Inspection on 04/05/06 for Ambleside Avenue, 15

This inspection was carried out on 4th May 2006.

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 4 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 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 Ms Rehema Russell Unannounced Inspection 4th May 2006 09:30 am DS0000022718.V291260.R01.S.doc Version 5.1 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.V291260.R01.S.doc Version 5.1 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.V291260.R01.S.doc Version 5.1 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 www.southsidepartnership.org.uk Southside Partnership 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) DS0000022718.V291260.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include two persons aged 65 years and above Date of last inspection 21st October 2005 Brief Description of the Service: 15 Ambleside Avenue is a detached purpose built house designed to provide support and accommodation for six service users who have learning/physical disabilities. It is managed by Southside Partnership, a voluntary organisation. The property is wheelchair accessible with wide internal corridors and room entrances. There are six single bedrooms, all above minimum space standards. The ground floor has two bedrooms, a lounge, a large kitchen/diner, 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 cupboards. There is a lift, a garden to the front, side and rear, and a solid ramp to the front door. 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. Prospective service users/their relatives are given a Statement of Purpose and Tenant’s Handbook (equivalent to the Service User’s Guide) for information and the Manager also explains the complaints and confidentiality policies. A copy of the most recent CSCI inspection report is available to be read at the home – one copy is kept in the office and one copy is kept near the visitors book in the visitors’ area on the ground floor. The current fee for the home is approximately £1,300 per week and there are no additional charges. DS0000022718.V291260.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this report was obtained from the inspection record, a preinspection questionnaire received from the home and by an unannounced inspection of the home on Thursday 4th May 2006. Subsequent to the inspection information was also obtained from a Care Manager. Several attempts were made to contact a relative by telephone but were unsuccessful. During the inspection the inspector toured the premises, spoke with the manager and several support workers, one in depth, observed service users and looked at documentation and records. Service users were not able to communicate verbally with the inspector but their behaviours and body language indicated their moods and preferences. The Manager of the home is Ms. Bessie Okoro, who was present for this inspection. She was the Registered Manager for the home which transferred to Ambleside Avenue last November, but has not yet been registered for this establishment although this is now in progress. What the service does well: What has improved since the last inspection? What they could do better: The Registered Provider must ensure that information in the Statement of Purpose and Service User Guide (Tenant’s Handbook) is fully up to date and DS0000022718.V291260.R01.S.doc Version 5.1 Page 6 accurate following recent changes. They must also send a copy of the electricity and small electrical appliances certificates to CSCI. 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.V291260.R01.S.doc Version 5.1 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.V291260.R01.S.doc Version 5.1 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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about the home. Their individual needs are assessed so that the home can meet their needs and aspirations. Prospective service users and their relatives have opportunities to visit and try out the home. EVIDENCE: The Statement of Purpose is written in clear and simple language and the Service User Guide (called “The Tenants Handbook”) is written in simple language with explanatory pictures throughout. These formats ensure that the information about the home is suitable to service users’ needs and therefore accessible to them. The Statement of Purpose has all of the information required by regulation with the exception of the arrangements made for dealing with complaints (see Requirement 1). It also states that the home can take service users “aged up to and over 65”, however the home is registered for younger adults only (18-65 years old), although it currently has a condition allowing it to care for the two service users who are over the age of 65 (see Requirement 1). The Service User Guide/Tenants’ Handbook should be updated so that the information about the former Quality Officer is updated (see Recommendation 1) and the Manager said that she would check whether the reference to a Carers Forum under the section on activities actually refers to the Service Users Committee run by the parent organisation. DS0000022718.V291260.R01.S.doc Version 5.1 Page 9 Six months previous to this inspection the Manager, staff and four service users from another registered home had transferred into this home, combining with the two service users and some of the staff already in the home. All six service users had been at their respective homes for several years and so to assess Standard 2 the inspector checked on the process that had been undertaken to assess