Inspection on 21/10/05 for Ambleside Avenue, 15

This inspection was carried out on 21st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ambleside Avenue, 15 23/10/07

Ambleside Avenue, 15 04/05/06

Ambleside Avenue, 15 09/06/05

Ambleside Avenue, 15 15/12/04

Ambleside Avenue, 15 07/06/04

Ambleside Avenue, 15 26/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ambleside Avenue, 15 Streatham London SW16 1QE Lead Inspector Ms Lynn Hampton Unannounced Inspection 21st October 2005 2.15 DS0000022718.V260549.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000022718.V260549.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000022718.V260549.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ambleside Avenue, 15 Address Streatham London SW16 1QE 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 8769 9723 020 8769 9723 Southside Partnership Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places DS0000022718.V260549.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: 15 Ambleside Avenue is a detached purpose built house, located within easy walking distance of a large shopping area with full community facilities and bus and rail public transport. The home provides a service for six service users who have learning and physical disabilities, and is fully mobility accessible. The care is provided by Southside Partnership, a voluntary organisation specialising in the care of people with mental health needs and/or learning disabilities. At the time of this inspection, there were four vacancies in the home. Plans were in hand for four residents from another Southside Partnership home to move in, and for the staff teams of the two homes to merge. A number of registration and operational issues will need to be resolved arising from this change. DS0000022718.V260549.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during the afternoon, on Friday 21st October 2005, and lasted nearly four hours. During the visit the inspector met two care staff and the Manager. A range of documents was examined and a tour of the building took place. The inspector met and spent time with both residents. Residents were not able to communicate verbally with the inspector, but were able to show their preferences and mood in gestures and body language. What the service does well: What has improved since the last inspection? Action has been taken to meet Requirements made in the report of the last inspection, which mainly concerned repairs and refurbishment. Several changes in the resident group have taken place over the last year. The home has responded to this well, demonstrating that issues around ageing, illness and death are sensitively handled. The manager of the home is ensuring that residents are being consulted regarding pending changes. DS0000022718.V260549.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000022718.V260549.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000022718.V260549.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Appropriate systems are in place to ensure that prospective service users are given information and consulted prior to moving to the home, and that assessments are undertaken to ensure that the home meets their needs. Issues arising from the wide range of ages of service users will need to be reviewed and the Statement of Purpose and Certificate of Registration amended if necessary. EVIDENCE: The home currently has only two residents, and there are four vacancies. Southside Partnership have taken the opportunity to review the needs of a group of residents in another home that they manage (Kestrel Lodge) to determine whether a collective move to Ambleside Avenue would be appropriate, to fill all four places. The mobility accessible design of Ambleside would meet these residents’ changing needs, and it would provide consistency if they move together, along with staff from Kestrel, to effectively merge the homes. Southside Partnership have arranged for re-assessments to be undertaken by residents’ allocated Social Workers, and are involving residents by organising visits to Ambleside, introducing them to the current residents there, and, as far as possible, consulting with them regarding the proposed move. This is good practice, and will ensure that the move is in the best interests of the residents. DS0000022718.V260549.R01.S.doc Version 5.0 Page 9 Attention will need to be paid to ensuring that the needs and wishes of the residents are addressed with specific reference to their age. The current Statement of Purpose for Ambleside states that it provides a service to ‘elderly’ people with learning disabilities. The current residents are 60, and 80 years of age. The group of residents who are being considered to move to the home vary in age, from 40 years old to 65. Southside Partnership must ensure that it gives due consideration to the significance that this may have on the routines and operation of the home, and must consult with the Commission appropriately. This will need to include review of the home’s Statement of Purpose, the Service User Guide and registration categories/conditions. As the Operations Manager reported that the home hopes to be able to arrange the move by the 17th November 2005, this must be addressed as a matter of urgency. See Requirements. The Statement of Purpose has not been updated to reflect a change in the number of bedrooms in use at the home, which was agreed with the Commission (and a new Certificate of Registration issued) in January 2005. This must be addressed as part of the Requirement above. Current residents were seen to have a copy of a licence agreement on file, and an informative Tenants Handbook, which has a range of photographs, is produced. DS0000022718.V260549.