. The Manager, during this discussion, identified several areas, which would have impacted upon the resident’s wellbeing. Care plans need to provide staff with a framework to enable them to give consistent and appropriate interventions to address issues. The Community Options package of information was completed and a CPA care plan was on file dated 8/6/07. The weight chart had two entries although both in different measures i.e. one in stones the other in kilos. This needs to be addressed for clarity. Those residents who are under CPA procedures, should have a care plan in place, which reflects collaborative working with the multi disciplinary team to meet the same objectives . Care plan are reliant on resident identifying their own problems, this is not always appropriate with mental health residents due to lack of insight and mental capacity. Please see requirement 1. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an environment where rehabilitation can take place under staff supervision and guidance. More structured rehabilitation is needed for some residents to enable them to reach their optimum level of functioning to promote more independent living. EVIDENCE: All seven residents in the home are in for rehabilitation purposes to enable move on to more independent accommodation. Currently there are no residents who are in paid or voluntary employment attending adult education classes. One resident was attending the day centre although this had ceased in the last two months. Three residents are planned for relocation to less supported accommodation. Two of these residents were said to be very independent and this was seen as a beneficial move for them. The home has a number of residents who have been referred for possible admission Residents were observed to spend time as they wished taking meals at different times and come and go throughout the duration of the site visit. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 13 One resident had been allocated the dusting and polishing for his daily chores. he confirmed he went out locally unaccompanied did his own food and clothes shopping as well as own laundry. Residents are encouraged to do their own cleaning their bedrooms and have allocated chores for the rest of the home. Staff assist and support resident to budget, shop and prepare meals. Resident’s are allocated separate storage in the fridge and cupboards for foodstuffs. Staff were observed to assist resident with meal preparation although this was led by staff who id the majority of the preparation, cooking and serving. On checking the fridge there were three items, which were past their use by date one item jam needed using Before September 06. Staff need to be extra vigilant in respect of health and safety issues including auditing of food as this could pose a risk to residents. There was also an item of staff food, which was out of date. One of the residents who met with the inspector explained that he attended Mind in Beckenham. He stated that he had little in the way of family or friends visiting him in the home. He liked watching TV at weekends and going out locally. He explained that there was a trip to Brighton planned. The home had been on holiday last year the lsle of White was the destination. Residents discuss their preferences in respect of leisure activities with their key worker and from this discussion a weekly activities programme is drawn up. This was evident in care plans. Another resident stated that he potters about and does some cooking, he goes out locally to shop .He didn’t like the home and wanted to move although did not know where to. One observation the inspector did make was that the staff on duty seemed to spend long periods in the office without residents present .The inspector felt that engagement with resident was mainly task orientated and limited for other aspects of care. Feedback obtained from one health professional who had visited the home was that there were some residents in the home who were not coping well with one another or the staff team. He also felt that there was some lack of consistency amongst the staff team and that areas such as personal hygiene needed more input. Another health professional felt he was well received and that information was appropriate. He also commented that the Manager had put forward suggestions for a resident, which had improved life for him. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Healthcare needs are well addressed both physical and mental health issues. Medications are safely managed. EVIDENCE: In this home the residents are able to address their own personal care although prompting is sometimes required. In the care plans there was information relating to health professional appointment, these were mainly on relation to GP appointments. The entries included a short summary of the consultation. Other health care input included that from the chiropodist, dentist and an ECG referral. In one file it was noted the resident had lost a significant amount of weight. There was a GP referral in relation to this and weekly weight records were in place. There was information on mental health follow up including appointments and visits by the CPN. Records relating to in house reviews were also available At the time of the inspection there were seven residents. It is proposed that three of them will be moving on to less supported accommodation a home which is part of Community Options although it is not a registered facility. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 15 Residents are encouraged to access health facilities in the community and domiciliary visits are discouraged. This enables integration in to the community and promotes rehabilitation for independent living. This can sometimes mean that residents do not provide staff with all of the information in respect of healthcare appointments although notification from the health care service is usually received. Medications. The medications were inspected of the current client group; there are three partially self medicating and one fully self medicating. Those residents who are self-medicating have care plans in place for this. There is confirmation from the GP re self-medication procedures. There were no controlled drugs in use at the time of the site visit. Medication charts were completed with resident’s photographs attached. Allergies were stated. There is a weekly medication audit conducted any anomalies would be investigated. There were information sheets in place with regards to those medications in use. The first medication