the suitability of the transfer for the four incoming service users. It was found that a very thorough assessment process had been carried out, which included consultation and liaison with the Care Manager, relatives, advocates and specialist community teams. The local authority Care Manager had visited the home several times with each service user and had undertaken a re-assessment for each of them. Relatives had also visited and efforts had been made to get advocates for service users with no relatives/next of kin. Specialist teams had also been consulted, such as the occupational therapist and community nurses, and guidelines were re-written as appropriate. The Care Manager was very pleased with the way the Manager had implemented the transfer and felt that service users had benefited from the move. The transfer process included trial visits to the home, consultation with service users by observation of their reactions/behaviours/moods, determination of the home’s capacity to meet the assessed needs of service users, assessment of the staff’s individual and collective skills to meet service users’ needs and consultation with specialists and advocates to ensure best practice. DS0000022718.V291260.R01.S.doc Version 5.1 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, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and Person Centred Plans are well kept and thorough and reflect service users’ individual needs and goals. Regular reviews ensure that needs and goals are being monitored and met. Service users are enabled to make decisions about their lives inside and outside the home and to practice choice and independence within the limits of their physical and cognitive abilities. Risk assessments ensure that relevant precautions are taken to facilitate service users’ independence and choice. Information about service users is handled appropriately and confidentiality maintained. EVIDENCE: Care plans contain all of the information required, including regular recorded monthly reviews which evaluate whether goals and objectives are being met. This ensures that service users’ assessed and changing needs and individual interests are reflected in their care plan goals and monitored to ensure they are met. All relevant interest parties are invited to attend annual care plan reviews, including specialist team practitioners and relatives. Person Centred Planning books are clear and informative with appropriate illustrations and with DS0000022718.V291260.R01.S.doc Version 5.1 Page 11 clear goals for individual service users. Service users are encouraged to attend review meetings. The inspector was told about one service user who normally attends reviews but at the most recent one exercised choice by wheeling herself out as she no longer wished to be there. Service users cannot communicate verbally but staff interpret their choices and preferences by observing their gestures, moods and behaviours. In this way they enable service users to make choices about food, clothes and activities. Although service users are non-verbal several occasions were observed during the inspection where service users made their preferences known by their behaviours, refusing to co-operate if they didn’t wish to do something and indicating by their gestures and body language what they wanted or where they wanted to be. As the majority of service users do not have family or relatives who visit, the home seeks to involve advocacy services in reviews and decision making whenever possible. Risk assessments demonstrate that the home puts risk management strategies into practice to ensure the safety of service users. One service user had been present at one of the risk assessments undertaken at the previous home, further indicating the commitment to service user participation and agreement in their care. The Manager and staff demonstrated a thorough understanding and commitment to the confidentiality policy and the Manager’s ensures that service users’ relatives and advocates are aware of this policy by explaining it to them personally. All service users’ files and confidential information are kept upstairs in the office, in locked cabinets where appropriate. DS0000022718.V291260.R01.S.doc Version 5.1 Page 12 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, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ mental, emotional and physical care needs are supported. They are enabled to take part in appropriate activities, to be part of the local community and to maintain family relationships. Service users are offered a healthy diet and their preferences are respected. EVIDENCE: Service users are given opportunities to develop social, emotional and independent living skills within the parameters of their learning and physical disabilities. Service users are encouraged to eat together in the dining room, to undertake activities at colleges and in the community and to practice daily living skills such as tidying their rooms, clearing the table and helping with their laundry. Two service users are supported to attend the nearby church on Sundays. DS0000022718.V291260.R01.S.doc Version 5.1 Page 13 Staff enable service users to take part in fulfilling activities by encouraging and supporting them to attend classes at a local college according to their individual preferences and abilities. These classes include keep fit, art, music, aromatherapy, yoga and drama communication. One of the older service users also attends an age-appropriate older person’s workshop. Inside the home, service users have games and