CARE HOME ADULTS 18-65
Albion House 8-12 Albion Way Lewisham London SE13 6BT Lead Inspector
Kate Matson Unannounced Inspection 28th November 2005 11:00 Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Albion House Address 8-12 Albion Way Lewisham London SE13 6BT 020 8318 3366 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 Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th June 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. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection took place over five hours. The inspection included speaking with six service users, the registered provider, acting manager and one staff member, a tour of the communal areas, examination of care plans, staff records and other records. What the service does well: What has improved since the last inspection? What they could do better:
Although some care plans were comprehensive, they were not signed and this must be addressed to evidence that service users have been involved in the development of the care plan. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 6 Medication systems are robust at the home, but a service user commented and it was noted at the inspection that staff sometimes touch medication without wearing gloves. This must be addressed, as it is unhygienic but also can affect the medication. Although most staff files now had a photograph and proof of identity, evidence of physical and mental fitness was not available and a new employee had been taken on without all of the appropriate checks having taken place. The provider stated that he was confident of the staff member’s fitness as he knew him; however, he must ensure that good recruitment procedures are in place to ensure that equal opportunities policies are followed and to ensure the welfare and safety of the service users for whom he has responsibility. Although the home has a well-qualified staff team, the provider must ensure that the training plan and the induction training evidence a proactive and comprehensive approach to training in accordance with sector skills specifications. 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 DS0000025602.V269262.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users needs are assessed to ensure that their needs can be met. EVIDENCE: 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. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Service users care plans do not always evidence their involvement. Service users are supported to make their own decisions. Risks are identified and managed safely. EVIDENCE: 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. However it was noted that only one of the four care plans was signed to indicate their involvement. The registered provider must ensure that care plans are signed by service users or a note made if the service user has refused to sign. 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. 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.
Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 10 Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16 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: The acting manager stated that one service user has a paid job and one does some voluntary work. 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. 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. The acting manager stated that service users are supported 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.
Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 12 At the last inspection it was found that service users’ rights and responsibilities were respected, though the location of the service users’ phone did not allow them to conduct private telephone conversations and some service users were unaware that visitors were allowed in their rooms as long as they were pre arranged. This led them to feel that they were unnecessarily restricted. At this inspection it was found that a phone booth had been fitted in the lounge to protect privacy when holding phone conversations and the minutes from the residents meeting showed that service users had been made aware of the rule about visitors. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 13 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 Service users receive flexible personal support. Physical and mental healthcare needs are met. The homes medications systems are largely robust though staff must wear gloves if medication is to be touched. EVIDENCE: 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. 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. The medication systems at the home were examined. These indicated that medication is appropriately stored, administered and recorded at the home. However one service user commented that staff do not wear gloves when administering medication and one staff member was seen handling medication without wearing gloves. The provider must ensure that staff do not touch medications with their hands, as this is unhygienic and also may affect the medication.
Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 14 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): These standards were considered met at the last inspection. At the last inspection, the following judgement was made:- 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: Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 15 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): 26 Some required items were missing from a service users bedroom. EVIDENCE: The inspector took a tour of the communal areas of the premises and saw one service users bedroom. The service users room contained all of the required items but only one chair and no table. The service user stated that he was happy with only one chair but would like a table. The provider must ensure that service users are provided with all of the required items unless they refuse them and this is recorded in their care plan. At the last inspection it was found that several of the toilets, showers and bathrooms were dirty, this had been rectified at this inspection. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 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 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): 34 and 35 The home’s recruitment practices do not adequately ensure that they are in accordance with equal opportunities policies and that they fully protect service users. Although the home has a well-qualified staff team, the training plan and the induction training do not evidence a proactive and comprehensive approach to training. EVIDENCE: At the last inspection it was found that none of the files examined included proof of identity or a photograph. At this inspection four staff files were examined including those of new staff. Photographs had been added to existing staff files though one still did not have any proof on identity. The newest member of staff had no proof of identity, photograph, record of an interview, only one reference (though the acting manager stated that a verbal reference had been given) and only a standard disclosure from the criminal records bureau (CRB) meaning that a check had not been made against the POVA list (list of people considered unsuitable to work with vulnerable people). The registered provider stated that a new CRB application at the appropriate level has been made for this person, however he knows him as he had worked at another care home the provider owns. The provider was reminded of the importance of good recruitment procedures to ensure that equal opportunities policies are followed and to ensure the welfare and safety of the service users for whom he has responsibility. The provider stated he was confident of this staff member’s fitness. It was also noted that none of the staff files included
Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 17 evidence of the person’s physical and mental fitness and this must be addressed to ensure that they are fit to perform their role. At the last inspection it was found that the home’s training plan had not been updated since the previous year and the inspector was informed that the home had recently begun to develop induction and foundation training to ensure that they meet the Sector Skills Council workforce training targets. At this inspection the inspector was informed that all staff have achieved NVQ level 2 and some were now doing NVQ level 3, which exceeds the National Minimum Standards. The acting manager provided a training plan. Although this was to represent training for the current 12 month period, it covered NVQ training and internal training only. There was also no evidence available of the training that had already taken place or the training assessments of individual staff. The plan must be reviewed to ensure that it reflects all of the training planned for the home and supported by evidence of staff assessments and records of training completed. Also although records of the homes basic induction were available in staff files, these were not to Sector Skills workforce training targets. Training records had been obtained to record sector skills workforce induction and foundation training but these had not been completed. This must be addressed to ensure that the induction received by all staff ensures a basic level of competence. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Quality assurance systems have been improved though the annual development plan needs to better reflect aims and outcomes for service users. The health, safety and welfare of service users are promoted and protected. EVIDENCE: At the last inspection service users confirmed that their views were taken into account and one service user said, “It’s a well run home”. However the annual development plan had not been reviewed since the previous year. Also although a consultation exercise had been completed 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. Also it was noted that the service user survey asked for their name and needs to be reviewed so that they know they can remain anonymous if they wish. Also although the views of relatives and professionals were also sought, this was done on the same form and needed to be reviewed, so that the surveys are tailored to the needs of the different stakeholders. In addition 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
Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 19 of the service. At this inspection the inspector confirmed that monthly monitoring reports were sent as required. The quality assurance survey had been reviewed and specific surveys for relatives and visiting professionals had also been drawn up. The acting manager confirmed that the results of surveys would be made available once the results of the latest survey had been summarised. An annual development plan had been produced but this was mainly a maintenance plan and needed developing further to reflect aims and outcomes for service users. 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 risk assessment of the necessity for water temperature regulation for service users had been completed as required by previous inspections. The acting manager had identified that staff training in first aid and food hygiene had recently lapsed and was organising refresher courses. Albion House DS0000025602.V269262.R01.S.doc Version 5.0 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 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 1 1 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Albion House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000025602.V269262.R01.S.doc Version 5.0 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 Standard YA6 Regulation 15 (1) Requirement The registered provider must ensure that care plans are signed by service users or a note made if the service user has refused to sign. The provider must ensure that staff do not touch medications with their hands, as this is unhygienic and also may affect the medication. The provider must ensure that service users are provided with all of the required furniture items identified in this standard unless they refuse them and this is recorded in their care plan The registered provider must ensure that copies of proof of identity and a photograph are retained on staff files (previous timescale of 30/09/05 not met) The registered provider must ensure that the recruitment procedure includes obtaining evidence of the physical and mental fitness of staff and that this is available on their files The registered provider must ensure that the training and development plan is reviewed
DS0000025602.V269262.R01.S.doc Timescale for action 31/03/06 2 YA20 13 (2) 31/01/06 3 YA26 16 (2) (c) 31/03/06 4 YA34 17 and 19 31/01/06 5 YA34 19 (1) (b) 31/01/06 6 YA35 18 (1) (c) (i) 31/03/06 Albion House Version 5.0 Page 22 7 YA35 18 (1) (a) 7. YA39 24 annually to reflect the assessed needs of staff and changing needs of service users (previous timescale of 31/10/05 not met) The registered provider must ensure that the home’s induction and foundation training meets sector skills council specifications. The registered provider must ensure that there is an up to date annual development plan for the home, based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users (previous timescale of 30/09/05 not met) 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Albion House DS0000025602.V269262.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SE London Area Office 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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