Inspection on 23/01/08 for Aldenham Road (122)

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aldenham Road (122) 23/07/08

Aldenham Road (122) 11/08/06

Aldenham Road (122) 13/01/06

Aldenham Road (122) 23/07/05

Aldenham Road (122) 22/11/04

Aldenham Road (122) 17/06/04

Aldenham Road (122) 05/05/04

Aldenham Road (122) 19/02/04

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 Aldenham Road (122) 122 Aldenham Road Bushey Hertfordshire WD23 2ET Lead Inspector Claire Farrier Unannounced Inspection 23rd January 2008 11:40 Aldenham Road (122) DS0000019263.V358836.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 Aldenham Road (122) DS0000019263.V358836.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. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aldenham Road (122) Address 122 Aldenham Road Bushey Hertfordshire WD23 2ET 01923 237770 01923 237770 FP aldenhamrd122@walsingham.com www.walsingham.com Walsingham 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) vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2006 Brief Description of the Service: 122 Aldenham Road is a two-storey, detached, family style house located in a residential area of Bushey. It is operated by Walsingham, which is a voluntary organisation. The home provides accommodation and support to six adults who have learning disabilities. All the bedrooms are single, and none have en-suite facilities. There is a mature garden to the rear of the property and a small garden with additional space for four cars to park at the front. The house is situated on a main road and has easy access to Watford town centre. There are also local shops that are within walking distance. The house provides a domestic environment and it is indistinguishable from the neighbouring houses. The statement of purpose and service users’ guide provide information about the services provided by the home for prospective residents and social workers. Information on the fees charged was not available on this occasion. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. We (the Commission) spent one day at 122 Aldenham Road, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. The majority of time during the visit to the home was spent talking to the people who live in the home. Several members of staff also gave their views about the home, and some time was also spent looking at records, care plans and staff files. We spoke to the acting manager about what we had seen during our visit. We sent an Annual Quality Assurance Assessment (AQAA) form to the home in June 2007. The AQAA provides information for the Commission about the home, and the manager’s assessment of what the service does in each area. This should have been returned to us, and in October 2007 we contacted the home to remind them to send it in. The AQAA had not been returned by the time of the inspection, and the acting manager said that they would send a copy of it to us. At the time of writing this report the AQAA has still not been received. The AQAA is a document that is required to be returned by legislation. Therefore we did not have the benefit of this information and selfassessment to prepare for the inspection or to write this report. What the service does well: What has improved since the last inspection? Due to the lack of management in the home, the previous high standards have not been maintained. Aldenham Road (122) DS0000019263.V358836.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. Aldenham Road (122) DS0000019263.V358836.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 Aldenham Road (122) DS0000019263.V358836.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): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on the needs of the people who live there, so that the staff can provide appropriate support them to meet their needs. EVIDENCE: Five people live in the home, and no one has moved into the home for several years. Walsingham has a process for assessment before anyone moves into a home, and care plans are written with information and procedures drawn from these assessments. During this inspection the staff said that they have sufficient information and training to enable them to meet the residents’ needs. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are actively involved in their own care planning, the care plans are person centred and provide the staff with appropriate information to enable them to meet people’s individual needs. EVIDENCE: We looked at the files of two people, which show what care is provided for them and how it is recorded. The care plans are written in a person centred format, which shows that people are involved in making decisions about their care and their lives in the home. Entries are written in the first person and describe the person’s personal preferences, how they make decisions, and the support that they need. A good example was for how one person is supported to manage their own finances, with support from the staff and sound procedures for recording and auditing personal finances. “I have a limited understanding of money. I have a detailed financial assessment plan in the front of my finance file. Also in my file there is a detailed procedure for Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 10 recording money going in and out of my bank account, and my personal petty cash tin. My personal allowance is paid straight into my bank account. This process is backed up by audits from members of the finance department twice a year…. I do hold