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 Care planning at the home is user-led, promotes independence, and is kept under review. Service users are supported to participate as far as possible in all aspects of life in the home. EVIDENCE: Case files seen contained a comprehensive range of assessments and documentation relating to residents’ needs. There were regular reviews of care plans in place, and details of Review meetings attended by the resident, an independent Advocate and other professionals involved in their care. Routines of the home are user-led, and staff demonstrated that they gave first consideration to the needs and wishes of residents. The ‘Monthly Tenants Meeting’ file held at the home indicated that staff ensure that each resident has a 1:1 with staff on a monthly basis, when efforts are made to determine if they are happy with the care that they receive or have any problems. A group meeting would be inappropriate for the current residents. Questions are asked, and gestures or body language is interpreted, and a full record maintained. As described above, independent advocates were involved with residents at the home, which promotes their rights and protection. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16, 17 Service users are supported to take part in appropriate activities in accordance with their preferences and wishes, both inside the home and in the community. Menu planning and recording would benefit from review. EVIDENCE: Staff interaction was observed to be appropriate and respectful. Although neither resident had verbal communication, they were able to indicate preferences to staff with non-verbal gestures or body language. Both care staff on duty were careful to introduce the inspector to the resident that they were caring for, to explain the purpose of the inspection, and as far as possible ascertain their permission to view bedrooms. One resident accompanied the inspector and care worker to show her bedroom, which was personalised with ornaments and pictures to suit her tastes. The other resident had a music centre in his room. His care plan indicated that he was seen by his Key Worker to respond positively to classical music, and appeared to find it soothing. Listening to Classic FM is now in his care plan. He is also supported to go out at least weekly; he regularly attends the cinema and also has gone to see musicals at the theatre. DS0000022718.V260549.R01.S.doc Version 5.0 Page 12 The manager has a particular interest in promoting the rights of older people, and he described what action was being taken to ensure that age-appropriate activities were available for residents. A care worker also described that ‘objects of reference’ were used with one resident, after consultation with a therapist, to improve his recognition of daily routines (e.g. a flannel is given to him to indicate washing/bathing). This is to be commended. However, it was noted that there was not many examples of sensory equipment available in the home. The home once had a dedicated sensory room, but it was reported that this had not been fully used by residents, and so it was converted to become the sixth bedroom in January 2005. This should be reviewed to determine whether residents would benefit from a greater range of individual sensory equipment. Consideration had been given to whether residents would have capacity to give consent, to write wills or sign tenancies. A letter from the G.P. was on file indicating his professional opinion on this. This is good practice. Fresh vegetables and salad were in the fridge, and a bowl of fruit was available in the kitchen. Staff reported that they usually cook meals from basic, fresh ingredients although some prepared frozen meals are used. The home has a set, pre-planned rota for meals. This should enable staff to ensure that appropriate shopping is done, and ingredients will be available to provide a varied and nutritious diet. On the day of this inspection, the listed menu option was ‘take-away’, but this had not been served and an alternative meal of fish was prepared. The pre-set menu system does not reflect individual choice, nor does it act as an accurate record of what residents actually ate (as and when alternatives are prepared). This will particularly be an issue when the home has filled its vacancies; it is more difficult to provide a set menu that meets the preferences and daily tastes of six people. Menu recording should be reviewed. It would promote user choice to have clear, written information about residents’ likes/dislikes available, to ensure that staff are able to offer appropriate options if needed. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 21 Personal support is given in the way that meets service users’ individual needs and preferences. Issues around ageing, illness and are sensitively handled. Consideration is to be given to ensure that gynaecological matters, and issues around same-gender care are appropriately addressed. EVIDENCE: Each person had a Life Planning book, which contained Person Centred Planning details with photographs and pictures. Case files contained comprehensive information relating to the care and health needs of residents, and evidence of appropriate referral to (and contact with) a range of health care professionals, including dentists, opticians and GPs as well as specialists when specific health issues arose. Staff were able to describe how one resident was being supported while plans were being made for an operation. A previous resident had moved to a nursing home, when his health needs changed and it was assessed that he needed more care than could be provided in the home. One resident out at doctor’s surgery having flu jab at the commencement of the inspection visit. DS0000022718.V260549.R01.S.doc Version 5.0 Page 14 The