chart was that of a resident who is not fully self medicating. He had an antibiotic prescribed although the dose was an odd amount. This was referred to the staff to clarify and was found to be an error when checked with the supplying pharmacist. This resident’s chart indicted that he had two does of medication lunchtime and evening, recorded as “TTA”which means, “ to take away”. Staff must be satisfied that when a resident is not fully self-medicating, that the resident is competent, to correctly administer all medications themselves when not on the premises, such as home leave. The second medication chart was completed and those entries, which were hand transcribed, had two signatures in place to confirm the information recorded. Medications, which are to be administered “as required “,had the maximum dose indicted and reason for administration. Homely remedies are recorded separately and there is a weekly check of such. A list of staff signature of those administering medications was in the front of the medication file. Those medications returned to pharmacy are recorded. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Community Options have an open and transparent approach to complaints and issues are taken seriously. The organisation provide complaints information and have supporting policies for staff and residents to access. Adult protection information is available and staff are provided with training on the subject, which provides safeguards to resident in the home. EVIDENCE: The CSCI has received no complaints regarding this service in the last 12 months. The home’s complaints register includes and entry sheet on which details of the compliant are recorded including a summary of the outcome and the “ date complaint resolved”. This record must clearly indicate if the complainant is satisfied with the outcome and where applicable the investigation. There are leaflets available throughout the home, which sets out what a complaint is and to whom to refer it. Community Options also have a complaints monitoring form for auditing purposes, although the last one completed was January 03. The complaints procedure was on display and included external organizations for referring complaints. Supporting policies were available generated through Community Options head office. Other policies available to staff include adult protection which indicates that all suspected abuse must be reported immediately. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 17 On previous contact with Community Options, when dealing with complaints, the organisation has demonstrated an open and receptive manner. Investigations are undertaken impartially and action taken as appropriate The two morning staff on duty were both asked about dealing with complaints and adult protection issues during their interviews. Both had a clear knowledge of dealing with complaints and how to forward the information on. In respect of adult protection both demonstrated a working knowledge of this. They were clear to offer support to the residents in the event, and indicated some avenues for possible referral, although in relation to external bodies they had limited information. They referred to internal reporting mechanisms. Both staff confirmed that they had received training on adult protection including a video session. All staff should be made aware of the adult protection interagency guidance, which details avenues for referral including Social Services and the CSCI. In the office the interagency guidelines were available for staff reference these should be revisited by staff. The staff member present during the afternoon had a good knowledge of adult protection and referral if such including two external bodies. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is suitable for its purpose that of rehabilitation in a community living setting. Some areas were in a poor state and represented a risk to residents. Bedrooms were not a satisfactory standard either in terms of the fabric and fittings or in standards of hygiene. EVIDENCE: A tour of the home was undertaken including communal areas and individual bedrooms. There are plans to upgrade areas in the home including individual bedrooms. The communal areas were to a satisfactory standard and one of the bedrooms was satisfactory although it was very cold. Also in this bedroom the skirting boards and radiator needed cleaning. The resident stated the heating was not working. The hot water on testing was running cool. On checking this information at the second site visit eh inspector was advised that a new boiler had been installed due to problems with the hot water and heating. Two bedrooms which were inspected were in a poor state. The carpets were stained, burn hole sin the furniture were apparent and cigarette butts Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 19 overflowing in the ashtray .The inspector noted that bedrooms had been included in the Regulation 26 reports and redecoration was due to begin. In the bathroom the bathmat had a hole in it and there was no toilet paper or hand towels. Staff explained this was because of a resident who took these whenever they were put out. Staff should in vestige alternative ways of ensuring there is sufficient toilet paper and hand towels to meet requirements. Also in this area the cold tap was continually dripping .The bin lid was missing. In the shower room, again the water was cool and the sink was in need of cleaning. One of the window sash cords was broken. The extractor was very dusty. The home has no lift provision and the main stairs are steep. This would prevent those who are not fully mobile from admission and with the aging population this must be taken into consideration when allocating bedrooms. The carpets in the corridors were stained and the skirting boards marked .The curtain in the dining room needed re hanging .The inspector was advised that carpets are shampooed regularly with little improvement. It is recommended that the carpets be replaced including that in the office. Please see requirements 2 and 3. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents care needs. Regular training provides staff with the skills and knowledge they require to undertake the work they do. Residents cane be confident in the staff’s ability to address their needs. EVIDENCE: At the time of the first site visit there were two staff on duty both support workers. The two staff member shad both been present at previous inspections and had been interviewed by the inspector previously .The home operates with the following staffing levels: two staff during the day time period and between 9am and 6pm, an additional support worker. The night duty is staffed with one waking and one sleep in staff member. The off duty rota indicated that the weekends are covered by the Managers and that they work flexible shifts throughout the week to maximise management input. There are eight care staff employed in the home of which three have completed NVQ 3 and two NVQ 2.There is one support staff vacancy which is due to be filled November 07. