Inspection on 17/07/06 for Amberley House

This inspection was carried out on 17th July 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Amberley House 09/03/09

Amberley House 17/04/08

Amberley House 01/10/07

Amberley House 28/11/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Amberley House 44-48 Amberley Road London N13 4BJ Lead Inspector Karen Malcolm Key Unannounced Inspection 17th July 2006 09:55 X10015.doc Version 1.40 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 Amberley House DS0000065136.V298132.R02.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 Older People. 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. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberley House Address 44-48 Amberley Road London N13 4BJ 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) 020 8886 0611 020 8886 1436 Waterfall House Residential Home Care Home 16 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (16) of places Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Amberley House is a privately owned care home for older people who are over the age of sixty five. The home is registered to accommodate sixteen older people, five of whom may have a diagnosis of dementia. There are fourteen single bedrooms and one shared room. There is a lift and a chair lift. The dining room and lounge are situated on the ground floor overlooking an attractive garden. The home is situated in Palmers Green, with good bus and train links. All the amenities of Palmers Green are within a short distance, including restaurants, shops, churches and a large park. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The current scales of charges are from: - £500 to £1738.00 Additional charges are made for hairdressing, chiropody and incontinence aids, private TV and newspaper. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours. Present on arrival were the manager, senior carer, two carers and a domestic assistant. The registered provider arrived later. Fourteen service users live in the home and there are two vacancies. Since the last inspection nine service users have been admitted into the home and five service users have been discharged. Prior to this inspection a copy of the Pre Inspection report was submitted. As part of the inspection process the inspector was able to speak to five service users and four members of staff during the handover period. The inspector completed a tour of the building, examined four service users care plans and five carers’ personal records. Service users interviewed expressed their satisfaction with the quality of care offered by the home and were happy living there. They also spoke of life prior to moving into the home and what they were use to. The inspector would like to thank the assistant manager, carers and service users for their time, patience and co-operation during the inspection process, which was positive and open. What the service does well: What has improved since the last inspection? At the previous inspection eleven areas of improvement were made. It was evident at this inspection that eight areas of improvement had been addressed. The areas of improvement addressed at the time of this inspection are: • Adult protection training had been undertaken by seven staff within the team • Appropriate door closures were found on fire doors that are constantly in use. • The stair landings were clear from obstruction • Weights charts were completed monthly • Medication Administration Records (MAR) were found to be in good order • The registered providers has submitted an application to the Commission to register the current manager in post Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 6 • • The current staffing levels in the home has been reviewed Staff references authenticity is checked prior to an individual gaining employment The outcome for service users is that the health and safety, some healthcare need is monitored and reviewed by the home. Therefore service users are confident that the home addressing their needs effectively. What they could do better: This inspection has identified nineteen areas of improvement seven of which have been restated. While it is evident that the staff are experienced and competent, there are still a number of areas that need to be addressed. It is therefore required that the registered person submit an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters of: • The registered person must request a further assessment of need to be completed by the social worker and GP. Regarding the specific service user who is diagnosed with paranoid schizophrenia and dementia. • Any service user admitted into the home an assessment of need must be completed by the home in conjunction with the placing authority’s assessment. • The registered person must apply to the CCSI for a variation regarding the placement of the specific service users who is diagnosed with mental health problems if the overriding assessment is mental health. • Care staff are to undertake mental health training, if the overriding assessment is mental health. • All complaints whether verbal or written are to be acted on appropriately and a record made of the action that has been taken • The registered person is to undertake environmental and fire risk assessment includes sections on fire doors and window restrictors • The registered person must ensure all new employee have a satisfactory Criminal Records Bureau (CRB) certificate prior to starting work • The registered person must ensure that all visitors to the home are aware of Health and Safety issues. The Health and Safety policy is to be amended to include a section relating to visitors • The registered person must ensure as part of the admission process to include a