Inspection on 07/03/08 for Albion House

This inspection was carried out on 7th March 2008.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albion House 23/01/07

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 Mary Magee Unannounced Inspection 7 17th March 2008 10:00 th& Albion House DS0000025602.V358827.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 Albion House DS0000025602.V358827.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. Albion House DS0000025602.V358827.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 020 8318 5443 rajdooraree@hotmail.com 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 Shepherd Mazwikwe Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 23 23rd January 2007 Date of last inspection Brief Description of the Service: Albion House is a registered care home for 23 adults with mental health problems. It was registered with Prime Care Choice Ltd as the registered provider. A change of directors within the provider organisation took place prior to this key inspection 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 re-integrate back into the community through a programme of daily activities and support. Fees range from £975 to £1500. Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes. This unannounced key inspection took place over two days. Present was the newly registered manager, the new director of the company, and four members of staff. A tour of the premises was conducted that included all communal areas and four bedrooms. Twenty three service users were residing at the home at this time. Information that informs this report was received from five service users spoken to during the inspection. Five completed written questionnaires were returned from service users too. Two written staff questionnaires were received. The previous acting manager supplied a completed AQQA. What the service does well: What has improved since the last inspection? A new manager was appointed at the home recently. He is very experienced and has registered with CSCI. Some minor refurbishment has taken place. Albion House DS0000025602.V358827.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. Albion House DS0000025602.V358827.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 Albion House DS0000025602.V358827.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): 1 2 5 Quality in this outcome area is adequate, This judgement has been made using available evidence including a visit to this service. The needs of individuals are assessed before they are offered a place at the home. The pre admission assessment process completed by the home is very basic and lacks detail and information; consideration is not given to the needs and numbers of those already living at the home. This has the potential to result in service users whose needs cannot be met being admitted into the home. EVIDENCE: The home has Statement of Purpose and a service user’s guide. Both documents need to be updated to reflect changes that have taken place including management and contact details. The requirement stated at the previous inspection is unmet and is restated. Case tracking was used to evaluate the admission process and the support arrangements. The personal files of two service users admitted since the last inspection were examined. These included detailed referrals comprising of assessments completed as part of the care management process and reports from professionals such as psychiatrists, and occupational therapists. A representative from the home undertook an assessment process. From the findings it was evident hat the assessment process completed by the home gathered basic assessment information. The assessments did not take fully into account all areas of need Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 9 in particular those that were more challenging, neither was there consideration for the needs and complexities of other service users. Feedback from staff was that additional pressure is sometimes experienced following the admission of some service users that are more challenging to the service. A requirement is stated that all prospective service users are fully assessed to determine if the home is the most suitable place to meet these assessed needs. Albion House DS0000025602.V358827.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): 6 7 9 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Planning and support arrangements are good with service users involved in agreeing individual care plans. The care plans record quite accurately all areas of need and support. Systems are developed and in place for managing risks appropriately. These systems promote independence and avoid unnecessary restrictions enabling service users lead as independent a lifestyle as possible. EVIDENCE: Care plans are developed with service users; signatures are present to show that plans are agreed with each individual. The care plans for two service users were case tracked. One of which talked to the inspector in depth of his support arrangements. He is satisfied that the service delivers well and has enabled him to overcome many obstacles. Care plans are fairly comprehensive and based on assessments completed by home staff and by other mental health professionals. They contain details of personnel profiles, treatment and rehabilitation plans, and the support to manage any risks associated with conditions and behaviours. Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 11 Service users are supported and encouraged to lead independent lifestyles with consideration given to risks associated with developing these skills. The staff team are good at recognising capacities and potential for development. However the written care plans are not as individualised or person centred as they should be. A recommendation is made. Care plans are regularly reviewed. There is evidence of multidisciplinary teamwork. CPA meetings take place. In the event of changes to individual’s state of well-being this is identified and discussed with CHMHT. The staff team work closely with all mental health professionals to achieve the best outcome for service users For one service user there was evidence of how staff monitored his condition and welfare and recorded key elements that signified a relapse was imminent. A CPA meeting took place and the service voluntarily agreed to hospital readmission. Key working sessions take place regularly every month. Records are made of these and used to inform reviews and future plans. Daily records are also held of individuals’ progress. Albion House DS0000025602.V358827.