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 21 The two staff members on duty during the inspection were interviewed again. Neither of these support staff had completed her NVQ training. One of the support staff stated that this was due to the fact that she was retiring early 2008.She did confirm training in the statutory topics as well as medication updates and adult protection. The second staff member had commenced employment March 2006; he confirmed a four day induction and training thereafter. He confirmed training in statutory topics medications mental health awareness and had completed the four day first aid course. Another afternoon staff member confirmed that she was NVQ level 3 trained, and had completed mandatory training. She had just attended a person centred planning course and had previously completed mental capacity and mental health study days. On those areas wher questions were asked by the inspector w she demonstrated a good working knowledge. The inspector asked two staff basic questions in respect of mental health and they had a satisfactory knowledge. Staff confirmed that supervision took place every six to eight weeks and this was an opportunity to discuss their work training needs and resident in the home. Albemarle Road, 33 DS0000006881.V344505.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation have experienced personnel within the management structure and the appointment of the home Manager will ensure that the home is effectively managed. Health and safety issues are subject to regular service and monitoring. Quality assurance systems are in place, which incorporate the views of residents and staff. EVIDENCE: The new Manager was present for feedback on the second site visit. He started in this home end of August 2007. He has started the CSCI procedure to become the Registered Manager. He has had previous management experience and immediately before taking up this position was at Wheathill Road as the Manager. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 23 A selection of health and safety documentation was inspected including the fire safety records. The fire risk assessment and the emergency plan were available dated March 07. The LFEPA had inspected the premises 2006. The fire alarm had been serviced March 2007.The emergency lighting was tested 23/9/07.Fire drills including staff and residents, were conducted approximately three monthly up to May 07,although signatures were omitted. The weekly fire alarm had a two week gap in September; however, records were weekly prior to, and after this. Health and safety audits were said by staff to be conducted every three months. The last report was March 07 and prior to this reports were sporadic. The monthly hot water temperature records were not recorded since 28/6/07. Other information included fire action and a HSE fire risk assessment. Other guidance for staff was produced on COSHH, RIDDOR and health and safety principals. The gas certificate was dated 23/9/06.Theannual inspection was due confirmation this has been addressed needs to be provided. The environmental health had inspected the premises January 07 and conditions were described as good. The five year electrical inspection was dated 2006 and the PAT testing certificate was May 2006 Staff confirmed this had been done although the certificate was unable to be located. Confirmation this has been addressed needs to be provided to the CSCI. The home tries to have a trained first aider on every shift. The Deputy Manager is a manual handling instructor. One support worker had attendee t a two day heath and safety course. The Regulation 26 reports were available up to 12/8/07 and prior to this June and March 2007. Regulation 26 visits must be conducted monthly unannounced and a report on the findings left in the home. Minutes of residents meetings were available indicating regular meetings where a number of topics are discussed. It was difficult to establish what action was taken when matters were raised .The action should be specified and the person responsible for addressing it indicated. Staff meeting minutes indicated regular meetings. Community Options have a three year project plan, which identifies areas for action, expenditure and time frame. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 24 The company conducts staff surveys and a report on the results is also made available. Each resident has a bank account. One resident has assistance with his personal finance due to previous problems in this area. The financial records were checked and found to include resident’s signatures and that of the staff member and a record of the balance for all transactions. Receipts are only retained if the resident provides them as they spend their own money this is not delegated to staff. Money checked was correct. Please see requirement 4. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 25 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 3 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 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 2 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 2 X 3 X X 3 X Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 26 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 covering physical mental and social needs. Previous time frame for action 30/08/05. This is now outstanding. Timescale for action 30/12/07 2 YA27 3 YA30 23 23 4. YA39 26 The Manager must ensure that 30/12/07 all facilities in the home are functioning correctly The Manager must ensure that 30/12/07 the environment is maintained to satisfactory standard both in terms of cleanliness and the fabric and fittings of the building The Registered Provider must 30/12/07 ensure that Regulation 26 visits are conducted unannounced and a report on the findings left. This is now outstanding. Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Albemarle Road, 33 DS0000006881.V344505.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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. 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