section relating their preference, being supported with personal care by a male or female carer • The registered person must ensure that the work of care planning is delegate to other members of staff as the role and responsibilities of the current manager has changed. • A clear record of falls, treatment and any intervention is to be in place. • The home’s policies and procedures are to be amended, in line with current legislation this includes the equal opportunity & sexuality policy • Supervision must be completed at least six times a year • The registered person must cease the practice of storing clinical waste yellow bags in the garden and the contract for this service must be reviewed Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 7 • Fire drills are to be completed at least four times a year This inspector identified that the outcome for service users is that they have a reasonable safe environment to live and that they are safeguarded by a number of policies and procedures. However, it still remains that a number of areas for improvement around health and personal care, complaints and protection of service users, staffing and management and leadership have not been addressed by the home. Therefore service user may not feel confident that their individual needs are not being managed and supported properly by the home and this is a matter for concern. Therefore the registered person must address these matters within the specified timescales in place. The recommendations addressed in the table at the back of this report are deemed good practice. 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. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is poor. This judgement has been made using evidence gathered both during and before the visit to this service. The home has breached their Conditions of Registration by admitting service users into the home, whose care needs are not apart of their overall registration. Therefore service users are being placed at risk of harm, as care staff are not skilled or experience to fully understand a number of individuals needs being placed. EVIDENCE: The home’s Statement of Purpose was examined. It was evident that this document is to be up dated to be in line with current changes in the home. To ensure that service users have the right information they need to make informed choices. The home supports sixteen older people, five of whom may be admitted with dementia and one specified service user who have dementia and is under sixty-five years of age. Any proposal to change to the home’s Conditions of Registration must be notified in writing to the Commission, as soon possible. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 10 Since the last inspection nine service users have been admitted to the home. One of the applications for admission was agreed without any reference to a needs assessment, or consideration of the skills, ability or knowledge of the staff that will be caring for them. The specific service user was admitted on the 19th May 2006. An assessment from the placing authority was faxed to the home on the 18th May 2006. In discussion with the line manager and provider is was evident that no assessment undertaken by the home was completed. It was also evident that the registered provider was slightly under pressure to place the individual. Reading the assessment, the main diagnosis of care was clearly stated as paranoid schizophrenia and dementia. However, in discussion with the provider he stated that the main reason for care was dementia. The manager and provider stated that the specific service user had settled well into the home since their initial placement. However, this was not evident in the daily progress sheets examined. The information recorded was brief and according to the logs, within days of the service user being placed there was a good routine. The inspector reminded the provider that the home is in breach of their Conditions of Registration. Therefore a requirement will be made pertaining to this. At present there are two vacancies and it was evident that one referral is in the pipeline. It is essential that a proper assessment of need is to take place prior to the any individual being placed in the home. To ensure that the home is able to meet there needs effectively. The home does not provide intermediate care. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. While care plans are in place these are not consistently monitored or reviewed. Therefore the information recorded is not always up to date and does not reflect the current care or support needs of the individual living at the home. Therefore service users may not be receiving appropriate care. Service users are confident that their own medication is protected by the home’s policies and procedures. EVIDENCE: Three care plans were examined. It was observed that staff provide sensitive and flexible personal support to maximise service users’ privacy, dignity, independence and control over their lives. It was also evident through discussion with the manager that a number of times during the week that male carers ratio to female carers is higher. However, the female service users ratio to male service users is higher. The question of choice, regarding personal care and male carer supporting, female service user was discussed. The manager stated that the female service users tend to like the male carers more. However, the manager was in agreement with the inspector as this could be a potential risk. It was advised that choice Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 12 regarding personal care should be a part of the home’s admission criteria. To ensure that service users are given positive & informative choice about