sensory equipment and one service user, who enjoys listening to classical music, has a music centre with a variety of classical music which he was observed to be listening to during the inspection. Another service user, who is blind and deaf, has specialist audio equipment in her room so that she can enjoy music via vibrations and also has other sensory objects that she can enjoy. Service users participate in the local community via trips to the shops, cafes, cinema, theatre and parks. On the day of the inspection one service user was taken to a local theatre in the afternoon and two others attended a day centre in the morning. Other social activities include annual holidays and attending the Registered Provider’s monthly social club. Four service users were taken to a cottage in Devon at the end of March this year, and keyworkers are currently planning this year’s holidays. A service user who is of Caribbean origin is going to Jamaica with service users from another of the Registered Provider’s homes. The home encourages and facilitates service users to maintain family links, although currently only two residents having regular visits from family members/friends. One of these two service users used to have weekly visits from her mother and since her mother’s death last year, staff have encouraged and facilitated one of her mother’s friends to visit and participate in the service user’s care/reviews. As previously mentioned, two service users are supported to go to places of worship, in accordance with their own and their families’ wishes. Daily routines are flexible and promote individual choice and freedom of movement. On the day of inspection service users were observed to move freely around the home, choosing where they wished to be at any time. One service user spent some time at the breakfast bar in the kitchen as she likes to observe any cooking that is going on. Another sat in her favourite spot in the lounge, near a puzzle game she is particularly fond of, but was observed to go to her room to collect things when she wanted. A third service user came into the office to see what was going on. In order to enhance the independence of one service user who has severe auditory and visual disabilities, objects of reference had been attached to her bedroom, nearest bathroom, lounge and dining room, and staff carry personal identifiers so that she will know who is addressing her. A guide rope system had been installed at her previous home and staff wished to re-install this but have to wait for an occupational health assessment by the local authority. Menus were seen and showed that service users receive a balanced and nutritious diet and although they cannot verbalise, their preferences are well known to staff and they can express their choice through body language or DS0000022718.V291260.R01.S.doc Version 5.1 Page 14 refusing to eat. One member of staff explained that the service user she key works likes her food to be colourful and so this was catered for, and a list of service users’ preferences was displayed in the dining area. The manager confirmed that appropriate cultural meals are provided for service users from a minority ethnic background. On the day of inspection the meal was salmon, mashed potato and mixed vegetable, as per the set menu, and records were seen of where the menu is altered or an alternative choice given to service users. DS0000022718.V291260.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive and flexible personal support and ensure that service users’ physical and emotional health needs are met. Staff should ensure that they follow the same gender care policy in regard to records. No problems with the storage, recording and administration of medication were found. EVIDENCE: Observation and verbal evidence from the manager and staff indicated that staff carry out personal support and prompting sensitively and in a way that ensures service users’ privacy and dignity. Staff spoken with were familiar with the behaviours and preferences of the service users they key work and demonstrated how service users are enabled to make choices in regard to daily routines and activities. Service users were well groomed and ageappropriately dressed. Case files and the appointments book evidenced that staff seek specialist support and advice from occupational therapists, speech therapists and others, as service users’ needs arise or change. Documentation and verbal evidence from staff also demonstrated that residents are supported to access the full range of health care professionals. Each service user has an individual health action plan with comprehensive DS0000022718.V291260.R01.S.doc Version 5.1 Page 16 information relating to their health care needs, and this is updated by the Community Nurse and used during review meetings. The home provides accommodation for both males and females, and has a mixed gender staff group. The Registered Provider’s policy in regard to personal care is for same gender care to be provided for intimate care whenever possible, but if not possible, then cross-gender personal care given should be recorded. In discussions with the manager it appeared that the two staff groups that had merged following the recent move may have different understandings of the policy and were not recording when cross-gender intimate care was given. The manager said that the policy would be fully discussed at the next staff meeting so that clarity of practice could be established. The storage, administration and recording of medication was checked and no problems were found. The deputy manager was not on the premises at the time of the inspection but the inspector was told that the deputy manager conducts regular tablet counts of the medications that are not administered via monitored dosage packs. DS0000022718.V291260.