Inspection on 23/01/07 for Albion House

This inspection was carried out on 23rd January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albion House 07/03/08

Albion House 28/11/05

Albion House 13/06/05

Albion House 20/10/04

Albion House 02/06/04

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 Albion House 8-12 Albion Way Lewisham London SE13 6BT Lead Inspector Keith Izzard Unannounced Inspection 23rd January 2007 10:00 DS0000025602.V324800.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 DS0000025602.V324800.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. DS0000025602.V324800.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion House Address 8-12 Albion Way Lewisham London SE13 6BT 020 8318 3366 0208 318 5443 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) Prime Care Choice Ltd *** Post Vacant *** Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places DS0000025602.V324800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 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. DS0000025602.V324800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection took place over six hours. The inspection included speaking with six service users, the Registered Provider, acting manager and three staff members, a tour of the whole building, examination of care plans, staff records and other records to do with health and safety. What the service does well: What has improved since the last inspection? The home had complied with all the requirements made at the previous inspection. Quality assurance systems had been improved with monthly unannounced monitoring visit reports now being sent to CSCI and quality assurance surveys being tailored to meet the needs of relatives and professionals as well as service users. DS0000025602.V324800.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025602.V324800.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 DS0000025602.V324800.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. Service users’ needs are assessed to ensure that their needs can be met. EVIDENCE: Standard 1 In view of the change of address for the CSCI office the Statement of Purpose and the Service User Guide and any other documentation giving the CSCI contact details will need to be amended to reflect this. See Requirement 1 Standard 2 The personal files of four service users were examined. These included detailed referrals comprising assessments completed as part of the care management process and reports from professionals such as psychiatrists, and occupational therapists. All of the files included a care plan and the provider stated that the care planning and risk assessment process starts before admission to the home and takes up to one month to fully complete. DS0000025602.V324800.R01.S.doc Version 5.2 Page 9 DS0000025602.V324800.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 good. This judgement has been made using available evidence including a visit to this service. Service users’ care plans show that they have been involved in their compilation as they were individually signed. Service users are supported to make their own decisions. Risks are identified and managed safely. EVIDENCE: Standard 6 The care plans of four service users were examined. These considered all areas of need for each individual and were regularly reviewed. Monthly key working sessions are also held. It was noted that all of the four care plans examined was signed to indicate their involvement. The Registered Provider had responded to a requirement that this must be done following the previous DS0000025602.V324800.R01.S.doc Version 5.2 Page 11 inspection in November 2005. The manager also stated that a note would be made on the care plan in the eventuality that a service user refused; however, this had never occurred. Standard 7 Service users are supported to make their own decisions as far as possible. They are supported to be independent with their finances where possible. Where appointees are necessary, the Social Services Department fulfils this role. The home has information about advocacy services in place that explains the meaning of advocacy and provides details of some local services. Standard 9 There were risk assessments in the files examined. These indicated that risks were identified and incorporated into the care plan to ensure that they were managed safely. DS0000025602.V324800.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 good. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities and are part of the local community. Service users are supported to have appropriate relationships. Rights are respected and responsibilities recognised in service users’ lives. EVIDENCE: Standard 12 The acting manager stated that one service user has a paid job and one does some voluntary work with the Salvation Army two days per week. Some other service users attend day centres. Activities are offered inside the home including cooking (most service users cook at least weekly) and groups for relaxation, and current affairs. DS0000025602.V324800.R01.S.doc Version 5.2 Page 13 Standard 13 Service users also attend activities outside the home run by a local service for people with mental health problems. The acting manager stated that all of the service users have free travel passes and that they independently access the local community including shops, cafes and library. Three service users have joined a local pool club. Standard 15 The acting manager stated that service users are supported and encouraged to stay in touch with family and friends and that he was proud that many service users had been supported to renew relationships with family members with whom they had lost touch. However the wishes of service users are respected when they choose not to have contact. The manager stated that seven, out of the current twenty accommodated, do not have relatives or friends; in these instances service users are made aware of advocacy facilities locally. Standard 16 Service users are enabled to conduct private telephone conversations via the provision of a telephone cubicle in the corner of the main sitting/ dining area that affords privacy. Service users interviewed were aware that visitors are allowed in their rooms as long as this was pre arranged with staff members and this had been discussed within a service users’ meeting and individually with service users. Residents meetings were held on a regular basis, approximately monthly; the numbers attending was just under 50 but the manager confirmed that a copy of the minutes was provided for all, including those who chose not to attend. Standard 17 Menus were examined and showed that varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. Many of the service users are of Afro/ Caribbean origin, as is the cook. Culturally appropriate diets could be catered for upon request, as could any other special diets and it was noted that a choice is always available. DS0000025602.V324800.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 is good. This judgement has been made using available evidence including a visit to this service. Service users receive flexible personal support. The physical and mental healthcare needs of service users were met. The medication system for the home was well organised and recorded. EVIDENCE: Standard 18 Care plans described the support that service users need with personal care. Most require at least prompting with some tasks. Service users receive additional, specialist support and advice from professionals such as occupational therapists where needed. Standard 19 DS0000025602.V324800.R01.S.doc Version 5.2 Page 15 All service users are registered on CPA and see a psychiatrist and a social worker and/or a community psychiatric nurse. The weight of service users is monitored monthly. Service user files have appointment sheets for recording visits for blood tests, dentists, chiropodists and optician. Service users are supported to take responsibility for their own healthcare, though are supported to attend appointments where necessary. Standard 20 The medication systems at the home were examined. These indicated that medication is appropriately stored, administered and recorded at the home. At the previous inspection in November 2005 a requirement was made to ensure that staff do not touch medications with their hands, as this is unhygienic and also may affect the medication. This Standard was complied with, in that, the home now uses the blister pack system, thus avoiding the need to physically hold the medication when given. DS0000025602.V324800.