who will be supporting them on daily basis. The inspector asked one service user their preference with regards to male carers assisting them with personal care and their response was that they had no opinion on this. Each service users care plans is robust, but the practice of involving service users in the development and review of their care plan is variable. The home has systems in place to ensure that care plans are reviewed updated monthly and arranges additional reviews when any changes take place. However, in discussion with the manager it was clear that the manager completes all the care plans and daily progress sheets and this practice, has been in place since the home opened. It was the view of the inspector that this process must cease, as the manager’s roles & responsibilities have changed. Therefore this task should be undertaken by the carers working within the team and monitored and reviewed by the manager. The daily logs examined demonstrated that in consistent recording with gaps. This raised a number of concerns. For instance when new service users are admitted into the home. This has been addressed under the outcome group ‘Choice of Home’ in this report. A key working system not currently in place, the manager stated that this is being reviewed. Risk assessments were in place. Nighttime records were impressive as the night time actitivies for each service user throughout the night was recorded on an hourly basis. A number of falls were recorded since the previous inspection. The inspector completed a falls analysis. Although falls are recorded, there wasn’t a clear audit trail, as to how falls prevention is managed. It was also evident that three of the nineteen service users recorded falls had been admitted into hospital. The manager must seek advice from the local falls clinic with regards to support on falls prevention. Individual risk assessments must be reviewed and be updated after a fall has taken place. The inspector identified that some named service users have cot sides in place supplied by the local district nurses. It was advised that a thorough risk assessment must be completed for each service user with guidance for staff with regards to any risk that may occur. Healthcare information is recorded appropriately and any changes are updated accordingly. The manager stated that the home is supported by a good GP service, local district nursing team, a private chiropdist who visits every six weeks, a dentisit and optician. At the last inspection it was required that weight charts are maintained monthly, from the information recorded this was all in place. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 13 The medication is now supplied by Boots the Chemist. The manager stated that the system is easier and clearer and training has been provided by Boots to all staff. A record is kept of all named staff that undertook the training in the front of the MAR chart file. Records are kept of all medicines received, administered and disposed of. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. The home has made a great improvement on meeting individual service users dementia care needs with regards to social activities. Therefore service users social needs are now appropriate and meaningful, ensuring that individual’s quality of life is maintained. Service users maintain good family and friends contact. The meals in this home are good offering both choice and variety and catering for special dietary needs. Therefore service users cultural needs are being generally met by the home. EVIDENCE: The home has various activities to keep service users occupied and stimulated. An activities timetable was displayed in the lounge and activities listed included poetry, quizzes, board games, skittles and old films. The home employs an activity co-ordinator who visits weekly. All activities that individuals are participate in recorded separately in their care plan this was introduce prior to the last inspection and has continued. The inspector again commended this practice. Service users spoken to shared their past experiences, and how well they liked living in the home. They participate in various activities and one specific Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 15 service user stated they would like to go swimming sometimes. This was discussed with the manager, and it was advised that although the individual may not be able to paricipate in actual swimming lessons, they could go and watch some local events within the community. Menu plans clearly record individuals’ daily diet. Those with special & cultural diet are also met by the home. Service users interviewed stated that the meals are good and information is displayed on the notice board in the foyer. Service users are able to have visitors at any reasonable times and they are able to access the local community with support if they so wish. The visitor’s book was positioned at the entrance to the home. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to. However, this is not consistent. Therefore service users cannot be assured that verbal complaints are listened to and acted upon appropriately by the home. Service users are protected from abuse. However this is not line with the local procedures, therefore service users maybe at risk from harm if the correct procedures are not always followed. EVIDENCE: No complaints had been recorded since the previous inspection. Complaints were discussed with the manager and the providers, regarding how care staff record verbal complaints/concerns made by service users. It would appear that service users cannot feel confident that verbal complaints are taken seriously. Therefore this requirement is restated in this report. In addition at the previous inspection the registered person ensures that all staff working in the home receive appropriate adult protection training. Evidence presented showed that seven carers have undertaken the current Adult Abuse Awarenes training course. However, there were still a small number of carers who were unable to attend course. The manager stated that the tutor of the course had given her a copy of the course materials. To train those stafff, who were unable to attend. It was evident that the manager’s understanding of the home’s roles and responsilbities with regards reporting and making referrals under Protection of Vulunerable Adult (PoVA) was Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 17 unclear. It was advised that the manager must undertake further training with regards to this. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The home is decorated to a high standard, which meets the needs of the service users, therefore providing the service users with a warm and inviting pleasant environment they can call home. However, the health and safety aspect with regards to appropriate disposal and safe keeping of clinical waste needs to be monitored regularly to ensure service users & staff are not at risk. EVIDENCE: A tour of the home revealed that the house is well maintained and comfortably furnished. The décor and furniture are suitable for service users. All service users who were able to express an opinion said that they felt that the home provided them with a comfortable and safe environment. All bedrooms are of a high standard and personalised to individual taste and style. The standard of cleanliness in the home was very high and no offensive odour was detected. The communal areas are the dining room and a large extended comfortable lounge with conservatory, kitchen and laundry area are adequate in size. The garden is beautifully landscape and accessible to all. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 19 At the previous inspection it was required that the registered person ensures that all visitors to the home are aware of the health and safety issues regarding not obstructing the hallways were service users wander. In discussion with the manager it was evident that she had raised the issue with the hairdresser concerned. However, she had not addressed this with other visitors to the home and no policy was in place. Therefore this requirement is restated in this report. A number of service users are provided with a supply of continence aids. The provider stated that the home has recently ended their clinical waste contract with a private company and has now set up a new one with the Local Authority. During the tour of the garden, it as evident that there were at least six yellow clinical bags lying in the garden and the bin being used for clinical waste did not fit properly. This was discussed at length with the manager and provider to rectify this for the safety of service users Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Staff morale is very good resulting in staff working positively with service users to improve their quality of life. Service users also benefit from a competent staff team. The manager has failed to ensure that all care staff employed have been vetted appropriately. The home’s recruitment procedures are not robust enough to protect service users from harm. EVIDENCE: Staff morale is very good and staffing levels in the home is adequate. The rota was shown to the inspector and it reflected the current staff on duty. The manager stated that three members of staff have dual roles as the cook and carer. However, the rota shown did not reflect this clearly. It was advised that the rota reflect clearly the day-to-day roles of individuals working within the team. Part of the inspection process was to observe the staff handover. The process was very detailed. After the handover the inspector asked a number of questions regarding supervision, service users care plan information, changes to individual service users healthcare needs, training and staff morale. It was evident that carers were knowledgeable about individual care needs and all stated they had received regular supervision. The inspector sampled five staff records. At the previous inspection it was required that the registered person ensures that staff references authenticity is checked and the Criminal Records Bureau Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 21 certificates (CRB) are in place. At the beginning of the inspection three staffing records were checked at random. It was evident that two of the three CRB checked were not completed by the home. References had been verified regarding there authenticity. Seven staff had recently undertaken recently the PoVA training evidence of this was on file. Management prioritise training and facilitate carers to undertake external qualifications beyond the basic requirement. The home introduces internal developmental training, to complement formal training as part of an ongoing training plan. However, in discussion with the manager none of the staff have undertaken their NVQ level 2 or above. The inspector advised that since the end of 2005 that at least 50 of the staff team must be NVQ level 2 and above trained. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The management of the home is satisfactory and overall the records are well managed. Service users are assured that their health and safety is promoted and protected. However, this is not always consistently, therefore service users health, safety and welfare is not always fully promoted and protected. the home is run to the best interest of the service users, as the management and staff ensure service users needs are up most in the day to day running of the home. EVIDENCE: Since the last inspection the previous manager has left and one of the senior carer has been promoted to manager. The provider notified the lead inspector of these changes prior to this inspection. In the meantime the provider has submitted to the Commission an application to register the newly appointed manager. The manager is not qualified and only has basic management skills and minimal experience of running a care home. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 23 Training and development of staff is consistent, however, the staff do lack leadership guidance as the monitoring and reviewing of service users care plans and their daily progress reports are undertaken by the manager. Supervisions are not kept up to date and carers’ roles pertain mainly to supporting service users with their daily routine. It is the opinion of the inspector that as the senior carer is now the manger her role and responsibilities has changed. It is advised that the registered person reviews the roles and responsibilities of the manager and staff to ensure that the distribution of roles is fairly disseminated. During the tour of the building, interaction with service users was observed as warm. The manager was able to give the inspector a detailed account of each individual service user who resides within the home. This was impressive and was commended by the inspector on the day. Within the service there is a lack of awareness and understanding regarding equalities and diversity with a lack of direction provided by the service. The ideas underpinning equality and diversity are rarely discussed or highlighted. However, the manager was very open to discuss this issue with regards to sexuality and stated that she will explore this with regards to individuals needs within the home. At the previous inspection it was required that the registered person ensures that the environmental & fire risk assessment that includes a section on fire doors, window restrictor and gate leading to the basement. This must be reivewed annually or when any changes occur. A copy of the last report was on file. However,this has not been updated, therefore this requirement is restated. On all fire doors examined, release mechanism device were fitted. This was commended by the inspector. Fire drills are completed. However it was reminded that fire dirills are to be completed at least four times a year with the involvement of staff and service users. Those service users whom are unable to particapate in the fire drill must have a full assessment of need complete with regards to evacuation. Policies and procedure were examined. however, a number of these needed to beupdated to be in line with current legislation. It is recomended that these be reviewed. First aid was discussed and it was evident the none of the staff were a qualified first aider. It was therefore reminded at on each shift the there must be at least one person who is qualifed in first aid. The manager informed the inspector that a number training programmes have been arranged by the provider. This is so essential for the saftey of the service users. Wheelchairs were being stored in the hallway. This was addressed with the manager, who stated that this was the only avialable space in the home. The accident book evidence that one service user had a fall due to stumbling over Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 24 the wheelchairs in the hallway. Wheelchairs must be removed for the safety of individual service users in the home. Heath and Saftey certficates were checked and all were in good order except Legionella. Amberley House DS0000065136.V298132.R02.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 2 2 Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1) Requirement The registered person must undertake a further assessment of need completed by the social worker and GP with regards to the specific service user with paranoid schizophrenia and dementia. This must include a clear diagnosis of their care. A copy of the report must be submitted to the Commission. The registered person must ensure that any service user admitted into the home has an assessment of need completed by the home in conjunction with the placing authority’s assessment. This must take consideration the home’s Conditions of Registration. The registered person must ensure that the current manager undertakes further training with regards to the local authority’s reporting and making referral which are necessary for managing the care home. (Previous timescale of 28/02/06 was partially met at the time of this inspection) DS0000065136.V298132.R02.S.doc Timescale for action 20/08/06 2. OP18 10(3) 20/08/06 Amberley House Version 5.2 Page 27 3. OP16 17(2) Sch 4.11 4. OP19 13(4) 5. OP19 13(4) 6. OP29 7, 9, 10 Sch 2 The registered person must ensure that all complaints especially verbal complaints are recorded and actioned appropriately. (Previous timescale of 30/01/06 not met.) The registered person must ensure that the environmental risk assessment that includes a section on fire doors, window restrictor and gate leading to the basement, which is in place, must be reviewed annually or when any changes occur. (Previous timescale of 30/03/06 not met) The registered person must ensure that all visitors to the home are aware of health and safety whilst in the home. The health and safety policy is to be amended to include a section relating to visitors. This is to be reviewed and monitored regularly and evidence. (Previous timescale of 20/01/06 not met) The registered person must not employ any further person to work in the care home in any capacity without first obtaining a satisfactory CRB Disclosure check including a POVA check along