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and thorough, and is available in a format suitable for service users’ cognitive abilities. The manager and staff act appropriately to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: No complaints have been received by the home or the CSCI since the previous inspection. The complaints procedure for the home is in an appropriate form for service users with learning disabilities and is also available in audio form for service users with visual impairment. The procedure is available in the Service User Guide, in a suitable format, but needs to be updated as the Quality Officer has now left the parent organisation. Staff spoken with displayed a good knowledge of abuse issues and how to deal with them. The Manager and staff spoken with were familiar with the steps to be taken in the event of suspected abuse and the home holds a copy of the local authorities Vulnerable Adults Policy. One member of staff was not aware of the strategy meeting that should be held by the local authority in the case of an abuse allegation but the manager said that she would brief staff on this as the local authority developed its procedures. DS0000022718.V291260.R01.S.doc Version 5.1 Page 18 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, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. Bedrooms promote their independence and there are sufficient and comfortable shared spaces. Suitable aids area available to enhance independence and the home is clean and hygienic throughout. EVIDENCE: Several requirements had been made in previous reports relating to the physical environment of the home, and the majority of these had been implemented satisfactorily. The home had been made secure by the building of solid fencing on the low walls that surround one side of the home, and the fencing along another side had been repaired and the double gate replaced. Unfortunately, the new double gate supplied is not a solid gate but made of open latticework. This means that it gives very easily when pushed or leaned against and although it fits the purpose of access, it does not fit the purposes of security and safety as it would be very easy to breach. Given the strategic location of the double gate, on a main road with heavy traffic and as the main entrance to the home, the Housing Association must find a way to strengthen the gate so that it is fit for purpose (see Requirement 2). As it is difficult to DS0000022718.V291260.R01.S.doc Version 5.1 Page 19 determine which is the front entrance of the home from the street, the manager is in the process of getting a buzzer/entry system installed beside the gate, which will very much improve access to the home. The home is surrounded on three sides by garden areas. The previous staff group had a member of staff who was particularly interested in developing and maintaining the garden but as this member of staff no longer works at the home, the Registered Provider should consider employing a gardener/gardening hours to develop and maintain this large area so that it can be fully and safely utilised by service users. The previous member of staff was also developing a sensory garden outside the lounge at the rear of the house and it is recommended that this work is continued for the benefit of the current service users. Four of the six service users’ bedrooms were seen and all were found to be fitted, furnished and decorated to a good standard and to be personalised according to the interests and needs of the occupants. Although radiator covers have openings to the side to allow access to thermostats, some of the openings were narrow and difficult to access, while others were positioned so that it wasn’t possible to reach them (for example, behind furniture). This was fully discussed with the manager, who pointed out that none of the current service users possess the cognitive or physical abilities to implement choice in relation to the thermostats. For this reason no further requirement has been left at this time, but should the home admit a service user who would be able to exercise choice and the requisite manual dexterity in regard to thermostats, then the Registered Provider would be required to enable access. In the meantime, the Manager should carry out risk assessments and provide guidelines on how to determine whether service users are warm/cool enough in their bedrooms (see Recommendation 4). The downstairs bathroom has a hoist but the hoist in the upstairs bathroom has been removed as it was out-dated and none of the service users occupying the upstairs bedrooms have need of it. The occupational therapist has been asked to reassess the homes aids and adaptations and the inspector was told that the Housing Association have agreed to provide a purpose built shower should the occupational therapist recommend it. The home is fully wheelchair accessible, with wide doorways and halls, a passenger lift, and a purpose built ramp to the front door. Two moveable wooden ramps have been provided at the rear of the house so that the back garden is accessible to wheelchair users. The two indoor shared spaces for service users are the lounge and the dining area of the kitchen/diner. The lounge is attractive and comfortable, with good quality furniture, furnishings and fittings, and the dining area is also attractive, with potted plants, ornamentation and several seating areas. DS0000022718.V291260.R01.S.doc Version 5.1 Page 20 On the day of inspection the home was found to be clean, hygienic and free from offensive odours throughout. DS0000022718.V291260.