Inspection on 07/08/06 for Albion Road (44)

This inspection was carried out on 7th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albion Road (44) 30/11/05

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 Key Unannounced Inspection 7th August 2006 11:45a Albion Road (44) DS0000007156.V300177.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 Road (44) DS0000007156.V300177.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 Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 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.V300177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 30th November 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 and at the bottom of the back garden are causing some 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 with a residual ‘arts and crafts’ feel to the property. 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 (loft level) floor. A separate small building adjacent to the kitchen contains the laundry, a larder and a small sensory / activities room. There are sufficient bathrooms / showers and toilets (some ensuite) throughout the home to meet users’ needs. There is a drive at the front of the home for parking and a large wellmaintained (and well planted) rear garden with a patio area, and a patio area to the side of the house - close to the back door - which has tables and chairs to allow eating outside - and barbecues - when the weather is fine; this has clearly been well used this year and was being used for supper ‘al fresco’ on the warm evening the inspector was present at the home. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted from late morning to suppertime on a weekday. The manager, Cathy Lifely, was present at the home and was able to assist the inspector in reviewing the requirements and recommendation set at the last inspection, to tour the home with him, and to review documentation. Staff members were met and service users engaged with the inspector, as far as the inspector’s familiarity allowed. The inspector also called at the home two days afterwards, in order to appraise himself with the brand new documentation (revised policies and procedures) that had been brought to the home the day before. Again both staff and the manager were helpful and welcoming. The inspector is grateful to the service users, staff and the manager for their warm welcome, for the hospitality and attention shown during his visits. What the service does well: What has improved since the last inspection? Requirements overdue at the last inspection – relating to ensuring the protocol for the administration of PRN (when required) medication is adhered to, including gaining the endorsement of the GP - and the second relating to the ubiquitous door wedge holding doors open - were both satisfactorily met. A requirement concerning the Company’s Adult Protection / Abuse procedure has now seen the document being amended to acknowledge the pre-eminence of the Local Authority procedure. Three other recent requirements - the first relating to the need for a small secure safe for items held in safekeeping, the second relating to staff being ‘refreshed’ in their training relating to the ‘Dignified Management of Conflict’, and the third relating to replacing floor tiles which were breaking up in the upstairs bathroom, again have all been met. A recommendation relating to staff and management training in regard to NVQ achievement, is progressing well, though staff moves may well compromise these statistics. Albion Road (44) DS0000007156.V300177.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. Albion Road (44) DS0000007156.V300177.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 Road (44) DS0000007156.V300177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Prospective and current service users can be assured they will have their needs assessed, recognised and appropriately recorded by the home. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. EVIDENCE: The population of seven service users at the home has been constant 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 in 2004. The service user group’s age spans from early thirties to the early fifties; the average age being around 40. This constancy - also quite well reflected by the staff team - has been fundamental to the progress of a number of service user’s wellbeing; their behaviour programmes being well implemented thanks to the stability this constancy brings. Some seemingly intractable behaviour problems are now reported as much improved. 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, and / or the service user’s Care Manager, representing the relevant Placing Authority. All service users were admitted with substantial programmes of care planned and documented. The ongoing assessment provided at the home (including the Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 9 involvement of other professionals as necessary) ensures that a focused ‘assessment’ / review continues. It is clear that service users are central to the planning of activities at the home; each of the samples of care records taken by the inspector showing comprehensive reviews being undertaken each six months and a monthly review also being in place. Albion Road (44) DS0000007156.V300177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Service users can confidently expect to be provided with a care plan that addresses the specific needs and aspirations of the individual; this being developed as far as is practicable with the involvement of service users, and / or their representatives in the decision-making process. Risk assessments forms a fundamental part of the care planning process, enabling independence and self-determination for service users within a framework of safety and protection considerations. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. EVIDENCE: Care plans tracked were fully comprehensive and current in content. They continue to be reviewed and regularly updated, following the collation of a monthly review by the Keyworker; this enabling regular reflection on achievements - and also on changing needs. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 11 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 identifies the risk, the likely consequences, and the action required to minimise the risk’s negative effect. Individualised guidelines (i.e. risk management strategies) for service users assessed as likely to be aggressive or to self-harm have also been drawn up, with the involvement of specialist care professionals. 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 - and to live their lives to the full. Albion Road (44) DS0000007156.V300177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Service users can expect their lifestyles at the home to be individually focused and aimed at personal development whilst providing a fulfilling programme of engagement with fellow peers, friends, and with staff & families. Activities provided and pursued ensure positive engagement within the home and the local community, as far as is practicable, whilst acknowledging and respecting each individual’s needs and capacities. The needs of those of with a different cultural / religious background, however, should be more focused on. Service users can expect to receive a healthy and nutritious, culturallyappropriate diet, provided within a pleasant and comfortable environment. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users are individually encouraged to develop themselves and maintain their living skills; this ranging widely in the home - due to the differing levels of capacity for each specific individual. Service users are also supported - to some extent - to explore their inherited religious persuasion; one service user’s bedroom reflecting their Islamic cultural / religious background. A copy of a translation of the Qur’an was available and dietary needs are acknowledged. The manager and Inspector agreed that - now the service user’s behaviour had stabilised, a more solid approach to this aspect of their lifestyle should be developed - through more creative contact with family members and, perhaps, an appropriately selected advocate. Staff engage with service users to encourage a good level of interaction / communication; this is particularly important for those service users (about half) who do not have a significant level of verbal communication, and therefore demand sensitive observation / ‘interpretation’ of their actions / reactions to gauge pleasure, preferences and dislikes. Activities within the house include; relaxation (a separate designated relaxation room is provided for this) music therapy (a separate practitioner provides four hours input per week), reading / drawing and puzzles and gardening. Parties (for each and every occasion!) are well enjoyed. 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, cookery & 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) are enjoyed - as are meals out, shopping, and trips out to the country / local parks and pubs. The policy of the house is to promote individual engagement with life outside the home; very rarely would more than two service users be seen out together - a commendable ‘normalised’ approach to living life. 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 Weymouth, others visiting various seaside resorts for a holiday break, whilst for some, day trips are more valued than a full trip staying away (with the ‘trauma’ of excessive change / variables to tolerate / accommodate). Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 14 Service users have unrestricted access to the home and grounds, and all have been offered keys to their bedrooms. A keypad system is in place at the front door, based on a global risk assessment of access to the street - especially whilst demolition and building works proceed on more than one side of the home. Contact with families is positively encouraged, but for many, 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 families. Two relatives replied to the Commission’s questionnaire, both responding positively to the enquiry concerning their overarching satisfaction with the service provided to their loved one. The manager is not afraid of discussing addressing the sexual needs of the service users; they are a group of young men who no doubt have the need to express themselves. The manager’s approach to this aspect was sensitive and yet honest and practical; the inspector encourages the home to further explore this element of holistic attention to the needs of service users. Service users note a number of staff members for their culinary skills - most service users can eat their own food, but members of staff assist one service user. Mealtimes are unrushed and relaxed - and in the summer period, now enjoyed on the patio area outside the kitchen. 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; this is paying off with regard to some service users who are liable to put on weight very easily through indiscriminate eating. Another service user is constantly monitored for weight loss - and specifically focused on in the winter months with regard to additional nutritional attention. The service users with less verbal communication / capacity are closely observed and reactions to food and drink are relied on to indicate their preferences. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 15 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 can be confident they 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 (including ‘prn’ stocks) well, within the supportive context of policy, training and good record keeping. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. EVIDENCE: Care and support provided by the home was observed to be appropriate and sensitive to the needs of individual service users. Routines were flexible, and guidance and support was ‘second nature’ to staff members, ‘living alongside’ service users, whilst integrating support and assistance. Service users clearly chose their own clothes and initiate their own activities of choice; they are supported in activities and day-to-day routines by staff / by keyworkers. Respondents to the Commission’s questionnaire indicated that they were, overall, happy with the care provided and thought staffing was adequate. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 16 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. Comment cards from the home’s General Practitioner and the visiting Consultant Psychiatrist were both positive about the ‘caring and professional’ approach adopted by the home. Medication storage and records were examined and found generally well kept. Administration processes were observed and followed best practice. Previous concerns regarding the parameters of ‘prn’ (‘when required’) medication were the subject of focused audit trails undertaken by the inspector at this visit - all were well supported by documentation - including GP guidance / authorisation for all such medicines. Service User Health Action Plans are being piloted in the home (the ‘My Health’ booklet) - this involving them in assessing and identifying their regular and specific health care needs. Notice of a single medication mis-administration had been handled well by the organisation, leading to re-training and disciplinary measures being invoked. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 17 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, neglect and any form of abuse. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. 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 CMG Policy and procedure for ‘Alleged Abuse’ now refers directly to the Local Authority’s Guidelines for dealing with any incidents of Adult Abuse. The home is in possession of the 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 items are kept safe in locked containers in the office. The CMG organisation Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 18 (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 are held. Balances are checked daily. The home takes care not to keep too much money stored on the premises – a ‘safekeeping’ system is arranged by the manager to keep account balances at reasonable levels. A point previously noted that most staff had not undergone the annual ‘refresher’ training in the CMG ‘Dignified Management of Conflict’ process had been addressed, with all the staff team undertaking a refresher course ‘inhouse’ on 11.04.06. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 19 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 28 & 30. Service users may expect their accommodation to be clean - and a generally 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 decorated and maintained with equipment being appropriately serviced, ensuring the safety of service users. However, the home’s bathroom would benefit enormously from being refurbished / redecorated - leading to a global ‘quality’ experience of the premises. Quality in this outcome area is, overall, good. This judgment had been made using evidence gathered before and during the visit to this service. EVIDENCE: The house is well maintained, with more than sufficient space for the resident service users, and the patio outside the kitchen now fully established as an outside sitting / dining area. The premises are comfortable, light and airy; furniture and fittings are generally of good quality; new good standard sofas have recently been provided. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 20 The first floor bathroom would benefit from immediate attention; the ‘rest’ of the bathroom (which, having had new flooring installed) looking outdated and poor, compared to the rest of the fabric of the house. It seems curious that whilst the floor tiles were replaced, the opportunity was not taken to redecorate at the same time. The bathtub, in particular, has painted spots where the enamel has chipped and the grab rail in this area is rusting - a potential health and safety risk. The toilet bowl is also so aged that stains are, clearly, irremovable. A new bathroom suite is called for, along with wholesale redecoration and ‘warming up’ of this area. A previous recommendation is reiterated; that the registered provider should consider replacing the loose gravel / shingle surface driveway to the home 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. It is understood that the shingle has recently been topped up - but this surface is really not ideal for such a category of home. The home was noted to be generally tidy and was clean and odour-free on the day of the inspection visit. Cleaning materials are kept locked away in line with the Code of Practice for substances hazardous to health (COSHH). A sluicecycle washing machine is available to address any problems with incontinence. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 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 strives to meet the service users’ 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. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. EVIDENCE: The inspector took the opportunity to track-audit two new staff members’ personnel files and found the documentation to be complete and comprehensive. Evidence of Criminal Records Bureau checks, minimally two references, application form, interview schedule and proof of identity was all well catalogued. Induction records were fully completed / signed off, and the 1:1 supervision process was clearly being provided for staff beyond this first phase of their career at Albion Road. All new members of staff are subject to a sixth month probationary period. 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. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 22 There were two full time Support workers vacancies being advertised at the time of the inspection; no staff team members had left since the last inspection visit, however the part-time ‘bank’ cover which had been ensuring full staffing at the home can lead to problems during student staff’s college terms - and the manager is looking towards the greater stability that full time employees can bring. Examination of staff training records revealed that nine full time & bank staff members are trained in First Aid, and many other ‘statutory’ qualifications are well supported. The manager is undertaking the NVQ Level 4 - Registered Manager’s Award, one full-time staff member has just completed their Diploma in Social work, three staff members have nearly completed their NVQ in Care at Level 3, and one is starting the process at Level 2. With the projection of staff moving on, efforts must continue to be made to maintain this percentage urgently at minimally 50 - the target set by the Commission for qualified staff at level 2 or above. Other training input more recently provided either by CMG or the Local authority has included: Protection of Vulnerable Adults, Food Hygiene, Fire Safety, Administering Rectal Diazepam, First Aid and Health & Safety. 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 - and most have undertaken refresher training in April 2006. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 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): 37, 39, 40 & 42. 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 – through both the quality assurance and complaints mechanisms - and embodied in the Company’s policies and procedures, contributing to both the wellbeing and safety of those residing at the home. The safety and welfare of service users is guaranteed by the home having a clear management and supervision structure - and suitable support with regard to such issues. Quality in this outcome area is good. This judgment had been made using evidence gathered before and during the visit to this service. Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 24 EVIDENCE: The current manager, Catherine Lifely, 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 now completing the NVQ at Level 4 in Management and Care - leading to the Registered Manager’s Award. 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-toone meetings with Keyworkers, staff supervisions and through the home’s Quality Assurance and Complaints / Grievance procedures. 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. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes ‘Resident Times’ as well as the more global in-house Staff magazine. The responses are received centrally and collated, prior to being sent on to the home itself. The home has now received a substantial QA file - which requires focused work and Unannounced visits by representatives of the registered provider are being carried out on a regular basis (one Regional Operations Manager of the company was at the home when the Inspector arrived) and the subsequent reports are being forwarded to the Commission. Such visits involve checking documentation and the premises and interviewing both service users and staff. CMG has a comprehensive set of policy and procedures which cover the broad spectrum of needs identified for care homes; they have been very recently revised and the inspector is impressed by the clear focus and guidance provided by these documents. The inspector continues to be generally impressed with the attention to safety in the home. Regular maintenance / servicing records for equipment all appeared in date and fully undertaken. A recommendation arising in this section concerns ensuring that the terminology in records is used accurately (there appeared a confusion between fire ‘zones’ and ‘call points’, and the map was also somewhat out-of-date). Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 X 3 3 X 3 X Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 26 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 YA27 Regulation 23 Requirement The registered provider must upgrade the first floor bathroom to provide a quality environment for service users. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA12 YA24 Good Practice Recommendations The needs of service users with a different cultural / religious background should be more focused on. 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. That all the fire alarm break glasses in the house be properly and systematically numbered, mapped and organised and then tested in strict rotation. 3. YA42 Albion Road (44) DS0000007156.V300177.R01.S.doc Version 5.2 Page 27 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.V300177.R01.S.doc Version 5.2 Page 28 - 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!