Inspection on 12/06/07 for Aldeburgh House

This inspection was carried out on 12th June 2007.

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

Other inspections for this house

Aldeburgh House 07/02/06

Aldeburgh House 20/07/05

Aldeburgh House 09/02/05

Aldeburgh House 28/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Aldeburgh House 66 Seaview Avenue West Mersea Colchester Essex CO5 8BX Lead Inspector Tim Thornton-Jones Unannounced Inspection 12th June 2007 9.30 Aldeburgh House DS0000050959.V343366.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 Aldeburgh House DS0000050959.V343366.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. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aldeburgh House Address 66 Seaview Avenue West Mersea Colchester Essex CO5 8BX 01206 384392 01206 386659 aldeburgh@consensushealthcare.org www.caringhomes.org Consensus Support Services Ltd 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) Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) 7th February 2006 Date of last inspection Brief Description of the Service: Aldeburgh House is a home providing care and accommodation to 8 adults with learning disabilities. Previously owned by Aitch Care Homes Ltd, the home was first registered in March 2004 and is presently managed by an acting manager. Aldeburgh House is now part of Consensus Health Care following a take over of Aitch Care Homes in late 2005. The home is a large two-storey property in a residential area close to the sea front in West Mersea, about 10 miles from Colchester. The building has been modernised to provide accommodation in single rooms with en-suite facilities. The home does not have a passenger lift, although accommodation for those with mobility needs is available on the ground floor. There are enclosed, wellmaintained gardens and the home is close to the island facilities. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken in one day between 9.30am and 5pm. Service users and carers were spoken with throughout the day. The acting manager was co-operative and helpful throughout the inspection. A tour of the building was undertaken although not all rooms were visited. The service records were viewed on a sample basis and these included records associated with the running of the home, care related records and records of control systems such as quality assurance and health and safety. The ‘lifestyle’ and ‘personal and healthcare support’ outcomes were positive with outcome groups ‘staffing’ and ‘conduct and management’ indicating a need for review and improvement. The overall outcome of this inspection concludes that people living at the home receive adequate care and support. What the service does well: What has improved since the last inspection? People living at the home now have unrestricted access to some parts of the home that previously were locked subject to assessment of risk. Carers report that the environment is now more open, inclusive and relaxed. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aldeburgh House DS0000050959.V343366.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 Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 1 and 2. This judgement has been made using available evidence including a visit to this service. The service provides good information about how people will be admitted into the home and what they can expect. People do not have adequate information to assist them in making a judgement about whether the service can meet their needs and preferences. EVIDENCE: The Statement of Purpose document sets out to provide information about the service. In comparing some of the practice found during the inspection this did not accurately match the Statement of Purpose. The information is in need of updating. For example, the Manager details refer to a person who has now left the home. Care hours are stated to be 765 per week (See staffing section of this report). The inspection confirmed this was not accurate. Some of the regulatory requirements that must be included within the Statement of Purpose are not being met, for example it does not adequately include an organisational structure for the service and the complaint procedure summary was in need of review. (See complaint and safeguarding section of this report). Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 9 Based upon a case tracking approach, the service user files and information for the sample group did not contain a Service User Guide. The Manager could not locate them. The Service Users Guide should include the weekly fees and therefore were not available to service users. The home’s procedures were inspected in relation to the admission of people into the service. The procedure for this was set out within the Statement of Purpose document and meets the practice requirements. At the time of this inspection visit no persons had been admitted to the home during the period since the previous inspection and therefore the practice procedures were not reviewed. The current acting manager demonstrated a sound understanding of the practice principles associated with the admission procedure. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 6,7 and 9. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from the care plan arrangements that mainly reflect their needs and personal goals. People living at the home are not always consulted about the things that affect their lives. People living at the home are protected by the home’s risk assessment arrangements, although they should expect to benefit from participating in dignified risks that promote their independence. EVIDENCE: The plans of care were sampled as part of a case tracking. The present format has been in existence for some time and in discussion with the manager it was established that a review of the documentation was required. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 11 Based upon the sample taken a suitable broad structure was in place and included all of the key factors such as decision making, methods of achieving outcomes and monitoring and review. The overall presentation of the plan was somewhat complex and not easy to follow. There was no evidence that people are significantly involved in the plan of care although it is acknowledged that carers do reflect people’s likes and preferences as part of daily life. The plans were not clear about how people contribute and influence their plan of care. Risk assessment was weak in that there was inadequate reference to assessment within the decision making process. An example found was that no assessment was evident in relation to medicines administration or cash held on behalf of service users. There was no reference within the plans sampled that people have been consulted about what support they may need to take more control over their lives. Some presenting care planning issues that require decisions were missing from the plan since some service users are having cash and other items such as cigarettes controlled because the person is considered to use up these items too quickly, which may have adverse consequences. Within a person centred approach these matters should be addressed within the plan with the full consent, or otherwise, of the person and appropriate risk having been assessed. Other decisions present were relevant and realistic and aimed to support the person with improved self-reliance. The way in which the plans were written was rather a ‘one size fits all’ and each constructed in a similar way, for example…’my name is… I was born on… my mother and father… etc. The plans are completed in a style that implies the person themselves had written it, although evidently the text has been completed by a carer. Whilst this style undoubtedly has the benefit of the carer needing to think about the person when writing it, it is nevertheless not directly involving the person. Some service users completed CSCI surveys in there own handwriting and therefore it may be possible for people to make a more personalised contribution to their own plan of care. This would then reflect a good example of person centred planning. The Registered Person should consider formats and styles of recording that best represent the person the plan is intended for and the extent to which the person can control and influence the content, and more importantly, the outcome. Service users spoken with were confident and spoke positively about the support they receive from carers. A small number of people who are relatively able do acknowledge decisions in their plans by signing their name although this falls short of the person being supported to actively take control of the process. One service user spoken with expressed clear and realistic aspirations for their future although the plan did not fully reflect this. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 12 People are encouraged and do take part in various tasks and self help skills with the home and as part of external activities such as day services. These were recorded within the plan with clear objectives. Several people attend educational courses. expressed their motivation for these activities. Service users spoken with Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 12, 13, 15, 16 and 17. This judgement has been made using available evidence including a visit to this service. People are supported to take part in age, peer and appropriate activities that are part of the local and wider community. People benefit from the support provided by carers to maintain family links and friendships. People can expect their rights to be respected and recognised in their daily lives. EVIDENCE: There are opportunities provided for people to attend activities that promote self-esteem and citizenship, such as attending further education classes and work substitute/supported work. People spoken with returning from such activities were motivated and confident. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 14 People are also encouraged to live their life as ordinarily as possible. Those people who were more able were encouraged to visit the local shop unaccompanied. Local resources are used as and when needed in a flexible way. The service enables and encourages people to maintain links with relatives and friends. The home telephone is a portable type so the people are able to make and receive calls privately. One person has close family in France and with the support of staff member visits them on an annual basis. The service makes arrangements to enable people to use community services in a similar manner to anyone else living in the community. For example, most people have bank accounts from which they are able to access their cash from a card using a personal PIN number. For some service users who need support with this, carers have access to the PIN number. There is a system in place to ensure that some security measures are in place, although the system should be reviewed to ensure that a clear audit trail is possible, for example booking the card out and back in identifying who has the card in safe custody, if not the person themselves. Withdraw slips are maintained and these need to be cross-referenced to the bank statements. The activity must be subject to assessment of risk where service users take control of their own finances. The cash held in safe custody was checked at random and was accurate and well recorded. It was noted that for one service user the Registered Person is the appointee and it would appear that for this person, finances are paid into an account operated by the Registered Company and required cash paid to the home when required. The exact nature of the arrangement was unclear as few records were available for inspection. The Registered Person must review these arrangements to identify a person to act as appointee who is independent of the home/staff team. People living at the home are encouraged to take part as fully as possible with the catering arrangements. This amounts to contributing to the weekly plan of meals, shopping and some service users assist carers to cook meals for all people at the home. The Manager confirmed that a number of people have been trained and have obtained a food hygiene certificate as part of their day activities training, although the certificates were not available for inspection. Aldeburgh House DS0000050959.V343366.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 18 to 20. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and mainly in the way they require. Service users physical and healthcare needs are met although do not fully benefit from being consulted about the way their physical and health care needs are assessed. EVIDENCE: Based upon discussion with service users, staff and from observation, the language, tone and volume of communication was appropriate and supportive. In discussion with carers and the manager, practice has improved in this area with more freedom for service users having been created, for example previously the kitchen was locked and some areas of the home were not accessible but this has been lifted by the acting manager. All of the carers spoken with stated that the home is now more relaxed and has an ‘open’ and communicative feel with a move toward the service Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 16 becoming more person centred. This was evidenced in part by surveys that had been completed by carers approximately six weeks before the inspection took place. Some of these were critical of the way in which the home was being managed both locally and strategically. A more positive view was expressed on the day of inspection. Some positive examples of recognising peoples’ rights and dignity were seen, such as knocking on bedroom doors and asking peoples’ consent in relation to everyday matters. This approach has yet to influence the overall ethos of the service although the acting manager demonstrated a clear understanding of the ways in which a more inclusive service delivery can be encouraged by describing how service users could be empowered in areas that at present are underdeveloped, for example sensitive issues around gender, relationships and sexuality. The healthcare needs are adequately maintained. People attend medical appointments within the community as appropriate and each person has an individual Healthcare book, which the person can take to all appointments for updating. One person was planning to attend a healthcare appointment at the time of the inspection and was given the healthcare record by a carer prior to the appointment. The person recognised the book and appeared familiar with it and seemed to be a routine part of their health care. Healthcare records, which are separate from the individual books, held within the plan of care need to be better organised to ensure that carers are able to access the information easily. The service operates a Monitored Dosage System (MDS) for controlling prescribed medicines. All medicines are held in safe custody on behalf of people and at the time of the inspection visit all people were being prescribed medicines. None of the care plans seen had an indication that people are being encouraged to contribute, at whatever level, to controlling their medicines. The MDS system is not as conducive to facilitate this. It is recommended that the approach used at present be reviewed to ensure that people are given appropriate support, via assessment of risk, to be as empowered as possible whilst maintaining a safe continuity of healthcare support. The administration records associated with the system were well maintained. All carers involved in the medicine system had been trained to use it by the system provider. Aldeburgh House DS0000050959.V343366.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 22 and 23. This judgement has been made using available evidence including a visit to this service. People are confident about how to complain and, based upon the evidence available, can expect to be listened to and their complaints acted upon. People living at the home are not assured that carers are adequately trained in safeguarding their welfare. EVIDENCE: There have been no formal complaint investigations during the period since the previous key inspection other than a matter involving car parking between the home and a neighbour, which has since been resolved. The complaint procedure in place was produced by the former Registered Person and therefore requires amendment. Of the service user surveys received most indicated that people knew who to make a complaint to if necessary. The internal policy and procedure, and a service user version in easy read format is available. It is recommended that the policy needs to be amended to make clear that the CSCI does not investigate complaints on behalf of the care home. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 18 The service has not made any referrals regarding safeguarding matters during the period since the previous key inspection. The home has a copy of the Essex County Council safeguarding adult’s pack, which provides advice and support regarding safeguarding matters. The home also has a safeguarding distance learning pack although the manager advised that this had not yet commenced. Based upon a sample of three staff files, only one had information confirming they had attended safeguarding training. The inspection concluded that staff require training in safeguarding matters although in conversation with carers all demonstrated an intuitive understanding of what poor practice is although did not clearly illustrate the threshold at which point such practice would be raised as abusive. On this basis people may not be entirely safe until carers receive appropriate training and/or development. Aldeburgh House DS0000050959.V343366.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 24 and 30. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well maintained and decorated environment. EVIDENCE: The premises is a large detached house within a residential area in keeping with the ordinary life principles set out within the Statement of Purpose and the presenting ethos of the service supported by the acting manager. The locality of the house is within walking distance of some local shops and service users did access these at the time of the inspection visit, although it was evident that whilst most day-to-day shopping needs were available it was necessary at times to go further to the next town, Colchester. This was facilitated but needed some planning to ensure appropriate support. All services are ambulant although one person is accommodated on the ground floor as stairs present as a difficulty. In this bedroom it was noted that the lower half of the windows had been obscured to preserve modesty needs due Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 20 to aspects of the person’s behaviour. This is a matter detailed within the plan of care for the person. The home does not provide emergency short term or respite care facilities. The décor throughout the home is well maintained, although it is understood the style and type of furnishings and design is controlled by the organisation rather than influenced by the people living at the home. In discussion with service users those who expressed a view stated they liked the furnishings, however, the staff stated they would welcome the opportunity to include people in making decisions about any possible changes. The home was clean overall and there were no odours found anywhere. Carers undertake the cleaning, in the main, and some areas visited need a little more attention to avoid cobwebs forming, but generally the house was welcoming and pleasant. People living at the home contribute to the cleaning as appropriate. There were no obvious health and safety hazards found. Aldeburgh House DS0000050959.V343366.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 32, 33, 34, 35 and 36. This judgement has been made using available evidence including a visit to this service. People using the service are protected by the service’s recruitment practice although they should be able to expect a better arrangement of staff training, development and supervision. EVIDENCE: The recruitment of carers was considered in relation to the method, checks and records obtained to ensure that the process is safe for service users. Based upon a sample of more recently recruited carers, the recruitment practice was appropriate and the various checks and requirements had been made appropriately. At the beginning of the inspection visit a review of the service requirements were made with the Manager in terms of the required skills and knowledge carers needed to deliver the service based upon the presenting needs of people living at the home. People living at the home for example need support with challenging behaviours, continence management, epilepsy, speech and language and for one person, visual impairment. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 22 Carers were also confirmed as needing skills in supporting people with a learning disability, mental health needs and skills in food hygiene, risk assessment and safeguarding adults for example. In addition, carers should be working toward/achieved an NVQ qualification to at least level 2 in care practice. Surveys received as a result of this inspection visit indicated that the organisation were not adequately supporting staff training and development, which does appear to have some substance based upon the range of skills required as compared with the training outcomes of carers employed. Records were sampled to ascertain the position of the training and competency achievements of the workforce. Of the three sampled records all staff had completed moving and handling training and two of the three had received epilepsy awareness. One had received training in managing challenging behaviour and safeguarding adults. Another carer had received training in food hygiene and first aid. Of the eighteen staff employed, seven had achieved an NVQ2 or above and two carers were working toward this qualification. This level remains below that recommended by National Minimum Standards of 50 . Training and development would benefit from further development because based upon the known needs of people living at the home, carers have not received adequate training to ensure that adequate numbers of them have the necessary knowledge and skills required to provide informed and skilled support. Carers need to be trained in areas that present them with challenges frequently. One person at the home has a visual impairment, although none of the records seen identified training to assist carers to support this person. The majority of people, although not all, at the home have speech and language difficulties although no training was identified within the records available. People do need to be supported by an effective team of carers. Development around identifying training and development needs and then planning for areas of shortfall should be incorporate within the workforce development plan to improve the range of skills and knowledge across the carer group. There is information available within the records that training has been identified by the home but this has yet to be provided by the organisation. The number of carers deployed against the assessed needs of people using the service was not inspected on the basis that the information was not available. The manager was not able to provide evidence of how carer/service users ratios were determined, although suggested it was based upon individually negotiated hours based upon the contract for each person stated to be 644 per week. The weekly hours deployed, based upon the last whole week prior to the inspection (10th June 2007) was 521. This indicated a ‘surplus’ of some 123 hours per week, although from this support services for cooking, cleaning and laundry will need to be deducted as non-care hours. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 23 In discussion with carers they expressed a view that the support they receive and the manner in which the service was being managed had improved and were supportive of the changes and developments made during the period since the last key inspection. Formal supervision was being undertaken although the frequency was not in accordance with the recommendations within National Minimum Standards. The manager stated that their last supervision was undertaken on 4th April 2007 although there was no evidence available. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 37, 39, 41, 42 and 43. This judgement has been made using available evidence including a visit to this service. People living at the home cannot be assured that the quality monitoring approach and record keeping is properly maintained. People are safe in the way the environment is monitored and the manner in which the home is managed on a day-to-day basis. EVIDENCE: The acting Manager was recruited in January 2007 since the last key inspection of the home. An application has been received to determine the fitness of the manager to be registered. The person has extensive experience of working in service for people who have learning disabilities and is a qualified nurse for this service user group. In addition a qualification in teaching adults and in Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 25 workplace assessment have been obtained. This indicates that the person has satisfactory experience and training. The inspection concluded that the developments within the service recently have been positive and service user focussed. This was confirmed by discussion with people at the home, carers and from the inspection surveys received. The home is subject to a quality assurance audit by the registered person although on inspection this approach appears to be mainly focussed upon the efficiency of the service and organisational objectives. Some questionnaires were distributed as part of the quality approach were sent out in August 2006 although no evidence was available of how the questionnaires were used, or what quality standards they were seeking to measure. This aspect of the quality assurance and monitoring will need to develop. Various records were examined as part of the inspection. Various improvements are required resulting from some statutory records not being available or not being kept updated. These include for example; Statement of Purpose, carer supervision, record of the homes charges, cash held in safe custody for people living at the home and reports required to be compiled under Regulation 26 of the Care Homes Regulations 2001. The home maintains systems for monitoring health and safety including fire prevention, emergency lighting, portable appliance safety testing. This is managed by a combination of testing and checking on a periodic basis by the home and external specialist contractors. The home maintains a Care of Substances Hazardous to Health (COSHH) folder to reference the safe use of various materials in the home. The acting Manager confirmed that no budgetary information was being held or available for inspection within the home. It was noted that this was a matter raised at the previous inspection. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 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 Standard No Score 1 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 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 2 x 2 X 2 X 2 3 1 Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 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 YA1 Regulation 4(1)(2) Timescale for action The service must have an up to 31/08/07 date Statement of Purpose that sets out clear and accessible information for service users The financial arrangements for 31/08/07 service users to access their personal finances must be clear and auditable. Where support and tuition are needed, the reasons for, and manner of support must be documented and reviewed. The assessment relating to a 31/08/07 service user must be kept under review and revised at a time when it is necessary because of changes in circumstances. Service users must be protected 31/08/07 by training staff or other measures to prevent them being harmed or suffering abuse or being placed at risk of harm or abuse. Service users must be supported 31/08/07 by staff who are trained appropriately to undertake the work they are expected to do. This includes care related and support task (catering) related work. DS0000050959.V343366.R01.S.doc Version 5.2 Page 28 Requirement 2 YA7 16(2)(L) 3 YA9 14(1)(2) 15(1)(2) 4 YA23 13(6) 5 YA32 YA35 18(1)(c) Aldeburgh House 6 YA39 24(1 to5) 7 YA41 17(2)(3) 8. YA43 26 A quality assurance system is 30/09/07 needed that is based upon consultation with service users and their representatives. The results of the quality monitoring and action plan must be sent to the Commission. The records required by 31/08/07 regulation must be kept up to date and available for inspection. In particular records required as specified in Schedule 1, 3 and 4 of the Care Homes Regulations 2001. Visits to the service by the 31/08/07 Responsible Individual, or a person acting on their behalf, should be undertaken and report of the visit be compiled as per regulation. The report must be available for inspection at the home. The previous requirement dated 31/04/06 was not met. 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 YA7 Good Practice Recommendations The system for security arrangements relating to service users finances and access to bank accounts would benefit from review to ensure there is an improved audit trail. Care plans should be fully engaged with the person for whom the plan is intended and it is recommended that alternative formats and method are considered to improve the present approach. The monitored dosage system for controlling prescribed medicines is not fully suited to enabling service users to administer their own medicines and for those people assessed as being able to do so fully, or in part, it is recommended that alternative arrangements be considered. DS0000050959.V343366.R01.S.doc Version 5.2 Page 29 2 YA20 Aldeburgh House 3 YA22 4 YA33 5 YA36 The complaint procedure should inform people of how and to whom a complaint should be made. It is recommended the policy be reviewed to ensure that it does not give misleading information that complaints may be referred to the CSCI or that such complaints may be subsequently investigated. The number of staff hours required to meet service user needs should be based upon a reliable and valid system or method. It is recommended that the method used to calculate staff deployment be available for inspection. Staff should receive adequate formal support and supervision they need to carry out their jobs. It is recommended that in addition to the informal supervision provided, that formal supervision is maintained to the frequency set out in National Minimum Standards. Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aldeburgh House DS0000050959.V343366.R01.S.doc Version 5.2 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. 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!