Inspection on 30/11/05 for Albion Road (44)

This inspection was carried out on 30th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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) 26/09/05

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 30th November 2005 14:10 Albion Road (44) DS0000007156.V260669.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.V260669.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.V260669.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) www.caremanagementgroup.com Care Management Group Limited Catherine Lifely Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 26th September 2005 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 (though current building works across from the home are causing negative effects on some service users), the home is about a ten-minute walk from the town centre with its variety of shops, eating & leisure establishments, and excellent transport links. The building is a large late-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.V260669.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted across an afternoon, the inspector arriving soon after 2pm. The manager, Cathy Lifely, had just returned form a period of annual leave - but was sufficiently oriented to assist the inspector in reviewing the requirements and recommendation set at the last inspection, to tour the home with him, and to keep the ever-watchful managerial eye on the home. The inspector left the home just before 6.00pm. Staff members were also met and service users engaged with him, as far as the inspector’s familiarity would allow. The inspector is grateful to the service users, staff and the manager for their welcome, and for the hospitality shown. What the service does well: What has improved since the last inspection? A subject of an immediate requirement notice at the last visit, the thermostatic valve on a specific service user’s bathroom has been refurbished and adjusted to ensure safe levels of hot water delivered at all times. The extractor fan in the first floor bathroom has been replaced. Electromagnetic door holders have been provided for all communal and bedroom doors where it is felt expedient to hold the door in a ‘open’ position. Freezer temperatures are being more carefully monitored and recorded – to ensure that food safety measures are fully in place. Fire alarm break glasses are now numbered to enable ease of identification when recording the necessary checks. The manager is introducing a new system whereby the care plan is more briefly - given on a laminated format - so that all can easily access the ‘headline’ points of care to be delivered to each individual. Albion Road (44) DS0000007156.V260669.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.V260669.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.V260669.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): None were inspected at this visit. 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 above judgement statements are taken from the previous inspection report, when three – including the key standard – were inspected. No change in service users has occurred since the last inspection. Albion Road (44) DS0000007156.V260669.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): None directly inspected at this inspection. 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. EVIDENCE: The above judgement statements from the last report covered four of the five – including the three key – standards. Nothing seen or noted by the inspector led him to believe that the situation had changed – so these comments are confidently reiterated. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None directly inspected at this visit. 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: The entire set of standards above was inspected at the last inspection visit and all found to be met. Observations at this visit confirmed that all such measures are still in place. The inspector confirmed that the home’s focus on external community engagement was a strong as ever – opportunities being taken to ensure the best positive outcome for service users enjoyment. The list of activities engaged in by service users was complex and manifold in variety and frequency; certainly no opportunity is missed to provide fulfilment. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 11 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): Only standard 20 was directly reviewed. 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 criteria for the administration of ‘prn’ (when required) medication. EVIDENCE: The first judgement statement paragraph above indicates the outcomes for the first two standards that were inspected at the last visit and found to be met. The manager and staff continue, clearly, to seek the best health and wellbeing for all service users at the home. The second paragraph is repeated from the last report, as the inspector has had to reiterate the requirement concerning the ‘Protocol for administration of PRN medication’. These forms relate to individual service users specific medication and were found not to be completed, nor endorsed by the GP as required by this documentation process. Administration of ‘prn’ (‘when required’) medication must be carefully described in greater detail on the ‘prn’ medication detail guidance, and the GP’s endorsement must be obtained. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 12 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): 23 only. 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 support to service users to ensure that they are protected from harm and any form of abuse, however the policy and procedure relating to investigating allegations of abuse and dealing with vulnerable adults does not blend in with the local authority procedure adequately – thus putting service users at possible risk of mishandling of such situations. EVIDENCE: The first judgement paragraph is reiterated from the last report, covering the last inspection’s assessment regarding the home’s complaints process – which was – and continues to be - satisfactorily met. The second standard reviewed at the last inspection in September contained a reiterated recommendation requesting that the registered provider take urgent steps to ‘tie in’ the CMG Adult Abuse policy with that of the host local authority (London Borough of Sutton – a newly revised procedure has been issues in 2005). This has not been done, and the inspector is concerned that the two policies do not concur. The ‘current’ CMG policy (April 2002) does not cover immediately reporting the issue directly to the local social services care management team – a protocol that is now established with all care providers within the Borough (and common to other Boroughs too). Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 13 A significant number of the staff team has now attended training on Vulnerable Adults issues – and more is planned soon – however the possibility of confusion, and therefore potential delay of correct reporting and seeking advice in such incidents, could put service users at potential risk from mismanagement of such a situation. A small safe is required to be provided to ensure that larger sums of monies and service users valuables are kept suitably secure. Examining an audit of training regarding restraint procedures, it was noted that most staff had not undergone training (which is supposed to be ‘refreshed’ each year) in the CMG ‘Dignified Management of Conflict’ process for as far back as five years or so. This is unacceptable, as techniques and approaches change, and - with such sensitive an issue - the training does need to be ‘rehearsed’ to ensure ongoing competence as soon as is practicable. The manager stated that she hopes to access training ‘in-house’; this is very sensible, as the training could then be focused on issues that arise in the house itself. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 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. EVIDENCE: The two judgement statements are taken from the previous inspection report where all standards were inspected, with just a single immediate requirement notice being served on the registered provider in relation to an ineffective thermostatic hot water limiter valve. The issue was immediately resolved and is now monitored, ongoing, with the remaining hot water outlets. The upstairs bathroom’s floor tiles were showing sign of wear and pressure; two were totally cracked across – and could therefore become a health & safety hazard to service user’s bare feet. These must be replaced. The opportunity is taken to recommend that a non-slip vinyl flooring be put in place instead of such cold tiles – and the bathroom redecorated at the same time. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 15 A recommendation is also made that the registered provider should consider replacing the loose gravel / shingle surface driveway with a more suitable (either tarmac or paved) surface - to promote safety and easier access for service users (and others) from vehicles and from the roadway to the house. Albion Road (44) DS0000007156.V260669.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): None inspected directly at this visit. 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: The above judgement statements were made regarding the outcomes from the last inspection visit to the home. There was no suggestion from the inspector’s observations at this visit that any major changes had occurred since the inspection visit a couple of months previously. A single concern about training in ‘Dignified Management of Conflict’ is covered in this report under ‘protection’ – Standard 23. NVQ training is currently being stepped up – with the hope that the home will achieve the Commission’s targets early in 2006. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 17 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): 37 & 42. Service users and their relatives / friends can rely on the home being run well - the manager being competent in her practice - and can be sure that the home provides a professional service with the best interests of service users being central to the care provision. The registered providers can be relied upon to generally take seriously health & safety issues raised for their attention, to the benefit and for the safety of all those using the home. EVIDENCE: The remaining key standard not inspected this time – 39 – was found ‘met’ at the last inspection visit. The registered manager, Catherine Lifely, was previously the deputy at this home; she became the registered manager in January 2004, following the sudden 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; she hopes to complete this as soon as is Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 18 practicable – bearing in mind the fact that the Company has had some ‘glitches’ in its training input to its homes. The manager has a very ‘hands on’ and direct approach to management; the home is sufficiently small that the ‘service users first’ mantra is evident. Two small health & safety issues arose during the visit; wedges (seen in the kitchen door) continue to be unacceptable; the damage to door s and frames can lead to the seals becoming ineffective. It is vital that the home uses the door holding facility that is provided. Secondly, a recommendation is made that all the fire alarm break glasses in the house be tested in strict rotation – to ensure that a specific point does not get ‘lost’ in a random order pattern. The manager readily heeded this point. Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albion Road (44) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000007156.V260669.R01.S.doc Version 5.0 Page 20 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 - to ensure the clearest information is held in this regard. (Timescale of 30/11/05 not met.) The registered provider’s policy with regard to adult abuse must be amended to accurately tie in the approach required locally under the jointly agreed (and newly-revised 2005) London Borough of Sutton Vulnerable Adults Procedure Guidelines. (Previous report’s ‘strong recommendation’ not actioned.) A small safe must be provided to ensure that larger sums of monies and service users valuables are kept suitably secure. Staff must receive ‘refresher’ training in the CMG ‘Dignified DS0000007156.V260669.R01.S.doc Timescale for action 31/12/05 2. YA23 13(6) 31/01/06 3. YA23 16(2)(l) 31/01/06 4. YA23 13(6) & 18(1)(c) 31/01/06 Albion Road (44) Version 5.0 Page 21 Management of Conflict’ process as soon as is practicable. 5. YA27 13(4) & 23(2)(b) The upstairs bathroom’s broken floor tiles must be replaced. It is strongly recommended that a non-slip vinyl; flooring be put in place instead of such cold tiles. Wedges – such as seen holding the kitchen door (which has a safe ‘dorgard’ facility) are not to be used. They can, over time, distort the doorframe rendering its smoke seals ineffective. (Previous timescales of 30/05/05 & 30/11/05 not met.) 28/02/06 6. YA42 23(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 YA24 Good Practice Recommendations The registered provider should consider replacing the loose gravel / shingle surface driveway with a more suitable (either tarmac or paved) surface - to promote safety and easier access from vehicles and from the roadway 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. That all the fire alarm break glasses in the house be tested in strict rotation – to ensure that a specific point does not get ‘lost’. 2. 3. 4. YA31 YA37 YA42 Albion Road (44) DS0000007156.V260669.R01.S.doc Version 5.0 Page 22 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.V260669.R01.S.doc Version 5.0 Page 23 - 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. 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