Inspection on 26/09/05 for Albion Road (44)

This inspection was carried out on 26th September 2005.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albion Road (44) 07/08/06

Albion Road (44) 30/11/05

Albion Road (44) 03/02/05

Albion Road (44) 08/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Albion Road (44) 44 Albion Road Sutton Surrey SM2 5TF Lead Inspector David Pennells Unannounced Inspection 26th September 2005 14:30 Albion Road (44) DS0000007156.V253831.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 Road (44) DS0000007156.V253831.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 Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Albion Road (44) Address 44 Albion Road Sutton Surrey SM2 5TF 020 8642 2092 020 8661 0502 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) Care Management Group Limited Catherine Lifely Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 03/02/05 Brief Description of the Service: 44 Albion Road is owned, managed and staffed by the Care Management Group (CMG). This care home provides residential care for up to seven younger adults with learning disabilities and associated mental health problems / behaviours that may challenge. Located in a quiet residential street in Sutton, the home is about a ten-minute walk from the town centre with its shops, eating establishments and excellent transport links. The building is a large Victorian detached house. Communal facilities include a large lounge, dining area and kitchen. All service users have their own single bedrooms. There is a staff / manager’s office - which is now (since the creation of the seventh bedroom) situated on the first floor, and there is a sleeping-in facility on the second floor. A separate building adjacent the kitchen contains the laundry, a larder and a small sensory room. There are sufficient bathrooms / showers and toilets throughout the home to meet users’ needs. There is a drive at the front of the home for parking and a large wellmaintained rear garden with a patio area, and a new patio area to the side of the house - close to the back door - which has tables and chairs to allow eating - and barbecues – outside when the weather is fine. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced - and spanned from early afternoon until after the service users’ suppertime. Ashley Muthulingam, and another senior worker assisted the inspector, as the manager was absent – on annual leave. The home was running smoothly at the time of the visit, with service users coming and going from external activities, as well as some enjoying the general ‘run of the house’. During the visit, the inspector checked documentation, toured the premises, spent time with the service users and chatted with the staff. One issue arose, of principal importance, being the finding of a serious health and safety failing at the premises - a hot water bath outlet running at a dangerously high temperature. The inspector had to serve an ‘Immediate Requirement Notice’ on the home concerning this issue, requiring that the issue be resolved urgently. The Commission received confirmation that this issue was being resolved - by return - from the CMG Company’s Head Office. What the service does well: What has improved since the last inspection? Issues raised at the last inspection – such as providing security lighting outside the kitchen door, fitting a suitable heater in one serve user’s ensuite bathroom, and ensuring fire extinguisher checks were accurate and precise had all been addressed. Decoration of the hallway and new flooring in the dining room and a bedroom, had upgraded the premises, along with the kitchen having a new oven, hob and worktops. General safety checks in the house (other than those specifically identified below) were in good order. Records were generally up-to-date and well kept. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 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. Albion Road (44) DS0000007156.V253831.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 Road (44) DS0000007156.V253831.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): 1, 2 & 5 The home provides service users and relatives with adequate information concerning the home, enabling an informed choice to be made about choosing to live there. This process is assisted by the assessment process, which ensures that service users are appropriately placed at the home. Service users can expect to be provided with a clear contract, which states clearly the terms and conditions of staying at the home. EVIDENCE: The Statement of Purpose / Handbook is currently a good, readable, comprehensive document; it has been amended to demonstrate the relevant qualifications and experience of the staff team. Charges vary, and are dependent on each specific contract agreed with the particular placing authority, reflecting the service user’s individual needs; for instance, if a service user receives a number of dedicated 1:1 hours of staff input, this adds a ‘premium’ to the basic charge. There has been no ‘movement’ in the home within the last year; all seven service users (all men) at the home have been together as a single community since April 2004; five of the service users have resided at the home since April 1997, with the sixth coming to the home in November 2002 and the seventh arriving last year. The service user group’s age spans from thirty-two to fiftytwo; the average age being currently 39. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 9 In accordance with the home’s admissions procedure, referrals would only usually be admitted on the basis of a full needs assessments undertaken by representative(s) of CMG accompanied by the manager, or the service user’s Care Manager, representing the relevant Placing Authority. The inspector continues to be satisfied that the home would not admit anyone, or attempt to hold on to anyone, whose assessed needs either contradicted the Statement of Purpose or could not be met within the service. CMG has developed an excellent contract/statement of terms and conditions that are included in the home’s Service User Guide/Handbook. The contracts clearly state the room to be occupied by each service user; the terms and conditions of their occupancy, including periods of notice; fees charged, and arrangements for reviewing their care plans. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. Service users can expect a care plan to address their needs and aspirations; this being developed as far as is practicable with the involvement of service users – and/or their representatives. Risk assessments forms a fundamental part of the care planning process, enabling independence and self-determination within a framework of safety considerations. Service users can be assured that information concerning them is kept securely and safely within in the home. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 11 EVIDENCE: Care plans continue to be reviewed and updated, following the collating of a monthly review by the Keyworker; this enables regular reflection on achievements - and also on changing needs. The recommendation that the goals and aspirations of the individual - as expressed in the care plan - be held close at hand is carried forward; all reporting at the home should reflect on whether the care plan aims are being addressed / met or not. By having the goals immediately to hand the care workers can easily remind themselves and reflect on any achievement / regression in this respect. Individualised guidelines (i.e. risk management strategies) for service users assessed as likely to be aggressive or self-harm have also been drawn up with the involvement of specialist care professionals. Risk assessments were in place for all of the service users covering various aspects of care, including personal hygiene, community presence, and specific behaviours likely to challenge the service. Each assessment identified the risk, the likely consequences, and the action required to minimise the risk’s negative effect. It was evident from individualised care plans that - based on an assessment of acceptable risk and safety criteria - staff encourage service users to take ‘reasonable ‘ risks, whenever possible. The home has a corporate confidentiality policy which is available to service users and their families within the Service User Guide. Staff members must sign to confirm they have read and understood the provider’s confidentiality policy; this was seen on staff personal files. Service users are informed that they have the right to access personal information held about them by the home if they wish. Storage of service user and staff documentation is appropriately within the locked office on the first floor; this is vital as in such a home paperwork may be ‘removed’ [unwittingly] by service users very quickly. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 – 17 Service users can expect their lifestyles at the home to be individually focused and aimed at providing a fulfilling programme of engagement with fellow peers, friends, and with staff & families where appropriate. Activities provided and pursued ensure positive engagement within both the home and the local community, as far as is practicable – acknowledging and respecting each individual’s needs and capacities. Service users can expect to receive a healthy and nutritious diet provided within a pleasant and comfortable environment. EVIDENCE: Service users are individually encouraged to maintain their independent living skills; this ranges widely in the home due to the differing levels of capacity for each individual. They are also supported to practice a religious persuasion of their choice; one service user’s bedroom particularly reflected their cultural / religious background. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 13 Staff engage with service users to encourage a good level of interaction / communication; this is particularly important for those service users (about 50 ) who do not have a high level of verbal communication skills, and therefore demand sensitive observation / ‘interpretation’ of their reactions to gauge preferences and dislikes Activities within the house include; relaxation (a separate designated relaxation room is provided for this) music therapy, reading / drawing and puzzles and gardening – and parties (for any occasion!) are well enjoyed. One s/user had a 1:1 session of reflexology once a fortnight. Activities planned outside the home include attendance at day care / education centres (Cheam centre, Scola College, Orchard Hill College – providing sensory sessions, aromatherapy and keep fit, creative arts and cookery and aromatherapy). Staff time is provided - as evidenced by the rotas - to enable service users to engage with activities at weekends and in the evenings. Sporting leisure activities (such as bowling, swimming), meals out, shopping, and trips out into the country with trips to the local parks and pub. Mini-breaks and holidays – and individuals visiting their relatives are also encouraged; some service users ‘go home’ for short / weekend / holiday breaks. Holidays this year have included two service users spending five days at Bognor Regis, others visiting Clacton or Bournemouth for a holiday break and - for