with other information required by regulation. All staff employed since 27th July 2004 without an enhanced CRB Disclosure that includes a POVA check, must only work under the individual and direct supervision of a named staff member who has been appropriately checked. So as to safeguard service users, the registered person must in respect of these specific staff undertake a POVA First check for each person through their DS0000065136.V298132.R02.S.doc 20/08/06 30/08/07 20/07/06 20/07/06 Amberley House Version 5.2 Page 28 7. OP1 8. OP10 9. OP7 10. OP8 Umbrella Body. The strict supervision arrangements must then, remain in place until the full CRB Enhanced Disclosure is received and is seen to be satisfactory. This includes all staff including temporary or volunteer staff. A copy of the POVA first for the two staff members must be submitted to the Commission within the timescale specified. (Previous timescale of 30/01/06 not met) 4(1)(c) The registered person must Sch 1 amend the Statement of Purpose with regards to current changes and copy sent to the CSCI. The registered person must 15(1) consult with each service user or 14(1)(c) their representative on their behalf whether or not they prefer being supported with personal care by a male or female carer. The service user’s preferred choice is to be recorded on their care plan and this to be signed and dated by both parties. This must be demonstrated on the rota. 18(1)(a)(c The registered person must )(i) ensure that the work of care planning is delegate to other staff. The registered person must ensure that the care staff are appropriately trained to undertake the task of completing care plans or any other written work relating to their role. 17(1)(a) The registered persons must Sch ensure that the home keep a 3.3(o) clear record of falls, treatment and any intervention. The registered person must seek advice and guidance from relevant professionals with regards to managing service DS0000065136.V298132.R02.S.doc 30/08/06 30/08/06 30/08/06 30/08/06 Amberley House Version 5.2 Page 29 11. OP37 17 12. OP12 12(3) 13. OP27 17(2) Sch 4.7 14. OP37 18 (2) 15. 16. OP30 OP38 18(1)(c)(i ) 13(4) 17. OP38 13(4) users who are deemed at high risk of falling and those who have cot sides in place. Evidence of this must be kept on file. Any changes must be reviewed accordingly. The registered person must amend the equal opportunities policy in-line with current legislation. This is to include a section on sexuality. The registered person must review and amend the home’s policies and procedures in line with current legislation changes. The registered person must ensure that the specific service user, who requested to participate in swimming, is supported appropriately to meet their individual needs. For example going to watch a local swimming event. The registered person must ensure that rota accurately reflects individual’s care staff different role changes within the team and on a daily basis The registered person must ensure that supervision is completed at least six times a years and evidence of this is kept on file. The registered person must undertake the Registered Manager’s Award. The registered person must cease the practice of storing clinical waste yellow bags in the garden. The registered person must review the current clinical waste contract. To ensure that clinical waste bags are stored appropriately. The registered person must cease the practice of storing the wheelchairs in the hallway. DS0000065136.V298132.R02.S.doc 30/09/06 30/08/06 20/08/06 30/08/06 30/09/06 30/07/06 30/07/06 Amberley House Version 5.2 Page 30 18. OP38 17(1)(a) Sch 4.17 19. OP38 13(4) The registered persons must 30/08/06 ensure that fire drills are completed at least four times a year these are to be completed at different times of the day. A record of all fire drills undertaken must be maintained and reviewed accordingly. The registered person must ensure that on each service users care plan is a detailed risk assessment of needs with regards to fire checks, fire drills and evacuation procedure. The registered person must 30/09/06 ensure the water supply (water Fittings) Regulation 1999 with regards to Legionella is in place. 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 OP3 Good Practice Recommendations In receipt of the assessment confirming mental health is the overriding care needs The registered person must apply to the Commission for a variation regarding the placement of the service user who has mental health problems. In receipt of the assessment confirming dementia is the overriding care needs. The registered person must ensure that all care staff undertake mental health training to ensure that the specific service user who had mental health needs are properly supported. It is recommended that daily progress sheets should be completed daily. It is recommended that records of fire drills include a list of all carers and service users who were present at the time. The record also indicates any difficulties experienced and any remedial action undertaken. It is also good practice to complete at least one of the fire evacution drills during the night. DS0000065136.V298132.R02.S.doc Version 5.2 Page 31 2. OP3 3. 4. OP7 OP38 Amberley House 5. 6. 7. OP7 OP38 OP30 It is recommended that the home should adopt key working roles & responsibilities should be in place. It is good practice to have on each shift at least one staff member who is a qualified first aider. The registered person must ensure that 50 of the staff team NVQ level 2 trained and above. Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Amberley House DS0000065136.V298132.R02.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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