Inspection on 09/05/06 for Albert House

This inspection was carried out on 9th May 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Albert House 13/02/09

Albert House 07/04/08

Albert House 15/05/07

Albert House 03/11/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Albert House 167 High Street Clapham Bedfordshire MK41 6AH Lead Inspector Mr Paul Worthy Unannounced Inspection 9th May 2006 12:00 Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Albert House Address 167 High Street Clapham Bedfordshire MK41 6AH 01707 652053 01707 662719 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) CareTech Community Services (No.2) Ltd Donna Maria Lee Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of people that can be accommodated at the home is 8. The home shall only admit service users between the ages of 18 and 65 years. All persons who are admitted to the home must have learning disabilities as their primary assessed need. The home may admit service users who have physical disabilities in addition to their learning disabilities. 3rd November 2005 Date of last inspection Brief Description of the Service: Albert House is located in the village of Clapham, a short car or bus ride away from Bedford, which has shops, leisure facilities and links with national bus and rail services. The home has been sympathetically converted from its original purpose as a domestic dwelling. The building is an extended bungalow which provides single room accommodation for 8 younger adults with learning difficulties and who may also have physical disabilities. The home has adequate bathing and toilet facilities. A communal lounge/diner and a room that can be used for activities are located to the rear of the property. A shared drive at the front of the property leads to a parking area for several vehicles. To the rear of the property is a large garden that leads directly to the river Ouse. Access to the garden for service users has been limited by the construction of a paved area immediately behind the home that has been fenced in for safety purposes. Access to the remainder of the garden is with staff escort only. The home provides care for people with learning disabilities, including those who have additional physical disabilities. Most service users at the home need considerable support with their personal care and communication. The home also provides day activities for most of the service users. The monthly fee was not checked at the time of this inspection. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over approximately 18 hours on 9th and 10th May 2006. he inspection consisted in case tracking two service users and looking in less detail at some others. At the time of the inspection there were 8 people living at the home. Personal records were inspected and other relevant records and documents such as policies and procedures. All of the building was seen and three staff were met with. Some service users rooms were seen. There were opportunities to see the service users and the manager and staff together. The limited ability of those living at the home to communicate meant that the inspectors were dependent on observing the service users and their interaction with staff to determine their satisfaction with the services provided. The inspector would like to thank the manager, staff and those living at the home who participated in this inspection. This inspection report should be read in conjunction with the National Minimum Standards for Care Homes for Adults (18-65). What the service does well: What has improved since the last inspection? All the previous requirements had been addressed since the last inspection. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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): 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to ensure that the needs and known preferences of people moving to the home could be met and to help their representatives support them in choosing to move to the home. EVIDENCE: The previous report had noted that there had been satisfactory arrangements for the two service users who at the time of the last inspection had recently moved to the home. There had been no further moves to the home since then, but the procedures and related recording documents would be used following any future referral. There was a service users guide and statement of purpose that would be available to the prospective service users representative. The manager confirmed that work was being undertaken to review the guide to ensure that it covered all the required areas and was also produced in a format appropriate to the individual service users abilities to understand. Ways of making other relevant documents accessible to the individual service users were also being looked at. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was appropriate reviewing of the assessed needs of those living at the home and planning for meeting them to ensure that, as far as possible, this was consistent with their preferences while helping them to remain safe. EVIDENCE: A number of documents were seen on the service users personal files. These ensured that there was up to date information relating to their needs and preferences, and that plans were made to meet those needs. The assessment and planning information was held on a number of documents that together constituted, in terms of content, the required assessment and planning information. There were risk assessments and these were seen to provide the context for activities such as swimming or horse riding that might present special risks. While some of the risk assessments seen, such as the one relating to horse riding, were clearly individualised, others appeared to have an impersonal and generalised nature for covering areas where there might be safety issues for any of the service users. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 10 The staff spoken to were all very aware of the current assessments and plans for the service users and made clear their proactive approach to ensuring that newly identified needs were properly investigated and planned for. Staff confirmed that there were good arrangements for regularly monitoring and reviewing the assessments and plans. Monthly reviews of the Individual Support Requirements were seen. This was very good practice, but it was noted that while stating if a change had been made it did not note what that change was. It was also not clear that the whole document that went to making up the plan was reviewed. Reviews occurred every six months with one being internal to the home and the other being chaired by Social Services, with the home submitting an updating report. Assessment and care planning information was seen to have been updated by overwriting with a pen, showing that the records were kept up to date. The manager confirmed that these were then sent to HQ for typing, as the home has no computer. The plans contained very good information about the way people living at the home could be communicated with by staff. The foundation of this in all