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): 11 12 13 15 16 17 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to take part in appropriate activities and be integrated into the community. Relationships with family and friends are encouraged and supported if it is in accordance with expressed wishes and appropriate. Rights are respected and responsibilities recognised in service users’ lives. EVIDENCE: The lifestyle afforded varies according to individual capacities and preferences. All service users have free travel passes and that they independently access the local community including shops, cafes and library. There are service users that regularly attend external day activities and special clubs; also some are involved in volunteer work. Activities too are offered inside the home including cooking (most service users cook at least weekly) and groups for relaxation, and current affairs. Service users are encouraged to go for walks and integrate into the community. The busy shopping centre of Lewisham is close by. Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 13 Observations were made over the two-day period of the engagement of service users in activities in the home. Some enjoyed playing table games such as Snooker or watching television, others choose to chat with staff. Difficulties are experienced with motivating some service users, some tend to relax and choose not to participate in stimulating activities and spend too long a period in their bedrooms. Staff acknowledge the difficulties in motivating service users and endeavour to engage them in a pursuit they enjoy. Not all service users have activity planners in place, from examining records it was observed that attempts are made by staff to develop activity plans but frequently service users decline these. A service user spoke of feeling settled in the home but that he prefers not to interact with others living there or become involved in activities. A recommendation is made that consideration is given to developing activity plans that are appropriate for needs and that are therapeutic. Mealtimes are flexible. During the inspection service users that were absent when lunch was served had a lunch prepared and served on their return. According to the two service users spoken to, the home is flexible and adapts routines to fit in with service users’ lifestyle. Service users according to their wishes receive visits from family and friends. According to three of the service users spoken to visitors and friends are welcomed at the home. A telephone is supplied in a booth off the lounge area; it offers privacy and the opportunity for service users to stay in touch with relatives and friends. There are certain restrictions in place for visitors accessing individual bedrooms. This is in accordance with agreed care plans. It is implemented to avoid placing a service user at risk, for example if it is deemed that there is a risk of using illegal substances. As a result not all visitors are allowed access to service users’ bedrooms. Menus are developed with service users in mind. Meetings take place regularly with service users so that they can choose meals that reflect their preferences and dietary needs. All five-service users spoken find that the food served is to their liking and provides for their cultural needs. Menus for a period of a month were viewed; these demonstrated that the meals are varied. Hot nutritious meals were served at lunch on both days of the inspection. Albion House DS0000025602.V358827.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): 18 19 20 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is good at supporting service users manage their healthcare and enabling individuals access to all statutory health care services. Service users receive personal support that is flexible, consistent, and reliable, and responsive to individual changing needs. Medication procedures are good with service users receiving prescribed medication, action is taken to record and report if there are any areas of non-compliance. EVIDENCE: For the majority of service users assistance is not required with personal care. Service users receive sensitive and flexible support that maximises privacy, dignity and independence. Service users dress in attire that reflects their personality. For a service user that requires support with bathing appropriate provision is made to provide a support worker of the same gender where possible. Consistency and continuity of support is promoted through designated key workers. Individual choices are respected in selecting key workers. Trust and confidence is developed with staff. As a result support staff work in partnership with service users to find the most effective way to manage their healthcare. Individual service users are supported to attend appointments with healthcare Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 15 professionals. Records are present to evidence this. All service users are registered on CPA and see a psychiatrist and a social worker and/or a community psychiatric nurse. Medication is reviewed at these meetings. The weight of service users is monitored monthly. Service user records contain details of appointment s for blood tests, dentists, chiropodists and optician From viewing and case tracking the support given to two new service users evidence was seen of close working relationships with mental health professionals. Staff monitor the physical and emotional health of service users. Potential complications and problems are identified and dealt with at an early stage, also referrals made when necessary to appropriate specialist. Service users are supported through periods of relapses with a focus placed on positive outcomes. None of the current service users are assessed as competent to self medicate safely. A record is held of prescribed medication for service users. According to MAR sheets the prescribed medication is administered at appropriate times and signed for by staff. Medication is received in blister packs and stored safely at the home. Staff respond promptly and inform mental health services if there are issues of non-compliance. Photographs are held on the individual medication records of the service user, however for one the photograph of the service user was not present. A member of staff said that this had been overlooked and agreed to place a photograph on the file. A recommendation is made. Albion House DS0000025602.V358827.