home has had to address issues of ageing and death over the years, as it provides a service to older people with learning disability. The recent death and funeral arrangements of a resident were handled with sensitivity, and staff were aware of the impact that this may have had on residents. The manager has a keen interest in the rights and needs of older people with learning disability, and he reported that he had contacted a Health worker and was hoping to arrange input to the home regarding health needs of older people, to cover topics such as dementia, pressure area care, etc. This is to be commended. Health Authority reminders relating to gynaecological check-ups were on file, but it was unclear whether these had been followed up. These checks are considered routine, but may be experienced as invasive and uncomfortable by some users. Consideration is to be given to this specific area in Reviews, or Best Interest Meetings where appropriate, and the Commission notified of action being taken. The home provides accommodation for both male and female residents, and has a mixed staff group, which promoted good practice in terms of reflecting the resident group and also enabled same-gender care for both male and female residents. One resident’s file seen indicated that she was to have same-gender personal care. The four people being considered for admission are all female, and the merger of the two home’s staff teams is likely to create a team with several male staff, which will mean that some cross-gender care will have to be given. Southside has a policy regarding provision of crossgender personal care, which indicates that residents’ views would be sought. Current residents would need support for their views to be determined. Given the recent and pending changes, this area of practice would benefit from review, to ensure that residents’ rights and views are promoted at all times. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Clear Complaints and Vulnerable Adults procedures are in place, in suitable formats. Action is taken to respond to complaints, or to concerns relating to service users. EVIDENCE: Southside Partnership has clear policies relating to Whistle-blowing and protection of vulnerable adults. The manager explained that he was currently following the Vulnerable Adults procedure in relation to an incident at another Southside home. The police, social services, advocacy and Appropriate Adult had been involved. The Complaints file held at the home indicated that no complaints had been made since the last inspection. However, the manager described how staff had dealt with an incident outside the home, where a resident had been discriminated against due to his disabilities when visiting a cinema. The staff had promoted the resident’s rights, and had clarified the person’s requirements with the cinema’s manager. The manager was monitoring the situation. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 29, 30 The home is furnished in a domestic style, and service users are able to personalise their bedrooms. There is adequate space and specialist equipment is provided where needed. The home is clean and repairs are being addressed. EVIDENCE: Ambleside Avenue is laid out over two floors, with a shaft lift as well as stairs to enable full mobility access. Corridors are wide throughout the building, to allow adequate turning for wheelchairs. Communal areas are on the ground floor, consisting of a large kitchen/diner, a lounge, a bathroom with toilet, and a separate toilet. The first floor has four bedrooms, a bathroom with toilet, a separate toilet, the office, the laundry room and storage rooms. Outside, there is a garden to the front and side, a parking bay, and a ramp to the front door. The inspector saw all the bedrooms, including the vacant rooms that are being prepared for the pending admission of four new residents. Four rooms meet minimum space requirements for wheelchair users, the remaining two meet minimum space requirements for non-wheelchair users. The bedrooms currently occupied were furnished in a domestic style, with high quality furniture and personal items reflecting the tastes and interests of the residents. DS0000022718.V260549.R01.S.doc Version 5.0 Page 17 A number of Requirements and a Recommendation were made in the report of the last inspection (June 2005), regarding the physical environment. The manager had taken action to address all the Requirements made, although there had been some delay due to the process of negotiating work to be undertaken via the Housing Association that owns the building. The manager had contacted the Commission and requested an extension to the timescale for completion, which was agreed and a new timescale of 30th November has been set. At the time of the inspection, progress had been made as follows: • Automatic door closers have been fitted, and this Requirement is met. • Action had been taken to meet a Requirement that access to thermostatic controls on radiators be improved. Although radiator covers now had openings to the side to allow access, some of these were narrow and difficult to access, while others were positioned so that it wasn’t possible to reach. For example, one opening had been covered by a wardrobe placed next to it. This Requirement remains in force, to be checked at the time of the next inspection. • A survey had been undertaken of the kitchen fittings, equipment, and lighting, and a report of this survey was in place in the ‘Housing File’. A copy of an e-mail on this file indicated that work would be undertaken following this. • A survey is to be undertaken, relating to the security of the home and access issues. The manager is to keep the Commission informed of progress in these matters in writing, and is to include information on progress regarding the Recommendation that the hoist in the upstairs bathroom be upgraded. The home was clean, tidy and attractively decorated to a high standard. There was a range of storage space throughout the home, the doors of which were labelled “Please Keep Locked”. None were in fact locked. This did not present any immediate hazard, as there were no hazardous substances stored, and also the current residents were not able to mobilise independently to access these areas. However, care must be taken in future to ensure that areas are kept locked as appropriate. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 There have been a number of significant changes in the staff team over the last year. Vacancies and gaps in the rota are covered by regular nonpermanent staff, and the manager must continue to ensure that this does not undermine consistency of care. Plans regarding staffing at the home must be notified to the Commission. Staff have access to a range of training, but documentation relating to this would benefit from review. EVIDENCE: The home has a minimum of two staff on duty at all times during the day, (there is one Waking Night care worker at night). At the moment, this means that the residents have 1:1 staff attention, plus management cover from the manager or Deputy, during the day. Staff on duty at the time of the inspection had worked at the home for a number of years, and were able to speak knowledgeably about the residents and their care needs. However, an examination of the rota indicated that there were only four full-time, permanent care staff on the team (two of whom are Waking Night staff), in addition to a recently recruited Deputy Manager, and the current manager who is also undertaking duties as Operational Manager for Southside Partnership (see Conduct and Management of the Home, below). Vacancies and gaps in the rota are covered by Bank and Agency workers. Three Agency staff work approximately 5 shifts each per DS0000022718.V260549.R01.S.doc Version 5.0 Page 19 week, and three other non-permanent staff cover on an occasional basis. This is a high level of use of non-permanent staff, although it is clear that every effort is made to ensure consistency and so promote continuity of care. Issues around recruitment and retention in the home are naturally being effected by the pending proposals to move the residents and service from another Southside Partnership home to Ambleside. It is likely that the staff team will merge with that team, and so current vacancies will not be filled. The current manager indicated that appropriate consultation and negotiation was being entered into with staff, regarding their position and how they will be effected by the move. The Commission is to be kept informed about progress with this proposal, and of any significant changes that will need review of certification or documentation relating to the home (see also Conduct and Management of the Home). In the interim, the manager must ensure that every effort is made to ensure that there continues to be consistent staffing in the home. One member of staff on duty during the inspection was an Agency worker, who had worked at the home over a period of two years while undertaking study. She spoke positively about the service, and the support that she had got from Southside Partnership, particularly relating to training – Southside ensure that Agencies that they contract with provide training to their employees, as well as making in-house training available to them. There was information relating to training kept in the home, which included evidence of management training, and induction training for new staff. However, other training records were in need of updating. One list of courses attended only went up to October 2003. A document entitled ‘Core Mandatory Training Booking Form’ listed nominees but it was unclear if they had actually attended the training. See Recommendations. DS0000022718.V260549.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, 43 A number of changes had taken place in the home, or were planned, that had not been notified to the Commission. Despite this, the home is functioning well and benefits from clear leadership, and residents are being consulted regarding pending changes. EVIDENCE: The previous registered manager of the home left the post approximately six months ago. There is no record that this was notified to the Commission in writing, as is required. The current manager of the home has not submitted an application to register with the Commission. He is also undertaking duties as Operational Manager for Southside Partnership as a whole, which means that he spends time away from the home (approximately two days a week). This dual role could lead to blurring of boundaries or conflicts of interest. A Requirement was made in the report of the previous inspection that the Responsible Individual was to write to the CSCI to explain how the current management arrangement ensures sufficient daily management for the home and how potential conflicts of interest are being addressed. The Commission DS0000022718.V260549.R01.S.doc Version 5.0 Page 21 has not received this, although the inspector was informed that a letter was sent in July 2005. A copy of this is requested. Further changes are planned that would clarify this situation. The current registered manager at Kestrel Lodge will apply to register as manager for Ambleside Avenue at the time of the move. This will enable the current manager at Ambleside (who has not yet applied for registration) to become Operations Manager on a full-time basis. However, at the time of the inspection visit, no formal notification of the proposed changes had been made to the Commission. The Responsible Individual must