cases was the knowledge that staff had of the service users, in particular their preferences in various areas. This information did not look, however, at what could be realistically achieved in communicating with them about their wishes and determining their understanding of matters concerning them. The planning information was often written in the first person but staff agreed that this reflected their knowledge of the service user. The plans and associated documents did not, where the service user might have been able to sign them, make clear how they are involved or the problems in doing so. The manager said there were plans to introduce person centred planning (PCP) training in the near future. There was evidence of some initial moves in this direction with scrapbooks being introduced for containing photographs of interests and activities. One that was just started was seen and was complemented by pictures in the persons room that brought to life his positive experience of living at the home. There was, however, no computer and digital camera in the home to support the person centred planning. It was difficult to navigate ones way around the file. The division of the assessment, planning and reviewing information led to a lot of duplication and a need to move between various parts to be sure that one had all the information needed and then to be sure that all parts of the document were equally up to date. Staff noted that, while recognising the importance of good recording, they found, because of duplication, time was unnecessarily spent completing the paperwork. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were working well with the people living at the home to normalise their lives as much as possible and respect their preferences so that they could live lives that were as full as possible. EVIDENCE: Talking to staff and observing their interaction with those living at the home showed that there was ongoing work with the service users to help them maintain their social, emotional and communication skills and develop them. There was good assessment and planning information relating to this and also to activities. This was translated into specific plans and there was a board showing the weekly programme of activities planned for each individual. Two of the people living at the home attended day centres, one four times a week and the other three times a week, for the day. Activities included taking the service users into the community, in the case of one service user this included Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 12 attending church. It was planned for another to start attending. The manager and staff confirmed that holidays were planned for all the service users over the summer period. The choice of activities depended on the knowledge staff had of their likes and dislikes. Staff stated that a lot of effort had gone into trying to extend the service users repertoire of enjoyed activities including ones that helped one to one interaction but these had not changed greatly despite the effort. In one case a staff member was seen doing a jigsaw with a service user and in another a staff member was playing football with a service user in the lounge while the service user was sitting. The service user was participating and appeared to be enjoying the intervention. The very pleasant and extensive grounds were seen to be used for having tea on one day and lunch on another. The view of staff was that once there was a full and stable staff team it would be possible to increase activities. One of the problems being identified was the need to have one to one staffing and sometimes more for activities like swimming. Staff said that they would like to see more one to one interaction, more activities for the service users and more involvement in the community. The manager and staff said that an attempt was being made to obtain some day care for one of the service users but were finding that the criteria that Social Services applied was making this difficult. In the case of one service user the assessment/planning document (Individual Support Requirements) listed only going horse riding, which happened once a week. Some of those living at the home needed special equipment to enable them to have appropriate stimulation and activity. The staff were seen to support them in using the equipment and to respect the choices of the one service user about where he wished to use the equipment. It was not clear how equipment was chosen and whether it was the most appropriate given the needs of the person, for example the size, colour and texture of objects or the size and ease with which the jig-saw could be put together and provide a clear enough picture. Staff did point out that in some cases there was a strong attachment to certain activities and objects, which were rightly being respected. There were regular routines for meals to provide a structure to the day but staff reported a flexible approach to getting up and going to bed. The assessment and planning information covered household tasks and independent living skills. These were clearly meant to reflect the service users abilities and from what staff said provided an opportunity for interaction and activity. In one case the entry said, may prefer to watch and should be an option making clear that the aim here was to allow choice. The meals that were served for both evening meals were seen to be substantial and nutritional and attractively served. Staff confirmed that the menus were drawn up based on the known likes and dislikes of the service users, and the assessment and plans were seen to cover special eating and Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 13 dietary needs. Appropriate support was seen to be being given to those service users who needed help with eating and in the case of one service user whose plan noted that the person needed time to eat his meal, it was observed that he was not rushed. The mealtime was turned into a pleasant time for those living at the home and the staff to interact. There was in some cases close contact with relatives but in others far less. In only one case did the service user have an advocate. There was evidence from the records and from staff confirming that where possible relatives were being encouraged to maintain contact. There was active work being undertaken, which was seen to ensure that people living at the home had pictures of their relatives where possible. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were good arrangements to ensure that those living at the home remained well cared for in respect of their personal needs and there healthcare so that their wishes and dignity were respected and they enjoyed good health. There was concern about the arrangements relating to the management of medication as mistakes were arising that could compromise the well being of the service users. EVIDENCE: Staff confirmed that all those living at the home required a high input of personal care. This was particularly needed during the first part of the morning but staff were observed providing personal care throughout the day. The assessment and planning information was seen to be good in covering the service users needs for personal care. The individual assessments and the personal plans covered service users needs for personal and health care in detail, including details of the medication being taken and why. There were good arrangements for ongoing monitoring of the health of those living at the home, including regular monitoring by the consultant. The records and talking to staff provided evidence that the staff Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 15 were proactive in obtaining medical help when confronted with health problems. A number of mistakes were seen to have been made in administering medication, when looking at the medicine packs being used and the MAR (Medication Administration Record) sheets, although a monitored dosage system was in use. Since it was not clear why this should be happening, the inspector has referred the matter for specialist advice along with his concern that the correct arrangements for training and overseeing staff who may be expected to administer rectal diazepam were not in place. The CSCI pharmacist will be carrying out an inspection and a further report relating to these matters will be issued. The staff explained that details of medication were not being correctly added to MAR (Medication Administration Record) sheets by the pharmacist and that this was something that had been taken up with the pharmacist, but was not yet resolved. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements for the manager and staff to identify and respond to any distress on the part of those living at the home and for picking up on issues that required activating the protection of vulnerable adults procedures so that the service users would remain satisfied with their care and protection. EVIDENCE: Good guidance was seen in the Service Users Guide on how concerns could initially be dealt with in the context of the home, thereby complementing the formal complaints procedure of the company. It was, however, apparent that those living at the home were unlikely to have any grasp of what was involved in making a complaint and how this might link to deficits in the service to which they had a right. Talking to the manager and staff provided strong evidence of awareness of this and of the need to act on their behalf. A good example of this was the work being undertaken to obtain day care facilities for two of the service users and the work undertaken to find an alternative church for a service user when the one attended could not provide the necessary support. There was, however, no addressing of the special problems created by the service users difficulties in communicating and understanding a complaints procedure, and establishing on a more formal basis the already present monitoring of service deficits on their behalf and including the use of advocates. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 17 Talking to staff provided evidence that they were aware of the local protocols relating to the protection of vulnerable adults (POVA) and a staff member produced the local protocol when asked for the protection of vulnerable adults (POVA) procedures. The company procedure that was seen did not, however, refer to the local protocol and was not consistent with the local protocol in respect of who is responsible for a protection of vulnerable adults (POVA) investigation. As in the case of the concerns and complaints policy the corporate protection of vulnerable adults (POVA) policy did not address the additional dangers that arise if the service users ability to communicate and understand is limited. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided a suitable home for the people presently living there so that they were comfortable and their independence was encouraged. EVIDENCE: The accommodation was seen to be appropriate to the needs of the service users. The fact that it was single storey made it suitable for the people living there, all of whom had some mobility problem and two of whom were seen to need wheelchairs. Only one of the service users was seen to move around the home without staff assistance. The bedrooms seen were attractively decorated and appropriately individualised, reflecting the interests of the service users. There were appropriate bathing facilities and lifting equipment to meet the needs of those living at the home. The shower room was not as well maintained as the rest of the building. A number of those living at the home have their bedroom doors kept open and the manager confirmed that all but two of these doors now have automatic fire closures on them and the other two had been requested. Two reasons were given for keeping the doors open. One was that the service users liked to have them open and the other was that it allowed staff to monitor in case of seizures. Service users were unable to Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 19 use a call system in their rooms as they did not understand its purpose. The manager confirmed that she was seeking further advice on the matter, but thought the only solution was a risk assessment and close monitoring. The call system was there to all staff to call for back up help. The home was well maintained, clean and fresh. The extensive grounds were attractive and were seen to provide an alternative to the lounge on sunny days. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements were good and ensured that the needs of the service users could be met. EVIDENCE: Staff confirmed that there were always four staff on duty across the two dayshifts and two waking night staff. Talking to them indicated that while there was a heavy demand on their time in the morning for personal care this did not create a problem across the day in providing one to one time with service users and ensuring they were involved in activities. At the time of the inspection the numbers of staff were being maintained by the use of agency staff because of the number of vacancies at the time. Staff and the manager confirmed that there were regular agency staff who were used so that continuity and consistency could be maintained. At the time of the last inspection there had been good progress in recruiting new staff but there had been further losses in staff since then. Staff were looking forward to a full staff team as it was felt that this would allow more activities to be organised. A problem was the need for some of the service users to have a one to one ratio with staff when out of the home. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 21 Appropriate staff records were being held at the home, including ones for agency staff. The staff records and the information provided by staff showed that there were induction and training arrangements, including NVQ training. There were also good support arrangements including supervision, annual assessments and team meetings. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good management systems in place, which ensured that the service users had appropriate care and support provided. EVIDENCE: Good management arrangements were seen to be in place to ensure continuity and consistency of care and support to those living at the home. This included a management structure that included a deputy and two senior care workers. There had been a vacancy for the deputys post and one of the senior support workers. A new deputy manager had just started at the time of the inspection. There were handover meetings between shifts and a good hand over sheet was used. There was a corporate six monthly audit of the home carried out, the most recent of which was seen, and visits on behalf of the provider (regulation 26) were also being carried out. There were some arrangements in place for Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 23 internal monitoring in the home and ongoing reviewing to ensure that the needs of the service users were being met. There were, however, no arrangements to ensure that an annual development plan was produced that would be linked to the annual business plan. Their regulation 26 reports highlighted problems but there was no evidence of a systematic checking of these at the next visit to ensure that they had been overcome. There were good health and safety arrangements in place, with regular monitoring arrangements. The regulation 26 reports covered health and safety matters and had recently picked up on some omissions. Health and safety concerns identified at the last inspection had been acted on. Risk assessments were carried out where hazards were identified. This included the ramp between the lounge and the activity area, which had resulted in an application for a new tread to be laid. At the time of this inspection the work was still to be carried out. The need for the COSHH book detailing hazardous substances used in the home was known to be in need of updating and the work had been allocated. Albert House DS0000065423.V292819.R01.S.doc Version 5.1 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 3 2 3 3 3 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 3 x x 3 x Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 25 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Consideration should be given to producing the service users guide as a document that assumes there will be full understanding on the part of the reader, so as to ensure that all the required items are included, and then tailored to the communication needs of the specific service user as identified in the service users plan. Given the different needs of each person consideration should be given to linking the development of suitable ways to best communicate this type of information while being clear about the limits of what is possible, to the development of person centred planning and using the trainers to obtain advice on taking it forward. The service users plans should each constitute a welldefined document that covers all the required information and is clearly cross-references to other information that provides more information on specific topics, as is DS0000065423.V292819.R01.S.doc Version 5.1 Page 26 YA6 2. Albert House presently the case with risk assessments. It should then be easy to turn to that information. If the aims identified in the plan are translated into goals (i.e. where there are clear criteria for saying the goal was achieved and so can be monitored) elsewhere then this should be made clear in the plan. All the information referred to in the plan should then be reviewed and updated at the same time as the plan. The plan should be signed, dated and the date of the next full review noted. 3. YA6 The monthly review of the plan should not just note that changes to the plan were made but should specify what they are, and should note the success in meeting objectives with the service user, comment on any problems meeting them and how they can be corrected, or refer to where this information is held. The risk assessments on the files of individuals should be reviewed to ensure that as well as a general consideration of risks in a certain area, the risks that may be greater for the particular individual are highlighted and considered in terms of reducing for the specific person. The service users plans should make clear the real involvement of the service users in drawing them up and in the review process. Consideration should be given to the way person centred planning is going to facilitate this. Plans to meet for each service user the recommendation of the last company audit that they should have an individually prepared development programme to enable them to develop new skills and maintain current ones should be introduced into their service users plans. They should take account of the attempts that have been made in the past, and seeking professional help in drawing them up should be considered. They should be extended to developing their repertoire of activities and one to one activities. Consideration should be given to the way the introduction of person centred planning can play a role in taking this programme forward (see 7 below). YA11 The recreational and games equipment that those living at the home have should be reviewed, with consideration being given to obtaining professional advice, to ensure that it is appropriate to their abilities (see6 above). 4. YA7 5. YA6 YA11 6. 7 Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 27 YA22 8 The service users plans should determine, based on the identified need for each service user, whether they need an advocate to act as their representative; there being a need if there is no independent representative to act on their behalf to ensure that their rights are being respected. YA22 9 The policy and procedures relating to complaints should clearly take account of the problem that service users may have in understanding what a complaint is and in communicating concerns to others and look at the role of advocates and a robust QA system which monitors service deficits and the way to correct (see 12 below). YA22 10 The corporate POVA policy should be revised to ensure that it is consistent with the local protocol in respect of the role of the local Social Services, and draws attention to the place and role of local protocols. YA7 The service users plans should be reviewed to ensure that when service users doors are left open is noted and the reasons. The basis for determining that it is their preference, if this is the case, should be noted. If the reason is for health monitoring then the reason for not adopting approaches that are more consistent with ensuring respect for privacy should be noted. The arrangements for monitoring and reviewing the services that are provided should result in an annual development plan that provides for maintaining and improving the service and links to the financial plan for the year. 11 YA39 12 Albert House DS0000065423.V292819.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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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