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): 22 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users find that issues of concerns and complaints are listened to and responded to appropriately. The home has a stable and experienced staff team that are familiar with service users and recognise indicators of or neglect. Training for staff in Safeguarding Adults Procedures is overdue and needs to be addressed so that staff are competent at following appropriate procedures. EVIDENCE: The home has a complaint’s procedure. It is displayed prominently in the home for both service users and visitors to see. Service users (five) spoken to feel confident in the complaint’s system, they also feel that their views are listened to and find the system accessible. The home holds a record of all complaints received. This demonstrated that that those received were minor issues, and that they were resolved satisfactorily and well within the specified timescales. CSCI did not receive any complaints about the service. The complaint’s procedure I operation needs further developing and organising, currently it is not logging the initial response acknowledging the complaint, neither is the system effective in analysing the pattern of complaints. A recommendation is made. The staff team has a number of experienced staff that has worked at the home for some years. From discussions with them it was demonstrated that they have a good knowledge of safeguarding adults procedures. They recognise and respond to changes in service users. Training records present were not up to Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 17 date. There is no evidence that the staff team received recent training on Safeguarding Vulnerable Adults. A Requirement is stated. The majority of service users take control of managing their own personal money. Four service users receive support with this. Cash books were available with records of all transactions and signatures to acknowledge these. The balance for two service users was checked against the receipt book, these were accurate. There is no sign that senior management audits these systems regularly. A recommendation is made. Two new members of staff were recruited in the last six months. According to the AQQA supplied all new staff are fully vetted first before they commence work. For one of the new members recruited pre employment appropriate documentation was not available. Confirmation of A POVA check or CRB Enhanced Disclosure was not available for this member of staff. It was unclear if these were filed elsewhere by previous management. A Requirement is stated in relation to this. The registered person must ensure that all staff are fully vetted before they commence employment and that appropriate documentation is available to confirm this. Albion House DS0000025602.V358827.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): 24 27 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users find that the home is comfortable and homely and safe, but a significant amount of investment and refurbishment is needed to make it a pleasant and inviting environment. EVIDENCE: All of the communal areas of the building were toured, also seen were four bedrooms. The home is clean and hygienic. All five service users spoken to find it to be comfortable. “It is more homely than a hospital room” was the comment from a service user. A number of areas appear shabby and are in need of refurbishment, these include bedrooms, bathrooms, toilets and shower areas, laundry. The communal areas also show signs of wear and tear. A change of directors has taken place in the holding company Prime Choice LTD. The new director of the organisation met with the inspector and spoke of the need for the refurbishment of the premises. A requirement is stated in relation to the refurbishment programme. The registered person must provide a copy of the refurbishment programme with Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 19 timescales for plans in addressing the areas of the environment that need attention. The previous inspection report had a Requirement stated in relation to the refurbishment of bathrooms and toilets. This has not been responded to and is restated. Albion House DS0000025602.V358827.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): 32 34 35 Quality in this outcome area is adequate, This judgement has been made using available evidence including a visit to this service. The service benefits from a stable staff team that are experienced and familiar with the needs of the client group. The service is consistent which service users value. Recruitment procedures can be unreliable and do not safeguard service users. As a result of the lack of investment in training and development for the staff team the staff team have not continued with professional development. EVIDENCE: The home has a retained a stable staff team. The majority of staff employed has worked there for over three years. Five of the regular staff team are either registered general or psychiatric nurses. Other senior staff members have completed NVQ Level 3 in care. On each shift is a senior experienced member of staff that is in charge of leading the staff team; title given is person in charge. Service users find that staff are supportive, they are interested and motivated. As a result of their experience and relevant qualifications a good level of competency is displayed in the care home. Service users told of feeling safe and trusting the staff team. According to records of events staff take appropriate action when a service user displays any adverse behaviour or indications of a decline in health. The competency level of staff ensures that Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 21 appropriate referrals are made to relevant mental health professionals to prevent further relapses in mental health. According to records supplied on the AQQA 70 of staff have NVQ Level 2 or equivalent. Additional staff are also completing NVQ Level 3 in care. There have been lapses in the training and development for staff. A training and development programme was not available. Records of training were not up to date. Mandatory training was provided to staff according to records present on personnel files, staff members confirmed this too. Qualified nursing staff have not been kept updated in professional development. The new director of the registered provider Prime Care Choice Ltd spoke of plans to focus on training and he proposed to introduce a training and development programme that would meet the needs of the staff team. A copy of this to be forwarded to the inspector. The newly appointed registered manager (in post two weeks) was unable to verify other training, as there were no records available to confirm this. Neither was it possible to evaluate the content of training delivered. A requirement is stated. The registered person must ensure that the training records of staff are updated, A copy of the updated training records to be forwarded to CSCI for evaluation. Two new staff members have begun work at the home in the past twelve months. The records for both of these staff were examined. For one staff member all the necessary documentation was available to confirm the suitability of the candidate before employment began. Shortfalls were found in the recruitment procedures for the second member of staff. A POVA First or CRB Enhanced Disclosure was not present. The member off staff is working under the supervision of a senior support worker and completing an Induction programme. He has worked in care settings prior to working in the home. The previous manager who was on leave undertook the recruitment, but the necessary documentation was unavailable. According to information received on the completed AQQA all staff are fully vetted before employment is offered. The registered manager agreed to pursue the necessary documentation and submit this to CSCI. A Requirement is stated. Albion House DS0000025602.V358827.