ensure that proposed changes are notified in writing without delay. This is to include details of how the proposed move is to be managed in relation to residents and staff; what changes are to be made; and proposals for the future of Ambleside Avenue. The process that was reported to be in place in respect of the move confirmation includes discussion with staff, residents and advocates. This would promote their rights and ensure their safety through comprehensive re-assessment, consultation and independent representation. The Responsible Individual is to include written details confirming this - what consultation has taken place with residents, their family/advocates, and with staff. See also the report of the inspection to Kestrel Lodge. Staff spoke positively about the management of the home and the support that they received. The manager was described as open and receptive, and he talked with enthusiasm about working with the resident group. The philosophy of the home, and of the organisation, is user-led. Person in Control visits are undertaken in accordance with Regulation 26, and monthly reports were seen to be thorough and comprehensive. DS0000022718.V260549.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 4 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 X X 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 4 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 4 Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X 3 2 DS0000022718.V260549.R01.S.doc Version 5.0 Page 23 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 YA1YA3 Regulation 4, 5, 14(1) Requirement The Responsible Individual must ensure that it gives due consideration to the significance of changes in the age range of service users, and the impact that this may have on the routines and operation of the home. The Responsible Individual must provide written information to and consult with the Commission regarding these matters, including ensuring that the home’s Statement of Purpose, the Service User Guide and registration categories/conditions are appropriate and correct. The Registered Person must review menu planning and recording in the home, to ensure that adequate information is available on service users food likes and dislikes, and that staff offer alternatives to the preplanned menu. An accurate record is to be maintained of what residents actually ate. Timescale for action 10/11/05 2 YA17 17(2)Sch 4(13) 21/01/06 DS0000022718.V260549.R01.S.doc Version 5.0 Page 24 3 YA19 12,13(2) The Registered Person must ensure that gynaecological checks are reviewed in service users Reviews, or Best Interest Meetings if necessary, to determine the appropriate health care options for each individual. The written outcome of these reviews to be placed on file and available for inspection. 21/04/06 4 YA24 13(4) The Registered Person must 10/11/05 ensure that areas designated to be locked for safety purposes are kept locked when not in use. The registered person must ensure that radiator covers are adapted so that access to thermostats is facilitated. The original timescale of 30/9/05 has been extended to 30/11/05. 30/11/05 5. YA26 23(2)(p) 6. YA30 16(2)(g) The registered person must 30/11/05 ensure that renewal/replacement of kitchen equipment and cupboards to meet acceptable standards takes place. The original timescale of 30/9/05 has been extended to 30/11/05. The registered person must ensure that adequate lighting is supplied to the kitchen/diner. The original timescale of 30/9/05 has been extended to 30/11/05. The registered person must ensure that the home is made secure in relation to the two French doors, the garden fencing and gate, and access to the rear of the home. The original timescale of 30/9/05 has been extended to 30/11/05. DS0000022718.V260549.R01.S.doc 7. YA30 23(2)(p) 30/11/05 8. YA24 13(4) 30/11/05 Version 5.0 Page 25 9 YA33 YA37 YA43 38,39,40 10. YA43 10(1) 11 YA43 38,39 The Responsible Individual must 01/11/05 ensure that proposed changes to the service are notified in writing to the Commission without delay. This is to include confirmation that the proposals meet the assessed needs of residents, and what consultation has taken place with residents, their family/advocates, and with staff. Also, details of how the proposed move is to be managed in relation to residents, staff and management of the home, and what changes are to be made. The registered person must write 30/11/05 to the CSCI to explain how the current management arrangement ensures sufficient daily management for the home and how potential conflicts of interest are being addressed. The original timescale of 30/9/05 was not met. The Registered Person must 10/11/05 ensure that any changes to the management or operation of the home are notified in writing to the Commission without delay. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA11 YA18 Good Practice Recommendations The Registered Person should ensure that a review takes place to determine whether service users would benefit from a greater range of sensory equipment in the home. The Registered Person should review practice regarding cross-gender personal care being provided in the home, following recent changes in the resident group. Action should be taken to determine service users preferences and wishes in this respect. DS0000022718.V260549.R01.S.doc Version 5.0 Page 26 3. 4 YA29 YA35 The hoist in the upstairs bathroom should be updated to improve comfort and dignity. The Registered Person should review and update records relating to staff training, to ensure that they accurately and clearly document training undertaken, by whom, and when. DS0000022718.V260549.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022718.V260549.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!