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. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. Five complaints had been made to the provider since the previous inspection. These were all of a very minor nature and had been dealt with to the satisfaction of the complainant and in accordance with the Standard. No complaints had been received directly by the Commission since the last inspection. All residents have the ability to raise concerns and when spoken to by the Inspector four indicated that they were happy within the home and had no complaints. As stated in Standard 1, the home does need to update the contact details for the CSCI within the complaints procedure and Service User Guide. See Requirement 1 Standard 23 DS0000025602.V324800.R01.S.doc Version 5.2 Page 17 The home had policies and procedures in relation to adult protection and as whistle blowing policy. No allegations of abuse had been made to the provider or the Commission since the last inspection. The home did not have copies of the London Borough of Lewisham Adult Protection Procedures and it is recommended that this is obtained and shown to staff members, to ensure that the home’s policy matches the requirements within the local authority procedures. Those staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. However, the Inspector recommends all staff should receive this as soon as practicable. See Recommendation 1 The Inspector examined the system for dealing with the personal monies of four service users within the home for whom the manager acts as appointee, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited via the monthly Regulation 26 visits, when these accounts are audited on a random basis. DS0000025602.V324800.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 good. This judgement has been made using available evidence including a visit to this service. Service users generally live in a homely, comfortable, and safe environment. The home was clean and hygienic throughout. EVIDENCE: Standard 24 The Inspector undertook a complete tour of the building, including communal areas, the kitchen, staff office and laundry areas; and also saw six service user bedrooms and all the bathrooms / showers and toilets. The service users’ rooms contained all of the required items to meet this Standard and a previous requirement to ensure that a service was provided with a small table was complied with. The manager confirmed that any items in the Standard not provided for would have an explanatory note made in the individual care file. Four service users, who were interviewed, stated that they were satisfied with DS0000025602.V324800.R01.S.doc Version 5.2 Page 19 the equipment provided for them in their rooms. The Inspector noted that whilst clean, bathrooms and showers and toilets are generally in need of some refurbishment and redecoration. See Requirement 2 Standard 30 The home was clean and hygienic throughout including the kitchen and laundry areas, which were appropriately equipped to maintain good standards of hygiene and easily cleanable surfaces. DS0000025602.V324800.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. The home’s recruitment practices had improved. Staff training was comprehensive and a high level of staff members qualified above the minimum Standard had been achieved. EVIDENCE: Standard 32 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were DS0000025602.V324800.R01.S.doc Version 5.2 Page 21 content within their environment and responding positively to any staff interventions. Standard 34 Three personnel files were examined for the new staff recruited since the previous inspection and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Two requirements made at the previous inspection, to ensure that proof of identity and photos are included on the personnel files, and also evidence obtained of the of the physical and mental fitness of workers, had been complied with in the three files seen. A member of care staff, who was interviewed, stated that she had received a thorough recruitment and induction programme when she commenced working for the home. Standard 35 At this inspection the inspector was informed that 90 of staff have achieved NVQ level 2 or 3 and two new staff members were doing level 3, which exceeds the National Minimum Standards. The acting manager provided evidence of a training plan for the year 2006-2007and this was comprehensive. All three new staff members had received induction and foundation training and had, in place, an individual training and development plan. DS0000025602.V324800.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 home needs to appoint a Registered Manager as an acting manager has run the home for two years. Quality assurance systems have been improved and the annual development plan reflected aims and outcomes for service users. The health, safety and welfare of service users are promoted and protected. EVIDENCE: Standard 37 DS0000025602.V324800.R01.S.doc Version 5.2 Page 23 The acting manager is a first level Registered nurse and both experienced and competent to run the home and ensure that service users’ needs are met. However the registered Provider must ensure that the acting manager applies to be come the Registered manager as soon as practicable as the home has been without a registered Manager for two years. See Requirement 3 Standard 39 Six service users who were interviewed confirmed that their views were taken into account and that the home was well run. The annual development plan had been reviewed since the previous year. Also it was noted that the service user survey that previously asked for their name has now been made anonymous. Evidence was available through regular meetings with service users that their views were regularly sought in respect of the running of the home. The Registered Provider had conducted monthly Regulation 26 unannounced visits to review the welfare of service users and the running of the home. Copies of the reports were retained within the home and had been sent to CSCI to evidence the provider’s monitoring of the service. An annual development plan had been produced and reflected aims and outcomes for service users. Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. Environmental health and fire inspections had also been conducted in the recent past and no concerns were identified. A number of areas were picked at random and checked against the pre inspection questionnaire, this information provided, was found to have been accurately recorded. DS0000025602.V324800.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 3 STAFFING Standard No Score 31 32 33 34 35 36 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X 3 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000025602.V324800.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Version 5.2 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. 1 Standard YA1 Regulation 4&5 Requirement Timescale for action 01/03/07 2 YA24 23 (2) b 3. YA37 8 The Statement of Purpose and Service User Guide and complaints procedure must be updated with the new contact details of the CSCI. The Registered Person must 01/04/07 ensure that all bathing and toileting facilities are refurbished or redecorated as necessary. The Registered Person must 01/04/07 ensure that the manager submits an application to become the Registered Manager as soon as practicable. 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 YA23 Good Practice Recommendations The home should obtain a copy of the London Borough of Lewisham Adult Protection Procedures to ensure compatibility with the home’s procedures. Staff should see these procedures and any staff that have not received training in this area, be provided with training as soon as DS0000025602.V324800.R01.S.doc Version 5.2 Page 26 practicable. DS0000025602.V324800.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup 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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