some - day trips are more valuably enjoyed that a full trip staying away (with too much change / variables to tolerate or accommodate). Service users have unrestricted access to the home and grounds and have all been offered keys to their bedrooms. A keypad system is in place at the front door, based on a global risk assessment. The manager had previously confirmed that all service users are on the council’s electoral register - but they do not express an interest in voting. Contact with families is positively encouraged, but for most, the home is their ‘family’ - due to the work some staff have to undertake in substitute for the hoped-for family connections. The home does make positive efforts to keep in contact with family contacts. One relative replied to the commission’s questionnaire stating: ‘I am always made welcome at Albion Road and if I have any worries I know that we can work together to sort this out. The staff are always helpful & understanding.’ Some service users can eat their own food, whereas members of staff feed one service user. Mealtimes are unrushed and relaxed. Appropriate eating equipment is provided as required. The House collectively plans menus around what the service users evidently ‘like’ / enjoy - but within the framework of a ‘healthy eating’ approach (i.e. not too much repetition or ‘stodge’). The three service users with less verbal communication are observed and reactions to foods are relied on to indicate their preferences. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users will be supported in personal care according to their own preferences or assessed needs, and will receive physical and emotional health care support through the timely intervention of allied professionals - including any prescribed medication - in an appropriate way. The home manages the administration of medication generally well, however more close attention should be focused on accurately recording the administration of ‘prn’ (when required) medication. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 15 EVIDENCE: Care and support provided by the home was observed to be familiar, appropriate and sensitive to the needs of the individual service users. Routines were flexible, and guidance and support was ‘second nature’ to the staff - who live alongside the service users, whilst integrating support and assistance, as appropriate. Service users clearly chose their own clothes and initiated their own activities; service users are supported in activities and day-to-day routines by staff, and by Keyworkers in particular. All three of those responding to the Commission’s questionnaire – and having loved ones living at the home - indicated that they were, overall, happy with the care provided at the home. All three indicated they thought staffing was adequate and were consulted / involved in making decisions with regard to their relative / friend. Service users are supported to attend routine annual health checks covering general health, medication, vision, and dentistry / oral health needs. Chiropody is provided, where necessary, at the home on a bi-monthly basis; domiciliary visits of a private practitioner are charged per appointment. Medication storage and records were examined and, with regard to regular day-to-day prescriptions and prescriptions, found generally well kept. The inspector chose to ‘audit trail’ one particular service user’s ‘prn’ (‘when required’) medication. The inspector found that records did not ‘tie up’ – for example, where a ‘prn’ medication dose was given and recorded on the Medication Administration Record chart, this was not reflected in the day-today record – which failed to note even that additional medication was given. A stock-take of the actual medication against the record also showed that the drugs were ‘one out’. It was established that – through comparing all the various notes - a staff member had failed to record an administration. Mindful of the situation found, the inspector requires closer monitoring of medication stocks of a ‘prn’ type and also greater detail on the ‘prn’ guidance established against any person, to ensure that a full description of the process and reasoning behind administering a ‘prn’ is given. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Service users and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescale. The home provides adequate support to service users to ensure that they are protected from harm and any form of abuse. EVIDENCE: The home’s complaints procedure is included (in symbols format) in the Statement of Purpose / Information Handbook and contains information about how a complainant can contact the Commission should they wish to do so. The procedure has clear timescales given, so that a complainant knows what to expect - and time frames for the resolution of such complaints. A record book for all concerns / complaints made about the service at the home is kept. The previous inspection comment suggesting that the Abuse policy should be written for ‘Sutton‘ homes specifically - using the LB Sutton policy as its guiding benchmark - should still be considered. The CMG Policy and procedure for ‘Alleged Abuse’ does not cross-refer directly into the Local Authority’s joint protocol guidelines for dealing with any incidents of adult abuse; the CMG policy should directly refer to this, and a local (‘Sutton homes’) policy be evolved tying in the best practice guidance as indicated by this document. The home was in possession of the ‘old’ 2002 Local Authority protocol; this has now been replaced with the 2005 version. Steps must be taken to obtain the revised document. The home now