CARE HOME ADULTS 18-65
Albion House 8-12 Albion Way Lewisham London SE13 6BT Lead Inspector
Kate Matson Unannounced 13 June 2005, 10:00am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Albion House Address 8-12 Albion Way, Lewisham, London, SE13 6BT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8318 3366 020 8318 5443 primecarelimited@aol.com Prime Care Choice LTD Mr Zaid Mauderbocus CRH Care Home 23 Category(ies) of MD Mental Disorder registration, with number of places Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th October 2004 Brief Description of the Service: Albion House is a registered care home for 23 adults with mental health problems. It was registered in August 2002 to the current proprietors. The building is located close to Lewisham shopping centre and public transport routes. The home is on three floors, with ample internal communal space and a pleasant back garden. 21 of the 23 places are in single bedrooms and there is one double room that on the day of the inspection was being used by a couple who had chosen to share. Albion House aims to provide a rehabilitative and therapeutic environment where service users can develop their skills to reintegrate back into the community through a programme of daily activities and support. A few of the service users were said to be likely to remain in the home for a longer period. On the day of the inspection there was one vacancy. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was conducted over 8.5 hours. The inspection included a tour of the premises, talking to 16 service users, the registered provider, registered manager and other staff and inspection of records. What the service does well: What has improved since the last inspection? What they could do better:
Some service users’ rights and responsibilities are respected though it was noted that the service users’ phone was located in a corridor. The manager needs to take action to ensure that service users are able to hold telephone conversations in private. Also service users were unclear about a rule about visitors. The manager needs to clarify this to ensure that service users do not feel they are being unnecessarily restricted.
Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 6 The environment is generally good. It offers adequate private and communal space and is generally well maintained. However, it was noted that a few of the armchairs provided in service users’ bedrooms and communal areas were worn and several of the toilets and bathrooms were dirty. This detracts from the overall environment and could make service users feel that they are not valued. Some staff records did not have copies of proof of identity or evidence of interviews. These must be available to fully evidence that the home’s recruitment practices are in accordance with equal opportunities policies and that thorough checks are made to protect service users from abuse. The home’s training programme is still under development and requires further development to ensure that it meets the assessed needs of staff and the changing needs of service users. Service users felt that their views were listened to, though the results of a consultation exercise need to be summarised and made available to them, and the annual development plan requires review to evidence that review and development of the service is based on the views of service users. The health, safety and welfare of service users is promoted and protected though a risk assessment of the necessity for water temperature regulation for service users, as required by the previous inspection, requires further review in order to evidence that service users are able to manage water temperatures for themselves and that their health and safety are protected. 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. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 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 standard(s) None of these standards were examined at this inspection, however they were all considered met when examined in the previous inspection year. EVIDENCE: Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 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 standard(s) None of these standards were examined at this inspection, however they were all considered met when examined in the previous inspection year. EVIDENCE: Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14, 16 and 17 Service users engage in appropriate leisure activities. Service users’ rights and responsibilities are respected, though the current location of the service users’ phone does not allow them to conduct private telephone conversations and some service users were not clear about a rule regarding visitors leading them to feel that they were unnecessarily restricted. Service users were mainly positive about the food offered at the home. EVIDENCE: Feedback from service users varied about the activities offered at the home. Some said that there was little activity offered and others said there was something offered every day. The activity board in the communal area showed that some activity was offered every day. The staff said that some service users choose not to join in activities. The home has a pool table, board games, books, television and video. One service user said that she was learning to swim at a local leisure centre. Service users confirmed that there are trips out for ten-pin bowling and meals out or to places of interest in summer, and one was one coming up soon. Some service users had been on a short break, introduced since the last inspection as one of several throughout the year, to ensure that all service users are offered seven days holiday as when service
Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 11 users were consulted they stated that they did not wish to be away for seven days at a time. Service users are supported to be as independent in making choices as possible. Rules on smoking, alcohol and drugs are stated in the service user guide. Service users confirmed that mail is given to them unopened and staff enter their bedrooms only with permission. All service users have keys to their rooms. Service users confirmed that they were able to have visitors but several commented that they were not allowed in their rooms. When this was discussed with the provider, he stated that visitors are allowed in service users’ rooms provided visits are pre-arranged. This is because there have been problems in the past with some service users having several visitors in their rooms, creating noise late at night, compromising the peace of all the service users. However service users did not appear to have this knowledge. The manager needs to ensure that this information is made clear so that service users do not feel they are being unnecessarily restricted. It was also noted that the service user telephone is situated in a corridor area, preventing them from holding telephone conversations in private. Service users were generally positive about the food at the home. All confirmed that two choices are always available. One service user said, “The meals are very good.” Others said that the food met their cultural and other dietary needs. One service user said that she had a separate menu prepared for her as she had a cholesterol problem. One service user said that after the main meal is served at 6pm, the only food available to service users is toast. The registered provider and manager stated that sandwiches are always available and will ensure that all staff provide sandwiches to service users who want them at any time. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 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 standard(s) None of these standards were examined at this inspection, however they were all considered met when examined in the previous inspection year. EVIDENCE: Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users confirmed that they felt their views were listened to and acted upon. Practices and training at the home ensure that service users are protected from abuse. EVIDENCE: There is a complaints procedure up on the wall and a copy is included in the service user guide to ensure that service users know how to complain. Service user meetings are held and service users confirmed that they could raise any issues there. One service user said, “You can say what you want to say”. The complaints record indicated that there was a low level of complaints made and these had all been dealt with appropriately. All but two of the service users spoken to stated that they had never had to make a complaint but would feel able to do so if necessary. The two service users who had made complaints stated that these had been dealt with to their satisfaction. The home has adult protection policies and procedures in place including whistle blowing and an appropriate restraint policy, stating that restraint should be used only as a last resort. All staff have undergone adult protection training and an update is planned for November 2005. There is also ongoing internal training on management of aggression to ensure that the risk of potential abuse is minimised. Staff interviewed were clear about their responsibilities with regard to adult protection. Service users’ financial records indicated that they are supported to be as independent with their finances as possible and for the small number who require support; robust systems are in operation to protect their financial interests. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30 The home is safe and comfortable with adequate private and shared space, toilets and bathrooms. Service users bedrooms promote their independence. The home is generally well maintained and furnished though some worn furniture and dirty toilets and bathrooms detract from the overall pleasant environment and could lead service users to feel that they are not valued. EVIDENCE: A tour of the premises was conducted and the rooms of those service users who gave permission. The home is generally well maintained, and decorated and furnished in a comfortable style. The home has 21 single rooms and one double room arranged over three floors. All of the rooms are of adequate size. There are ten toilets, two bathrooms and two shower rooms in the home. All of the service users spoken to confirmed that they were happy with their rooms and that they had all of the furniture and fittings they require. There is a range of communal spaces, including smoking and no smoking areas and a pleasant garden with patio area. It was noted that a few of the armchairs provided in service users’ rooms and communal areas were in need of re-upholstering or replacement. It was also noted that although a cleaning schedule for less frequent cleaning tasks had been drawn up as recommended at the previous
Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 15 inspection, several of the toilets, showers and bathrooms were dirty, which could lead to service users feeling that they are not valued. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, and 35 Service users confirmed that they felt that they were supported by competent staff and records indicate the staff team is well qualified. Staff records do not fully evidence that the home’s recruitment practices are in accordance with equal opportunities policies or that thorough checks are made to protect service users from abuse. The home’s training programme is currently being developed to ensure that it meets the assessed needs of staff and the changing needs of service users. EVIDENCE: Service users were generally positive about the staff. There is a key worker system though service users said that they could speak to any staff. One service user said “I like it here, they look after you; if I have a problem I talk to the staff.” Another said “This place is a good place; the staff are very friendly and helpful”. Another said “There is always someone to talk to”. Staff are well qualified and although it is not a nursing home several of the staff are trained nurses. Other staff have completed NVQ level 2 or 3 in Care and others are currently taking the course or waiting to start. The registered manager stated that it is planned for all staff to be qualified to at least NVQ level 2 though many have achieved level 3. Five staff files were examined. These all included two written references as required and a file of checks with the Criminal Records Bureau was kept separately. However, none of the files included records of an interview to evidence that recruitment procedures are in accordance with equal
Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 17 opportunities policies and not all of the staff files included proof of identity or a photograph. One staff file stated that proof of identity had been seen but a copy must be made to evidence that thorough checks are conducted prior to employment to protect service users from abuse. The registered manager stated that the home had recently begun to develop induction and foundation training to ensure that they meet the Sector Skills Council workforce training targets. The home’s training plan had not been updated since the previous year. This does not evidence that training is provided in a planned way to ensure that it reflects the assessed needs of staff and the changing needs of service users. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Service users felt that their views were listened to though the results of the consultation exercise had not been summarised and been made available to them, and the annual development plan had not been reviewed, to evidence that review and development of the service is based on the views of service users. The health, safety and welfare of service users is promoted and protected though a risk assessment requires adjustment to fully evidence this. EVIDENCE: Staff encouraged service users to speak to the inspector in private to give their views on the home. Service users confirmed that their views are taken into account and one service user said, “It’s a well run home”. The registered provider usually implements requirements and recommendations from inspection visits soon after inspections. The annual development plan had not been reviewed since the previous year and does therefore fully reflect the current aims and outcomes for service users. A consultation exercise was completed in October 2004 though this had not been summarised into a report to evidence that the views of service users are taken into account in reviewing and developing the service. It was noted that the service user survey asked for
Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 19 their name and needs to be reviewed so that they know they can remain anonymous if they wish. It was also noted that although the views of relatives and professionals were also sought, this was done on the same form. This needs to be reviewed so that the surveys are tailored to the needs of the different stakeholders. Although the registered provider had been conducting monthly, unannounced visits to review the service, copies of the reports these had not been sent to CSCI to evidence the provider’s monitoring of the service. Records indicated that all fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. The gas check was due but was being followed up on the day of the inspection. Environmental health and fire inspections had also been conducted in the recent past and no concerns were identified. Staff have training around health and safety topics including first aid and food hygiene. A risk assessment of the necessity for water temperature regulation for service users had been completed as required by the previous inspection, though this did not make it clear that service users were able to manage water temperatures for themselves and requires further review in order to evidence that the health and safety of service users are protected. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 20 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
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 2 3 3 x 1 Standard No 11 12 13 14 15 16 17 x x x 3 x 2 3 Standard No 31 32 33 34 35 36 Score x 4 x 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Albion House Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 x G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 21 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. 2. Standard 26 30 Regulation 16 (2) 23 (2) (d) Requirement The registered provider must ensure that worn chairs are reupholstered or replaced The registered provider must ensure that all parts of the care home, including toilets, bathrooms and showers are kept clean at all times. The registered provider must ensure that records of recruitment interviews are kept on staff files The registered provider must ensure that copies of proof of identity and a photograph are retained on staff files The registered provider must ensure that the training and development plan is reviewed annually to reflect the assessed needs of staff and changing needs of service users The registered provider must ensure that copies of reports of visits conducted in accordance with Regulation 26 of the Care Homes Regulations are sent to CSCI Southwark Office. The registered provider must ensure that there is an up to date annual development plan Timescale for action 30/09/05 30/09/05 3. 34 17 and 19 30/09/05 4. 34 17 and 19 30/09/05 5. 35 18 (1) (c) (i) 31/10/05 6. 39 26 30/09/05 7. 39 24 30/09/05 Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 22 8. 39 24 9. 42 13 (4) (c) 10. 16 16 (2) (m) 11. 16 16 (2) (b) for the home, based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. The registered provider must ensure that the results of consultations with service users and others are summarised and made available to all interested parties. The registered provider must ensure that water temperatures are regulated to close to 43°C or produce a risk assessment that shows this is unnecessary.(Timescale of 31/01/05 not met, though risk assessment was sent to inspector before that date) The registered manager must ensure that service users are clear about any rules and restrictions in the home and in particular about visitors. The registered manager must ensure that service users are able to make and receive telephone conversations in private 31/10/05 31/07/05 30/09/05 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 39 Good Practice Recommendations It is recommended that the survey questionnaires for consultation with service users, relatives, professionals and others are tailored more specifically to meet the needs of the particular group and include the option of anonymity. 2. Albion House G52-G02 S25602 Albion House V232819 130605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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