Inspection on 23/10/07 for Ambleside Avenue, 15

This inspection was carried out on 23rd October 2007.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ambleside Avenue, 15 04/05/06

Ambleside Avenue, 15 21/10/05

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 Claire Taylor 23 rd & 25 th Unannounced Inspection October 2007 11:10 Ambleside Avenue, 15 DS0000022718.V347900.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 Ambleside Avenue, 15 DS0000022718.V347900.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. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 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 8772 6223 reception@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership Bessie Odeh Okoro Care Home 6 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Physical disability (0), of places Physical disability over 65 years of age (0) Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include two persons aged 65 years and above Date of last inspection 4th May 2006 Brief Description of the Service: 15 Ambleside Avenue is a detached purpose built house designed to provide support and accommodation for six people who have learning disabilities. Southside Partnership, a voluntary organisation, owns it. The property is wheelchair accessible with wide internal corridors and room entrances, a lift, and ramp to the front entrance. There are six single bedrooms, all above minimum space standards. The ground floor has two bedrooms, a lounge, a large kitchen/diner, bathroom with shower and a separate toilet. The first floor has four bedrooms, a bathroom with toilet, a separate toilet, an office, laundry room and storage cupboards. There is a small garden and the home is within easy walking distance of a large shopping area with full community facilities, bus and rail transport, and a large public common. More detailed information about the services provided can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the home. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on findings from two visits made to the home. The acting deputy manager facilitated the first visit and the manager was available for the second. Various records were looked at in relation to care planning, staffing and the general operation of the home. There was also a walk round the premises. People living in the home do not have the capacity to share their views regarding their care. In order to make judgements about the care that service users receive, observations of care practices and interactions with staff took place. Discussions were held with some of the staff on duty during both days. All registered adult services are now required to to fill in an annual quality assurance assessment. (AQAA) It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. The AQAA also provides the CSCI with statistical information about the individual service and trends and patterns in social care. The completed AQAA was very informative and is referred to in this report. Feedback from the written comment cards returned by four staff and two relatives also informed this inspection. Some concerns regarding risk assessments for one service user were identified during the first visit. As a consequence an official letter known as an “immediate requirement” was issued. This advised that the identified concerns must be put right within 48 hours or enforcement action may be taken. A second announced visit was undertaken on the 25 October 2007 to check compliance and the registered manager had promptly taken the required action. All those who took part are thanked for their time and contribution to this inspection. What the service does well: The home accommodates people who have both physical and learning disabilities, some of whom have highly dependent needs and sensory impairments. Appropriate care and support is dependent upon the home having sufficiently experienced and skilled staff who have developed a working knowledge of the behaviours, moods, signals and temperaments of the service users. The home was once again able to demonstrate an ability to meet their specialist needs with service users benefiting from a stable and familiar staff team. The manager and staff work hard to raise standards for the people who live in the home and to make sure that they are at the centre of its services. Plans of care are person centred, well created and closely reflect the specific needs of the person. This means that staff have clear information on how to support them. Staff closely monitor the health and wellbeing of the service users and there are good links with other healthcare professionals. Any changes in individual needs are acted upon and adjustments to their care and Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 6 support are put in place. People are treated with respect and dignity that promotes their individuality and values their rights. Activities are arranged to suit individual needs and choices as well as provide interest and stimulation both within the home and local community. The home is kept clean, safe and furnished to a good standard and provides homely and comfortable surroundings for the people who live there. Specialist equipment is available so that people’s physical and sensory needs can be met. Comment cards received from relatives were complimentary. “I feel the care home helps …… to lead an independent life” and “the care home have been very helpful over the past year.” The organisation ensures that staff at all levels are provided with good training opportunities to carry out their work effectively. One staff comment said “They are good in the areas of training” What has improved since the last inspection? What they could do better: Each person living in the home must have an up to date and relevant contract. This will help them and/ or their representatives to have a better understanding of the care that is promised and likewise the home’s duty of care to them. So that the rights and best interests of people living in the home are better safeguarded, some improvements are needed with record keeping. Firstly, staff files are currently held centrally by the owning organisation but as required by law and regulation, certain records need to be kept on site in the home. This will show that the employer has undertaken all appropriate checks and vetted its staff correctly. Secondly, the Commission needs to be informed more promptly of any events that affect the well being of people living in the home. The manager must therefore ensure that all staff are familiar with the required guidance. Given the age of some service users and their associated health conditions and changing needs, staffing levels need to be kept under close review to ensure that their needs will continue to be met. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 7 Each staff member needs an individual training and development profile and certificates of training must be kept on personal files. This will further evidence that staff are adequately trained to meet people’s needs. Southside Partnership must ensure that a responsible individual carries out monthly visits and the reports are sent to the Commission. This will further demonstrate how the organisation monitors progress within the home and identifies areas for improvement. Risk assessments concerning the premises and safe working practices are needed. This will show that all hazards have been identified and minimised to ensure the safety and well being of all those living and working in the home. 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. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 8 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 Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 9 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): 1, 2 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good Information about the home enables prospective service users to decide whether it can meet their support and accommodation needs. Arrangements are in place for assessing people’s needs so that staff are aware of how to support them. Up to date contracts need to be provided to each service user so that they have accurate information about the facilities and services they can expect to receive. EVIDENCE: As previously required, the home’s Statement of Purpose has been reviewed to include all the necessary information such as details about the complaints process and the correct age range for which the home is registered. The manager should sign and date the revised Statement of Purpose however. Available in a format that is supplemented with photos, the documents are easy to understand. The same group of people have lived at the home for a number of years and there have been no new admissions. Suitable policies are in place however to ensure that the home would only admit people whose needs can be met. The home ‘s assessment plan is detailed and covers all areas to ensure that any new person’s needs would be fully assessed prior to their admission. This covers all aspects of the person’s life, including individual Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 10 strengths, hobbies, social/ cultural needs, dietary preferences, medical history and personal care needs. The individual contracts for each service user are now in need of review as some dated back to 2002. All people living in the home must have an up to date and relevant Individual Service Agreement. This will help them and/ or their representatives to have a better understanding of the care that is promised and likewise the home’s duty of care to them. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 11 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. Care planning is well managed and ensures a personalised and consistent level of service provision for the people staying in the home. Regular reviews ensure that staff are aware of each person’s current needs and how to support them. Some risk assessments require updating and review or this has the potential to affect the quality of care if staff do not have accurate information to support people’s mobility needs. EVIDENCE: Three people’s care and support plans were looked at. Person centred planning has progressed well and plans are well written. They are structured and developed with the individual and their keyworker using pictures, photographs and symbols, to support the written text, making it more meaningful to them. Monthly reviews are carried out by keyworkers to evaluate whether goals and objectives are being met for each person. This helps to ensure consistent guidance and practice so that individuals have the right therapeutic support and treatment to meet their needs. People who live in the home are involved in Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 12 their reviews, as well as their families and other professionals such as their care manager from Lambeth local authority. Individual daily records were thorough, relevant, and gave an indication of each person’s experience of their day. Individual PCPs are kept in each person’s bedroom and outline how the staff should best support them to achieve their personal goals. Each person also has communication guidelines that inform staff on how to understand their individual means of expression. I.e. through body language, gestures or behaviour patterns. Discussions with staff and observation confirmed that they knew each person’s specific means of communication. Whilst the ability of the service users to make informed choices is limited, staff nevertheless try to consult them on everyday decisions that affect them. Daily records and observation of staff working with individuals reflected this. Although most information in individual files had been regularly and recently reviewed, one person’s moving and handling risk assessment did not reflect their current needs. Records showed that their physical needs had deteriorated and they were unable to bear weight and were now dependent on a wheelchair. In addition a Physiotherapist had assessed the person’s mobility needs in July of this year but the recommendations from the report were not readily available for the staff. Such lack of information may put the person and staff at risk if correct guidance on safe manoeuvres is not followed. An immediate requirement was therefore issued and the manager took the required action within the given timescale. Aside from this, other risk assessments and guidelines were informative and relevant to assessed needs. Examples seen were one for tripping hazards and door safety for the person with sensory difficulties and skin tissue care for two people who use wheelchairs. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to continue education and appropriate activities within the home and local community so that they can maximise fulfilment and achievement in their lives. Relationships with family and friends are well supported. Meals are nutritiously balanced and offer a healthy and varied choice for the people who live there. EVIDENCE: People living in the home have highly dependent needs including physical disabilities and limited communication skills. Staff therefore tend to organise activities based upon each individual’s assessed needs and knowledge of service users’ preferences. Records showed that the home supports people to follow their personal interests and activities. Care plans and PCPs contained detailed information about people’s activities and their likes and dislikes. At the six monthly review meetings, service users current activities and opportunities to take up new activities are explored. Daily diaries are completed to show Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 14 what social and leisure activities people have taken part in. Two people’s records were sampled. Outings for one individual included a visit to Kew Gardens and Battersea Park as well as a meal out. During the first visit, this person went out for a haircut with their keyworker. The service users attend a local day centre on a sessional basis. The “Adare” centre offers a range of activities such as creative expression, music, keep fit, aromatherapy and a workshop for older people. One individual had certificates from the centre for completion of courses including use of a sensory room. In March of this year four people and their key staff went on holiday to Blackpool. Two service users are supported to visit church each week meaning that their religious needs are met. During both visits, service users appeared relaxed and comfortable in their home. Staff spoke respectfully with individuals and supported them with their day-to-day routines. Records showed that family, friends and guests are welcome at the home and that the manager maintains good communication links with the service users’ respective families. Comment cards received from relatives were complimentary about the home. “I feel the care home helps …… to lead an independent life” and “the care home have been very helpful over the past year.” Where able to, some individuals are encouraged to participate in household tasks such as cleaning and tidying their bedrooms, laundry care or preparing meals. Menus seen indicated that people living in the home are provided with a variety of nutritious foods and balanced diet. Alternative meals are available and records kept. Pictures and photos supplement the menu display making it more accessible and meaningful to individual service users. The lunchtime meal served was minced beef, potatoes and a selection of vegetables. This corresponded with the daily menu and was prepared accordingly for those people who required a soft diet. The mealtime was relaxed and staff appropriately assisted service users who needed support with eating. Care plan entries confirmed that nutritional monitoring and dietician support occur where required. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Clear guidance and the knowledge of experienced staff helps ensure that individuals receive support in ways they are familiar and comfortable with. Promotion of health is well observed. Welfare is closely monitored to ensure that the physical and emotional needs of people living in the home are met. The home’s systems regarding medication are well organised to ensure safety and consistent treatment and support for each person. EVIDENCE: People who live in the home depend on staff to fully support them with their personal care needs. Where support is required with personal physical care, this is identified and guidance is available on how specific tasks should be undertaken whilst also maintaining privacy and dignity. Staff were able to demonstrate their knowledge and were observed undertaking a variety of care activities competently. They were attentive to individuals and were able to identify with the gestures and reactions they gave and what these were likely to indicate. Cultural needs and preferences are recorded in each person’s plan. One included guidelines on hairstyling and skin care to support one person’s ethnicity. Religious and spiritual needs had also been assessed. Records Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 16 concerning people’s healthcare needs were in good order and involvement with specialist services highlighted where necessary. They showed that potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. An example was seen for one individual where there had been some recent deterioration in their health. Records showed that their condition was being monitored closely with support from the GP as well as ongoing visits to other NHS services. Service users are in regular contact with General Practitioners, consultants and other health care services as required. E.g.. Physiotherapy, dentist and optician. Each person has an up to date health action plan that covers all areas of need. I.e. personal care, emotional well-being with a specific section on gender health issues. Records are completed for any medical appointments that individuals attend