has a small safe for the safekeeping of monies, valuables, and service user’s possessions handed in for safekeeping. Day-to-day monetary Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 17 items are kept safe in locked containers in the office. The CMG organisation (through their Finance Department) acts as Appointee to all seven service users, this being handled centrally by their Head Office located in Wimbledon. Finance hardback books for each service user’s personal allowance sums were seen - with records accurately kept. Balances are checked daily. The home takes care not to keep too much money stored on the premises – a ‘safekeeping’ system is managed by the manager to keep accounts at reasonable levels. A couple of entries in a book concerning ‘loans’ are being queried and followed up by the inspector directly with the home’s manager (who was absent on holiday at the time of the inspection). Another query – concerning the purchase of window blinds by a service user is also included in this additional enquiry. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 – 30. Service users may expect their accommodation to be clean - and a pleasant & homely, comfortable environment to live in, meeting the needs of the individual and providing privacy and the chance to express their own character through furnishings and decoration. The home is generally well maintained with equipment being serviced, ensuring the safety and security of service users, however lesser attention to a specific facility – a service user’s own bathing facility – has placed a service user possibly at risk. EVIDENCE: The house is a pleasant property, which is located in a residential area of Sutton not too far from local amenities and the town centre, with its many social, cultural, commercial and transport opportunities. The house is well maintained, with more than sufficient space for the service users, and the patio outside the kitchen being developed as an outside sitting / dining area. The premises are comfortable, light and airy; furniture and fittings are of good quality. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 19 Since the last inspection, new flooring has been installed in one service user’s bedroom, and similar in the dining room. In the kitchen a new hob and worktops have been installed. The main hallway has also been decorated. All service users have single occupancy rooms, all of which - as an existing home, under the revised minimum national standards - are satisfactory in size and facilities provided. The bedrooms, which were decorated to a high standard, are adequately furnished and personalised to reflect the individual occupant’s personality and preferences. Most service users have their own lockable storage space in which to keep prized possessions, and all the rooms have been wash hand basins. Four rooms now have ensuite [minimally toilet] facilities, this leaving three without. The home has three communal toilets and two bathrooms conveniently located, ensuring that no more than three service users should have to share these facilities, in keeping with the spirit of this standard. A previous requirement relating to an extractor fan in the upstairs bathroom being mended is reiterated in this report. One ground floor room that has a full bathroom ensuite was inspected – accompanied by the service user, who likes being in his room and enjoys its contents. The bathroom door is generally secured, to ensure that toiletries etc are safe. However, testing the hot water outflow, the inspector found water being provided at over 50 degrees centigrade – a dangerously high temperature. It was unclear whether there was a thermostatic mixer valve fitted on this tap. There was a clear risk in regard to this situation, as the service user could well access the bathroom and unwittingly cause an accident. An Immediate Requirement Notice was served on the home (under the ‘Health & Safety Standard No 42.3/4), requiring that – if there was not such a valve already fitted - a tamper-proof, fail-safe thermostatic mixer valve be installed on the hot water supply immediately – and also requiring that the outflow be very carefully – and regularly monitored in future. This Immediate Requirement Notice was immediately responded to by the CMG Company, guaranteeing that the remedial work had been undertaken. It has to be stated that this safety issue arising was unusual for a home that has a very rigorous and usually reliable focus on health & safety issues. Checks of maintenance and servicing records at the house showed that all other items of equipment and appliances were serviced, operational, safe and well maintained. Monthly health & safety checks were up to date to September, and issues that can be forgotten – for instance the checking of First Aid equipment boxes – were all in order. The main lounge and dining room were comfortably furnished and well used by the service users. Many of the service users were also noted to be using their Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 20 bedroom space as well. The large hallway was also a ‘meeting place’ between lounge, dining area and kitchen - having a large ‘arts and crafts’ seat as a part of its architectural features. Service users do not have specific physical disabilities, as such; so no specialist aids and adaptations are essentially necessary, although the inspector noted appropriate grab rails were suitably positioned throughout the home. All the bedrooms and bathroom / toilet facilities have been supplied with a call bell alarm, which are tested on a weekly basis. Renewed concern about the use of door wedges is covered