some money in my wallet, which I keep in my pocket, as I need to give 50p when I attend Monday Club and I like to give a small donation at the church service.” The staff who we spoke to said that the care plans provide them with good information on each person’s needs, so that they are able to provide a good quality of care in the way that each person wishes. The care plans are reviewed regularly, and the information that we saw about each person was accurate and up to date. In addition to the main written care plan, in one person’s file there was a pictorial weekly programme. This stated, “I go to the day centre” for each day from Monday to Friday, but this no longer happens. This should be updated when the main care plan is reviewed and updated. Each person has risk assessments for some activities where a decision has been made concerning their safety. The purpose of risk assessments is to ensure that the people who live in the home can take part in the activities that they wish to. The risk assessments that we saw covered all aspects of the person’s life in the home and in the community. For example, leaving the home unsupported, smoking, cooking, and the risks of epilepsy while in the community and at the swimming pool. The risk assessments are reviewed regularly to ensure that they are still required. Advocacy is available when needed from the advocacy group PowHer. There are plans to involve an independent advocate, to support people to understand and make decisions about plans for the future of the home. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The low number of support workers means that the people who live in the home are not supported to live full and active lifestyles. EVIDENCE: Most people attend a day centre several days a week. The care plans that we saw had programmes for each person’s weekly activities. [name] attends Earthworks, a gardening project, four days each week. This person is supported to be as independent as possible in the home, and they have a key to their room. [Name] makes their own packed lunch each day, does their own ironing, and takes their washing to the laundry room. [Name] vacuums their own room independently, and the staff support them to dust and to change the bedding. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 12 Most of the people who live in the home need more support than [Name]. The handover sheets list the activities that each person should do each day, and their daily activities are recorded in their personal daily logbooks. However there are usually only two support workers on duty at any time, and this limits what everyone can do, especially with regards to going out of the home. One person does not attend a day centre. The report of the company’s monthly monitoring visit for July 2007 stated that a member of staff spoken with talked about the effect of a service user’s (identified as Y) restricted mobility and need for greater supervision on other residents’ opportunities. This person needs a lot of support because of unstable epilepsy and a history of falls, and funding has now provided for an additional member of staff to support them to take part in their choice of activities each day. Due to the risks of falling and seizures, Y should have a support worker with them at all times. The activity programme in Y’s care plan lists different activities each day, including going for a walk, dinner or lunch out, cooking and craft work. We visited the home on a Wednesday, when the programme was to go bowling. We were told that this was not possible today as there were not enough staff in the home. For the previous week Y’s daily log book recorded that only two of the scheduled activities had taken place, cooking on Monday and out for an evening meal on Thursday. Most days the log recorded that Y was in the lounge, playing with toys and puzzles. During our visit to the home Y spent some time sitting in the lounge playing with toys. A support worker sat near them. The individual support that Y needs means that the staff are not able to spend as much time as they would like with the other people in the home, and most people have little opportunity to take part in individual community activities. This is also limited because some of the support workers have not had epilepsy training, including administering diazepam in case of seizures, which means that they are not able to go out with individual residents. Some people go to church regularly, and to Monday Club. One person went to the hairdresser with a support worker during our visit to the home, but this was possible only because another support worker started their shift early. No-one is able to take part in any other community activities because there are not enough staff to support them. But no-one is able to take part in any other community activities because there are not enough staff to support them. The report of the company’s monthly monitoring visit for December 2007 stated that monitoring of activities and the range of activities are to be developed. There is no evidence that this has taken place. Everyone has families or friends who visit them or who they visit regularly. They are supported to contact their families by phone. The menus looked varied and nutritious, and they reflect each person’s individual choices. The menu is drawn up each week with the involvement of the people in the home, and there is a choice of meals each mealtime. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans contain good details of each person’s care needs. However the low number of support workers and the lack of epilepsy training for staff means that some people’s specific needs may not be met appropriately. EVIDENCE: The care plans contain good details of each person’s care needs. The healthcare records that we saw included references to hospital visits, and contact with GPs and other health professionals. Some of the older residents have health problems associated with increasing age, and the staff spoken to showed good understanding of each resident’s personal and healthcare needs. Behaviour guidelines are in place for Z who has mental health needs. Following several incidents, a risk assessment was written that recommends that female staff are never to be alone with them. There is usually a male member of staff on duty during the day, but as there are only two support workers in the home during the day, and Y needs 1:1 support (see Lifestyle), there is a risk that this may not be achievable. Both the waking night staff are female, and they Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 14 work alone, although a member of the day staff sleeps in the home every night to provide support if needed. (See Staffing.) Several people are epileptic, and the staff who we spoke to showed good understanding of the support that they need. However some of the support workers have not had epilepsy training, including administering diazepam in case of seizures, which means that they are not able to go out with individual residents (See Lifestyle). Everyone is weighed regularly, and the weights are recorded in a notebook that is kept on the fridge in the kitchen. This can be easily seen by any visitor to the home, and must be stored securely in order to maintain confidentiality (See Conduct and Management of the Home). There is a marked fluctuation in the weights recorded for some people. One person is recorded to have lost 1st 2lb in two months, and to have gained 1st 5lb in the next two months. Another person’s record shows fluctuations of 10lb, 8lb and 12lb. There is no indication that these discrepancies were noticed, and no plan for addressing a large weight loss. This indicates that the staff have little understanding of the reason for monitoring weight, that it may be an indication of poor nutrition or a health concern that needs to be checked. The home has sound systems in place to manage people’s medication safely. There have been four medication errors in the past six months, which were noticed and put right immediately. We checked a sample of medication records, which were free of errors, with no signature gaps found on the MAR (medication administration record) charts. Several people have medication when they need it for managing anxiety or specific behaviours. Each incident when medication has been given for these purposes is fully recorded, with the reason why it was given. The medication and records are checked every day to make sure that all the medication has been administered properly, and to minimise the risk of future errors. Medication is stored in a wooden cupboard on the landing. This does not meet the requirements for storing medication safely in a care home. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are encouraged and enabled to make their views and concerns known. Policies and procedures are in place to ensure that they are protected from abuse and neglect. EVIDENCE: The home has a satisfactory complaints procedure in place that is available to all residents and their relatives. No complaints have been recorded since the last inspection. The staff encourage people to make any concerns known. One person had anxieties about going to church, and the staff listened to their concerns and responded appropriately. The home has up to date policies concerning adult protection that follow the Hertfordshire inter-agency guidelines and a copy of the guidelines is kept in the office. The report of the last proprietor’s visit to the home stated that not all staff have received training on safeguarding vulnerable people, but staff spoken with were aware of procedures. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people who live in the home benefit from a well-maintained, safe and comfortable environment some doors are locked so people are unable to freely access their bedrooms if they wish. EVIDENCE: The building is an ordinary detached house, furnished and decorated in domestic styles that produce a homely, comfortable environment, which allows the people who live there to relax and feel at home. Everyone has their own room, which is arranged and decorated to reflect their particular interests and tastes. The lounge and kitchen are domestic in style and are comfortably furnished and well equipped. The homely atmosphere is marred on the first floor because all the bedroom doors are locked. Some people have a key to their room, but everyone else has to ask a member of staff to open the door for them when they want to go into their room. This means that people are not able to move around the home without restriction. The kitchen has two doors, Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 17 one to the lounge and one to the entrance hall. The door to the entrance hall is locked, so that people can go from the kitchen to the hall, but not from the hall to the kitchen. There are no risk assessments in place to explain why all the doors should be kept locked, and none of the care plans that we saw made reference to this practice being for the benefit of residents. The