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): 37 39 40 41 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers stability and structure to people that have experienced many setbacks in their lives. The service has successfully focused on helping achieve the best outcome for service users. With the introduction of a new experienced manager there is potential to take this service forward and build on the strength of the staff team. Despite the fact that areas of the environment need attention to make the home a more pleasant environment attention is given to promoting the health and safety of service users and staff. EVIDENCE: The organisation has continued to operate this service for the past two years without a registered manager for over two years. An acting manager was in post, an application to register with CSCI was not completed however during this period. Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 23 Prior to the inspection a new manager was appointed. Registration with CSCI also took place. The newly registered manager was in post for two weeks when the inspection took place. The registered manager is an RMN, has extensive mental health experience, both forensic hospital and community. He is currently completing an MBA. Directorship changes also took place within the provider organization Prime Care Choice Ltd. The new director met with the inspector and spoke of submitting the application to be the Responsible Individual for the organization. Confirmation of this change of director was seen in a fax from the company solicitor. A recommendation is made. The registered person should ensure that all the relevant notifications are made regarding the changes to directorship and to responsible individuals. Visits are made in accordance with regulation 26, copies of these need to be forwarded to CSCI. A requirement is stated. Anonymous questionnaires from service users are used for monitoring and evaluating the service. A senior member of staff spoke of consultations with service users that take place regularly every month. Service users’ find that their views are sought in this forum. The history of the home is not fully demonstrating the effectiveness of the current quality assurance system, for example areas of refurbishment have not taken place within reasonable timescales. Staff training and development records have not been kept up to date. It was not demonstrated how effective the overall quality assurance process is in informing future planning. A recommendation is made As the organization has recently changed the registered person should ensure that the quality assurance system is effective and that the development plan is in place to respond to this, a copy of which should be submitted to CSCI. According to the completed AQQA supplied by the home relevant policies and procedures are in place for the home. Dates were not supplied to evidence that these were recently reviewed. A recommendation is made. Records relating to the servicing and maintenance of the premises and the equipment necessary for health and safety were examined. These indicate 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 are also conducted. Fire fighting equipment is maintained in good working order and frequent evacuation procedures are conducted. Albion House DS0000025602.V358827.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 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 2 3 X Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must be updated with details of the provider organisation. (Unmet in timescale of 01/03/07) The registered person must ensure that no service user is admitted unless the needs have been fully assessed first, and having regard to assessment that the home is suitable for the purpose of meeting these needs. The registered person must ensure that all the staff team receive up to date training on Safeguarding Vulnerable Adults. The registered person must ensure that staff employed at the home is fully vetted. Appropriate documentation must be available and in place to evidence robust recruitment procedures. The registered person must ensure that the premises is maintained to a good state of repair both internally and that all parts of the home are reasonably decorated. A copy of the DS0000025602.V358827.R01.S.doc Timescale for action 30/06/08 2 YA2 14 (1) a, be, d 30/04/08 3 YA23 13 (6) 30/05/08 4 YA23 YA34 19 30/04/08 5 YA24 23 (2) b 30/04/08 Albion House Version 5.2 Page 26 6 YA24 23 (2) b refurbishment programme to be supplied to CSCI on the plans to address all the areas of the environment that require attention with timescales for achievement. The Registered Person must ensure that all bathing and toileting facilities are refurbished or redecorated as necessary. Unmet in timescale of 01/04/07. The registered person must ensure that individual training records of staff are updated; a matrix is needed of the content of this. A copy of the updated training records to be forwarded to CSCI for evaluation. The registered person must ensure that copies of regulation 26 visit reports are forwarded every month to CSCI 30/06/08 7 YA35 18 (1) c 30/04/08 8 YA41 26 30/04/08 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 YA6 Good Practice Recommendations The registered person should ensure that care plans are more individualised and reflect more accurately the particular support needs of the person the plan is agreed for. The registered person should ensure that consideration is given to developing activity plans that are appropriate for individual needs, and that service users find therapeutic. The registered person should ensure that a photograph of the service user is held on the relevant medication file. The registered person should ensure that the complaints system is developed further so that acknowledgment of DS0000025602.V358827.R01.S.doc Version 5.2 Page 27 2 3 4 YA11 YA20 YA22 Albion House 5 YA23 6 YA23 complaint is held with each complaint, also that logs are maintained to analyse and respond to any pattern in complaints received. The registered person should ensure that all financial transactions involving the handling and the management of service users money is audited on a regular basis by senior management. 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 practicable. The registered person should ensure that all the relevant notifications are made to CSCI regarding the changes to directorship and to responsible individuals. The registered person should ensure that the quality assurance system in place is effective, and that the development plan is in place to respond to this, a copy of which should be submitted to CSCI. The registered person should ensure that polices and procedures of the home are reviewed. 7 YA38 8 YA39 9 YA40 Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Area Office River House 1 Maidstone Road Sidcup London 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. Extracts may not be used or reproduced without the express permission of CSCI Albion House DS0000025602.V358827.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!