and include details of any required follow up action. This shows that the staff team monitors healthcare needs closely and takes action to address any changes. Information about health conditions such as epilepsy is available in the home. Staff have received training on epilepsy to enable them to fully support those individuals with such specialist needs. None of the people who live in the home are able to self medicate. Sufficient staff are trained to administer medication. Records were accurate for the receipt and disposal of medication and sampled administration charts were signed and accounted for. The organisations procedure requires that a second member of staff witness medication administration. The supplying pharmacist visits the home to check the medication systems quarterly; the last visit was carried out in February of this year. Some areas of advice were given and these had been actioned. An appropriate healthcare professional reviews each service user’s condition regularly to ensure that they receive the correct medication regime or treatment where necessary. Although some medicine information leaflets were available, it is suggested that each person has a medication profile that outlines what the medicines are prescribed for. This will provide staff with on hand information about the medicines prescribed and why they are used. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good practices and policies are in place to enable concerns to be raised and responded to. Arrangements for protection from abuse are well managed and help ensure that people are safe. EVIDENCE: The home has a complaints policy that provides clear details of how concerns would be listened to and acted upon. The procedure is available in audio form for people who have a visual impairment. The current group of people living at the home would need total support to make a complaint and would rely on a relative, staff or other people to raise a concern on their behalf. The staff have The AQAA stated “New Complaints policy and procedure sent out to families following feedback from family satisfaction survey.” This was confirmed through discussion with a relative who also expressed a confidence that the manager would deal promptly with any concerns. Staff have written guidelines in a “complaints triggers” form for each person. This is used to outline how an individual may express himself or herself if unhappy. Given that people living in the home are unable to use verbal expression, this is a very useful way for staff to gauge how service users may be feeling and take the necessary action. There are appropriate policies in place regarding the prevention of abuse including the Lambeth local authority procedure for adult protection. All staff are given a booklet entitled “Stop adult abuse in Lambeth” to reinforce their awareness. Records confirmed that the manager and most staff have received training on safeguarding vulnerable adults. Plans were in place for the Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 18 remaining staff members to attend. The owning organisation plans to include such training as part of new staff induction. Discussions with staff confirmed that they were aware of their responsibilities to report any suspicion of abuse. People living in the home need full support with their finances and are reliant on staff or family to manage their monies. Appropriate documentation was in place with regard to income/expenditure made on their behalf as well as policies to safeguard their personal interests. Records are kept of all financial transactions and daily checks are made at the staff handover to ensure that these are correct. An annual financial audit was carried out by the organisation in September of this year. These systems are good and help to ensure that people’s financial interests are safeguarded. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is furnished and decorated to a good standard that provides people with comfortable surroundings in which to live. Facilities are clean, safe and homely. Bedrooms are designed and furnished to meet individual needs and reflect personal preferences and interests. Specialist equipment is provided to meet people’s needs and enhance independence. EVIDENCE: Since the last inspection, some home improvements have taken place. As previously required, the double gate entrance has been strengthened to provide better security for the service users. The lounge and hallway have been redecorated and new lighting fitted. The ground floor bathroom has been refurbished with a shower to suit the needs of people who have additional physical disabilities. Risk assessments have been completed for each person concerning access to their bedroom radiators. This enables staff to assess whether individuals are comfortable with the room temperature. A gardener now visits the home every 3 months to tidy and maintain the garden area. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 20 Four of the bedrooms were viewed. They appeared comfortably furnished and service users have the equipment and aids required for staff to meet their current needs e.g. wheelchairs, lift, hoist, rails and adapted beds for those who have physical disabilities. The staff have ensured that each person’s bedroom reflects their interests, hobbies and personal identities. This includes possessions that are meaningful to each person such as music CDs, soft toys and family photographs. Objects of reference are used as communication aids for one person who has both a hearing and visual impairment. These include door identifiers such as a spoon for the dining room, a shell for the bathroom and a guide rope fitted along the wall. The objects are used to improve the person’s recognition of daily routines and promote their independence. In addition, staff carry personal identifiers so that the person is aware of who is supporting them. The regulatory records from the Fire authority and Environmental Health departments were checked and