home appeared to be clean and generally well maintained. The home has appropriate procedures to maintain hygiene and prevent the risk of infection within the home. However the procedures for handling laundry do not meet requirements for effective infection control. The laundry is situated outside of the main home, in a shed that is kept locked. However the washing machine is a domestic model and it does not have a sluice cycle. No one in the home is double incontinent. It was reported that when someone is incontinent of urine, their sheets or clothes are soaked in the sink in the laundry before being washed on a hot temperature. Handling and soaking soiled laundry is not an effective method of infection control. The Department of Health’s “Infection Control Guidance for Care Homes” states, “under no circumstances should a manual sluicing facility or sluicing basin be used or situated in the laundry…. Manual soaking must never be carried out. The pre-wash/sluice cycle in the washing machine should be used after removing any solids.” The guidance recommends the use of colour coded water soluble/alginate bags for soiled linen, heavily soiled /infected linen and clothing. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff who have worked at the home for some time. But the low numbers of staff on duty and lack of some specific training may mean some people’s needs are not met, and may leave people at risk. EVIDENCE: The last inspection report stated, “There is usually two care staff, plus a manager on during the day. Due to the high demands of service users it is important that the back up of a third member of staff is available where ever possible.” There has been no increase in the number of staff who are in the home during the day. There are usually only two support workers on duty at any time, and this limits what the people who live in the home can do, especially with regards to going out of the home. One person went to the hairdresser with a support worker during our visit to the home, but this was possible only because another support worker started their shift early. No-one is able to take part in any other community activities because there are not enough staff to support them. Y needs a lot of support because of unstable Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 19 epilepsy and a history of falls, and funding has been provided for an additional member of staff to support them to take part in their choice of activities each day. We saw that one member of staff does support Y at all times, but this is not an additional member of staff, and the other member of staff on duty then has responsibility for the other four people in the home. (See Lifestyle.) Z has a risk assessment that recommends that female staff are never to be alone with them (see Personal and Healthcare Support). There is usually a male member of staff on duty during the day, but as there are only two support workers in the home during the day, and Y needs 1:1 support, there is a risk that this may not be achievable. Both the waking night staff are female, and they work alone, although a member of the day staff sleeps in the home every night to provide support if needed. The home has only five permanent full time staff: a deputy manager, and assistant manager, one day support worker and two night support workers. It was reported that another support worker has been appointed, and will start work in the home when their pre employment checks are completed. The rota is completed with the use of regular bank staff and agency staff. The member of staff who sleeps over during the night works a total of up to 20 hours without a break, from 2pm to 11pm, followed by the sleepover, then from 7am to 10am. This schedule does not comply with the Working Time Regulations, but the support workers who we spoke to said that they like this pattern of working as they have more time off. Each person works for only one sleepover a week. Walsingham provides comprehensive training for staff that covers all mandatory training in first aid, moving and handling, fire safety, food hygiene, etc, and training to meet special needs the residents have such as epilepsy and challenging behaviour. The staff spoken to said that the training and support provided for them is very good. However some of the full time and bank staff have not had epilepsy training, including administering diazepam in case of seizures, which means that they are not able to go out with individual residents (See Lifestyle). One of the four full time support workers has a qualification at NVQ2 or above, and the others are working towards the qualification. The acting manager confirmed that the recruitment procedures followed by the company are robust and that she sees all the information on each applicant during the recruitment process. The references, CRB (Criminal Record Bureau) disclosures, evidence of identity and full employment history are stored at Walsingham headquarters by agreement with us through the Provider Relationship Manager. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39,41 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of clear leadership and management has resulted in a poorer quality of life for the people who live in the home. EVIDENCE: The home has not had a manager since July 2007. In September 2007 the manager of another Walsingham home was seconded temporarily to manage both 120 and 122 Aldenham Road, until a new manager was appointed. We were informed that a new manager will be appointed to manage both homes in February 2008. However Walsingham has not applied to us for agreement for one manager to manage both homes, or to combine the two homes as one. In the meantime, at the time of this inspection the acting manager was temporarily managing a fourth home. A deputy manager and assistant Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 21 manager have recently been appointed to the home. However the lack of a permanent dedicated manager for this home may be the reason for many of the concerns that we found during this inspection, for example poor record keeping, insufficient staff to meet the needs of the people in the home, and the lack of essential training. These are already having an effect of the quality of life of the people in the home (see Lifestyle), and may put the health and welfare of the residents at risk (see Personal and Healthcare Support). We sent an Annual Quality Assurance Assessment (AQAA) form to the home in June 2007. The AQAA provides information about the home, and the manager’s assessment of what the service does in each area. This should have been returned to us, and in October 2007 we contacted the home to remind them to send it in. The AQAA had not been returned by the time of the inspection, and the acting manager said that they would send a copy of it to us. At the time of writing this report the AQAA has still not been received. Therefore we did not have the benefit of this information and self-assessment to prepare for and inform this inspection. Walsingham has a comprehensive system for quality assurance in its homes, which includes annual surveys of residents and their families. The company carries out regular service audits of the home and monthly Regulation 26 monitoring visits, and reports of the visits are sent to us. The home maintains appropriate records for the health and safety of the residents and staff in the home, including monitoring hot water temperatures, checks of fire equipment and regular fire drills. However some records are not monitored to make sure that any discrepancies are noted and acted on. The fluctuation of the records of people’s weights indicates that the staff have little understanding of the reason for monitoring weight, that it may be an indication of poor nutrition or a health concern that needs to be checked. The notebook that records people’s weights is kept on the fridge in the kitchen. This can be easily seen by any visitor to the home, and must be stored securely in order to maintain confidentiality (See Personal and Healthcare Support). The fridge and freezer temperatures are recorded every morning by the night staff. They show that the fridge temperature is consistently above 5°C, and frequently as high as 10°C. These temperatures could cause a risk for the safety of the food stored in the fridge. Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 22 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 3 X 2 2 X Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 YA13 Regulation 16(2)(m) Requirement Arrangements must be put in place so that the people in the home are able to take part in their choice of community activities outside of the home. Everyone in the home must have a choice of varied and appropriate activities throughout the day. Appropriate actions must be taken following a recording of abnormal weight loss, and the actions and results must be recorded in the care plan. This is to make sure that each person’s health is monitored effectively. Appropriate measures must be taken to make sure that medication is stored securely in the home, and that the storage facilities comply with legal requirements. All staff in the home must have adequate and appropriate training in the recognition and prevention of abuse, so that people in the home are safeguarded from the risk of abuse. Timescale for action 31/03/08 2. YA14 16(2)(n) 31/03/08 3. YA19 12(1)(a) 31/03/08 4. YA20 13(2) 31/03/08 5. YA23 13(6) 30/04/08 Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 24 6. YA24 23(1)(a) 7. YA30 13(3) 9. 10. YA33 YA35 18(1)(a) 18(1)(c) (i) 11. YA37 8 12. YA41 17(1)(b) 13. YA42 13(4)(c) Doors to bedrooms and communal areas must not be locked unless there is a properly assessed and documented reason to do so. The people who live in the home must have access to all parts of their home. The procedures for handling laundry must comply with the guidance of the Department of Health, to ensure that people are protected from the risk of infection. Sufficient staff must be available at all times to meet the needs of the residents. All staff working in the home must have appropriate specialised training in meeting the needs of people with epilepsy. This will make sure that everyone in the home is confident that their needs will be met in an emergency, and their activities are not restricted due to the lack of trained staff. The registered provider must ensure that a manager is appointed who can take day-today responsibility for the welfare of the people who live in the home. All personal information must be stored securely in order to protect the confidentiality and privacy of the people who live in the home. Fridge and freezer temperatures must be monitored effectively to make sure that food is stored safely in the home. 31/03/08 31/03/08 31/03/08 30/04/08 31/03/08 31/03/08 31/03/08 Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Aldenham Road (122) DS0000019263.V358836.R01.S.doc Version 5.2 Page 27 - 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!