in Standard 42. The inspector strongly recommends this time the review of the stone-filled driveway; at the time of the inspection, the route to the front of the house from the parking area was potholed and muddy; this is not safe for service users. A review and consideration of applying tarmac to the surface is suggested. The home was clean and generally odour-free on the day of the inspection. The service users rooms’ cleaning is self-managed - though staff intervention may be invoked if it too difficult for a service user to manage. Cleaning materials are kept locked away in line with the Code of Practice for substances hazardous to health (COSHH). A sluice-cycle washing machine is available to address any problems with incontinence. The extractor fan in first floor bathroom was found still to be not working; it is important - for proper ventilation, safety and a hygiene reasons. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Service users can rely on the home providing adequate staff in sufficient numbers and being duly competent and well-trained to provide a service that seeks to meet their individually identified needs. The home’s recruitment and staff support mechanisms are organised so as to ensure the safety, protection and wellbeing of service users. EVIDENCE: Staffing levels are provided at the home a minimum of three staff on duty for both the early and late shifts at the home and a staff member awake and one, on-call, on site - with the manager’s hours generally being supernumerary. There was on full time vacancy at the home at the time of the inspection; just one staff team member had left since the last inspection visit. Examination of staff training revealed that all six full time staff members are trained in First Aid, and so also are some of the bank staff. Three staff members only have NVQ Level 2 in Care or above. Efforts must continue to be made to increase this percentage urgently to at least 50 - the target set by the Commission for the end of 2005. Other training input more recently has included: Protection of Vulnerable Adults, Personal Hygiene, Individualising Services, Understanding Learning Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 22 Disabilities, the Dignified Management of Conflict, Keyworking, Fire Safety, Communication Skills, Food Hygiene and Understanding Challenging Behaviour. Staff members are all trained in the Dignified Management of Conflict (“Digman”), due to the occasional need to invoke restraint / ‘holding’ techniques with certain service users. Documentary evidence confirms that all staff members receive a structured induction within six weeks of their appointment, covering the principles of care, the individual needs of the service users, and safe working practices. All new members of staff are subject to a sixth month probationary period. The CMG parent company supports unit managers to recruit staff where necessary; the company has clear recruitment policies and procedures in place, and a standard process concerning the information and checks that have to be undertaken prior to a staff member starting work. The previous inspection visit report revealed that this standard had been met by the home and no new staff members have been recruited since that date. Confirmation that Criminal Records Bureau checks have been obtained is evidenced in writing from CMG personnel with the date and identifying Check serial number. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 23 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): Service users and their relatives / friends can rely on the home being run well, and providing a professional service with the best interests of the service user being central to the care provision. The registered providers can be relied upon to take seriously issues raised for their attention – to the benefit and for the safety of those residing at the home. EVIDENCE: The current manager, Catherine Lifely, (absent on holiday at the time of the inspection) was previously the deputy at the home; she became the registered manager in January 2004, following the sudden, unexpected departure of the previous manager. Catherine Lifely is currently undertaking the NVQ at Level 4 in Management and Care - leading to the Registered Manager’s Award. Recent training for management / senior staff has also included: ‘Managing a Team’, ‘Monitoring new staff’ and ‘Legislation’. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 24 It was clear, from comments made during the course of the inspection, that the manager still has a very ‘hands on’ approach. Both staff and service users are encouraged to participate in the day-to-day operation of the home and to voice their opinions at reviews, informal one-to-one meetings with Keyworkers, staff supervisions and through the home’s complaints / grievance procedures. One relative commented: ‘We feel the excellent care provided in the home is dependent on the senior staff, in particular the manager’ reflecting a satisfaction with the home and appreciation of the management style of the establishment. Quality Assurance surveys are regularly sent out to relatives, friends and representatives / advocates of service users to encourage feedback about the quality of the service provided. The responses are received centrally and collated, prior to being sent on to the home itself. Unannounced visits by representatives of the registered provider are clearly being carried out on a regular basis and the subsequent reports are being forwarded to the Commission. Such visits involve checking documentation, inspecting the premises and interviewing both service users and