up to date. The fire safety report identified that the laundry room window needs replacing with more suitable glass. Records showed that the manager had taken action to address this. The Environmental Health report stated “the standard of health and safety and food safety maintained at a high standard.” Good hygiene practices are observed and systems in place and well managed to control the spread of infection. Protective clothing is available and appropriate arrangements in place for the safe storage and disposal of clinical waste. The AQAA identified that there are plans to create a lockable space within the premises for the waste bins to be kept. In addition, to erect a garden shed for the storage of incontinence aids as current storage facility is not adequate. This will be checked at the next inspection as these issues have been highlighted as improvements to take place within the next 12 months. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a stable staff team who understand and respect the needs of the people living there. Training for staff is well managed and they are provided with good training opportunities to do their jobs effectively. Good recruitment practices are in place to ensure that people are cared for and protected. Record keeping could be improved however as a further safeguard. To ensure that the changing health needs of some individuals will remain met; staffing levels need to be kept under regular review. EVIDENCE: Positively, staff turnover has been low and the team remains largely unchanged. This means that service users benefit from a stability and consistency of care. Observations showed that staff respect service users’ individuality as well as demonstrate an understanding of their specific needs. Regular staff team meetings are held; minutes were clear and focused on people’s needs as well as the day to day running of the home. Written comment cards from staff were mostly positive on their experience of working at the home. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 22 Rotas were sampled and allocation allows for a minimum of two staff on the morning and evening shift with one staff on a flexi shift. The main purpose of the flexi shift is to support the service users with their scheduled activities. At the time of the visits, there was one vacancy, one staff on maternity leave and one staff on suspension. Regular agency staff are used to cover shortfalls or vacancies. Feedback from staff comment cards indicated some dissatisfaction with current staffing levels. In answer to the question of whether there are enough staff to meet the individual needs of all the people who use the service, “usually” and “sometimes” were common responses. Comments were “there are some staff who feel the work load can be a little much” and “Inadequate staff. It is extremely difficult to deliver good services to avoid staff working under pressure.” Another reason was due to the changing and complex needs of some service users. The manager was very aware of the staff concerns and has brought them to the attention of senior management. Given the age of some service users and their associated health conditions and changing needs, staffing levels must therefore be kept under close review. Staff recruitment records are currently held centrally at the Southside headquarters and were therefore not available for this inspection. On the second visit to the home, the manager provided a record of up to date CRB disclosures for the staff team. Discussions with staff and written comment cards confirmed that appropriate employment checks were carried out prior to starting work. “I was not allowed to commence duty until the checks were satisfactory” The registered provider needs to write to the Commission for Social Care Inspection local office should they wish to continue to hold staff records centrally. The Commission has developed a “staff proforma” form that should be completed for each employee and kept in the relevant home. The form can be used to evidence that appropriate recruitment checks have been undertaken by the employing organisation as well as other documents required by law. A copy of a blank form was therefore left for the registered manager. An organisational training programme is available that provides a variety of courses for staff to update their skills and knowledge along with recognition of mandatory training that they must attend. Staff feedback was complimentary about training opportunities. The induction process for new staff is comprehensive and relevant to service users needs. Staff comments confirmed this. “I had one week intensive training”. Induction is also based upon the required Skills for Care core standards. The home uses regular agency staff and it would be better if these staff sign confirmation when they have completed their induction. In addition the manager should keep a record of all training that agency staff have undertaken. Records showed that staff have had training that is specific to the needs of some individuals. I.e. epilepsy, using communication aids and dementia. 3 staff had attended an in house session on use of the hoist. Although there was a general record of staff team training, each staff should have an individual training profile. In addition certificates of training need to be kept on their personal files. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager has relevant qualifications and a good leadership approach to run the home in the best interests of the service users. Record keeping is generally well managed to ensure that people’s rights and best interests are safeguarded although reportable events must be notified to the Commission more promptly. The home aims to run in the best interests of the people who live there and good arrangements are in place for monitoring the quality of care provided. Overall, good systems are in place to promote and protect the health, safety and welfare of people living and working in the home. Risk assessments of the premises and safe working practices need to be completed as a further safeguard however. EVIDENCE: Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 24 Since the last inspection, Bessie Okoro has been successfully registered with the Commission to manage the home. Discussions and observation confirmed that she is knowledgeable about each service user’s specific needs and understands the importance of person centred care and effective outcomes for people who use the service. The manager has obtained the required qualifications and has also periodically attended various training courses to keep her knowledge and skills up to date. Staff feedback was generally positive about the manager’s leadership and staff felt well supported. A range of quality assurance systems are used to measure the success of how the home is achieving its aims and serve the best interests of the people who live there. Examples include care plan reviews, best interest meetings for service users, visits from the “person in control” and satisfaction questionnaires. The manager explained that other managers within the organisation carry out operational visits as required by regulation 26. Records showed that visits had been happening but not at the required frequency. The last report was dated 28/06/07. Southside Partnership must therefore address this and ensure that the monthly visit is completed and the report is sent to the Commission. An annual quality assurance action plan has been put in place for the next 12 months. The plan clearly outlines the expected aims and outcomes for improving the services for the people in the home. The completed AQAA stated that all relevant safety checks were up-to-date. The servicing and maintenance records for the home were sampled. As previously required, an electrical safety check on the premises and small appliances has been completed. Fire safety checks and practices were all up to date. Checks on hot water temperatures are carried out regularly to ensure that they are maintained at a safe limit. Accurate records are kept for accident and incident reporting although the Commission must be notified more promptly of reportable events. Records showed that a service user suffered an epileptic seizure that resulted in admission to hospital. This was not reported under the required regulation and the manager must therefore ensure that all staff are aware of the guidance for notifying the Commission of significant events. Key health and safety training for staff is organised and planned so that staff update their skills and knowledge at appropriate intervals. Training undertaken since the last inspection has included infection control, moving and handling, food hygiene, medication and first aid. The organisation has a rolling programme of training to ensure that staff update any mandatory courses. Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 2 X Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5(1b&c) Requirement An up to date contract must be provided for each service user so that they or their representative are given full information about the service that is being arranged. Risk assessments concerning moving and handling practices must be up to date. This is to ensure that staff have clear guidance on what action to take to support people’s mobility needs and minimise the risk of injury or harm. Immediate requirement issued on 23/10/07 and complied with within given timescale. 3 YA33 18(1a) Given the age of some service users and their associated health conditions and changing needs, staffing levels need to be kept under close review to ensure that their needs will continue to be met. 31/03/08 Timescale for action 31/01/08 2 YA9 13(4b)(5) 25/10/07 Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 27 4 YA34 17(2) The required records must be 31/12/07 kept in the home to show that the employer has undertaken all appropriate checks and vetted its staff correctly. To further evidence that staff are adequately trained, each staff member needs an individual training and development profile and certificates of training must be kept on personal files. Southside Partnership must ensure that visits are carried out monthly and reports are sent to the Commission. This will further show that the organisation monitors progress within the home and identifies areas for improvement. 31/12/07 5 YA35 18(1)(c) 19(5d) 6 YA39 26 (5a & b) 31/12/07 7 YA41 37 The Commission must be notified 30/11/07 more promptly of all significant events that affect the service users’ well being. The manager must ensure that all staff are familiar with the reporting of incidents and accidents under Regulation 37 of the Care Standards Act. Risk assessments concerning the premises and safe working practices must be carried out and regularly reviewed. This will show that all hazards have been identified and wherever possible minimised to ensure the safety and well being of all those living and working in the home. 31/12/07 8 YA42 13(4) 15(1) Sch.3 (3 q) Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 28 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 YA1 Good Practice Recommendations The manager should sign and date the Statement of Purpose and Service Users Guide so that it shows when the information was updated. Medication profiles should be written for each person so that staff have on hand information about the medicines prescribed and why they are used. The specific needs of each service user should be included in the home’s induction pack. Agency staff should sign the form in acknowledgment once they are familiar with the information. Training records for agency staff should be kept in the home to show that they have the knowledge and skills to meet the service users needs. 2. YA20 3. YA35 4. YA35 Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Ambleside Avenue, 15 DS0000022718.V347900.R01.S.doc Version 5.2 Page 30 - 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. 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