staff. CMG has a comprehensive set of policy and procedure manuals which cover the broad spectrum of needs identified under the headings of: Mission Statement / Staff Policies / Service Management / Service & Care Delivery / Health & Safety / Residents Welfare, and Emergency Procedures. CMG, as an organisation, is re-notified to the Information Commissioner under the Data Protection Act 1998 and, as such, commits to ensure the eight Principles of Data Protection are fully complied with. Accident and incident records seen were all satisfactorily completed, signed and dated. The inspector was generally impressed with the attention to safety in the home; as commented earlier: “…monthly health & safety checks were up to date to September, and issues that can be forgotten – for instance the checking of First Aid equipment boxes – were all in order.” Despite this, the failure to check that the bath hot water outflow in a service user’s ensuite bathroom could have lead to a serious accident, and so an Immediate Requirement Notice was served on the home (see fuller description in Environment Standards 24 – 30). The inspector has also required that fire alarm break glasses need numbering to evidence the progressive testing of each and every location in the house. Two other requirements under ‘Health & Safety’ – concerning door wedges not being permitted, and the freezer facilities in the house being double-checked and monitored (the inspector had some concerns about the effectiveness of one or two freezer areas), completed comments in this vital area. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 25 The overarching CMG management of the service clearly ensures the overview management, the financial viability and the accountability of the home. Lines of accountability both within, and beyond, the home, are clearly mapped out. The managing company employs staff in both human resources and staff training focuses, enabling the effective support for, and running of, this specialist home. A business and financial plan required by the Standards now forms, annually, part of the manager’s personal development plan. Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 26 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 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albion Road (44) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 2 3 DS0000007156.V253831.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation 13(2) Requirement The administration of ‘prn’ medication must be carefully described (including greater detail on the ‘prn’ medication detail guidance), and fully recorded - both in medication charts and care notes - to ensure the clearest information is held in this regard. The extractor fan in the first floor bathroom must be repaired or replaced to ensure proper ventilation, safety and a hygienic environment. Timescale of 30/05/05 not met. Timescale for action 30/11/05 2 YA30 23(2)(p) 30/11/05 3 YA42 13(4) Immediate Requirement 27/09/05 Notice served: The ground floor service user’s ensuite bathroom – where hot water temperatures of more that 50 degrees centigrade were found – should have a failsafe, tamper-proof thermostatic valve fitted or replaced without delay. Regular monitoring of hot water outflows from this tap must then be implemented thereafter. DS0000007156.V253831.R01.S.doc Version 5.0 Page 28 Albion Road (44) 4 YA42 13(4) & 26(4) Electromagnetic door holders must be used on the ground floor to hold doors open as appropriate; wedges (seen in a service user’s and the kitchen doorways) are not acceptable. Timescale of 30/05/05 not met. Temperature checks of freezers must be consistently kept and recorded. Thermometers must be kept within each separate fridge and freezer chamber. The freezers in the ‘outhouse’ should be monitored closely and disposed of if they cannot keep adequate low temperatures. Fire break glasses must be numbered individually throughout the house to make it easier to evidence that all the break glasses in the house have, indeed, been tested in rotation. 30/11/05 5 YA42 13(4) & 16(2)(g) 30/11/05 6 YA42 26(4) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the care plan action points are summarised into ‘bullet points’ and by some means situated close to the daily notes for the specific individual to ensure that all identified areas are addressed constantly by staff and to ensure that reports reflect on goals /targets as agreed with the service user. It is strongly recommended that the provider’s policy with regard to adult abuse (dated 2002) be amended to DS0000007156.V253831.R01.S.doc Version 5.0 Page 29 2 YA23 Albion Road (44) accurately tie in the approach required locally under the jointly agreed (and newly-revised) London Borough of Sutton Vulnerable Adults Procedure / Guidelines. 3 YA23 The Adult Protection protocol provided by the London Borough of Sutton (dated 2002) is now out of date; the registered provider should ensure the 2005 version is obtained and put in place at the home. The registered provider should consider replacing the loose gravel surface driveway with a more suitable (either tarmac or paved) surface to promote safety and easier access from vehicles to the house. A minimum of 50 of the care staff team must be qualified - nominally to NVQ Level 2 - in Care by 31/12/05. The manager must be qualified to NVQ Level 4 in Management and Care by 31/12/05. 4 YA24 5 6 YA31 YA37 Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albion Road (44) DS0000007156.V253831.R01.S.doc Version 5.0 Page 31 - 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. 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