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff, who are appropriately trained. Service users benefit from well supported and supervised staff and are protected by the Registered Provider’s recruitment policy. EVIDENCE: Staff spoken with were familiar with the needs, characteristics, preferences and behaviours of service users and understood the particular care needs of the service users they key worked. They demonstrated sensitivity to service users cognitive and physical disabilities and a commitment to their independence, choice and rights. One member of staff had noticed that a service user’s balance had deteriorated following an operation and had her assessed for a personal wheelchair. The service user can now wheel herself around in this chair, thereby maintaining independence. Staff also demonstrated a good understanding of when the manager or outside specialists need to be involved in care needs or other issues. With the merger of the two homes there was some loss of staff and so the home currently just falls short of the 2005 NVQ Level 2 training target. However, two of the three NVQ qualified support workers have Level 3 rather than Level 2, and three other support workers are studying for Level 3 or the equivalent. DS0000022718.V291260.R01.S.doc Version 5.1 Page 22 The parent organisation operates a thorough recruitment procedure based on equal opportunities and ensuring the required protection of service users. The inspector was unable to check staff files as these are held at Head Office and on the day of the inspection the Registered Provider’s Human Resources Advisor told the inspector that the organisation’s policy was not to release staff files from the Head Office. She said that a full audit of the files had just been carried out and that she was confident that all required documentation was in place and in proper order. She also told the inspector that the Registered Provider updated all Criminal Records Bureau checks for established staff every three years. The Registered Provider has a very thorough and comprehensive training programme, incorporating in-house and external courses, which is also available to bank and agency staff. All mandatory training is updated quarterly, and a range of other relevant training is available throughout the year. Training planned for staff at this home for this year includes: sensory impairment, age and ageism, Downs Syndrome, Autism and Learning Disability, oral hygiene and basic IT. Last year staff attended courses in visual impairment, advocacy, mental health awareness, welcoming diversity, spirituality and learning disability, vulnerable adults, medication and other relevant subjects. Induction for new staff is also comprehensive and includes Learning Disability Award Framework-accredited training. Staff were appreciative of the Registered Provider’s commitment to training and the range of courses provided. Staff confirmed that they receive regular, monthly supervision and that there are regular, minuted, team meetings. The latter are used to discuss individual service user’s changing needs as well as discussion of the Registered Provider’s policies and procedures and any other issues affecting the home. DS0000022718.V291260.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit form a well run home. Service users’ needs and rights underpin all self-monitoring, review and development by the home, and they are safeguarded by the home’s record keeping. The health, safety and welfare of service users are promoted and protected but proof of electricity safety inspections was not evident at the home. EVIDENCE: The Manager of the home is suitable qualified and experienced, having the NVQ Level 4 and Registered Manager’s Award and several years experience with the client group. She was the Registered Manager at the home from which the service users transferred, which was registered for people with a learning and sensory disability. At the time of writing this report the manager was in the process of registering for this home because it is regarded as a new establishment following the transfer of the service from the previous home. DS0000022718.V291260.R01.S.doc Version 5.1 Page 24 The Registered Provider has used the external PIQASSO quality assurance system for small homes to determine the quality of its services. It also carries out its monthly Regulation 26 reports, which are thorough and comprehensive. Other forms of quality assurance used are: health & safety risk assessments by an external company, six monthly visits from the Housing Officer, social services reviews, annual development plan, 3 year business plan and an annual financial audit. As the majority of service users have only been at the home for six months, an annual survey of service users views has not yet been carried out. Service users could not participate meaningfully in a conventional service user survey due to their limited cognitive and communication abilities but the inspector was told that the Operations Manager is currently carrying out consultation to ascertain how their views can best be obtained. The manager of the home also plans to undertake some further communication training. A range of records were seen and were found to be thorough and well kept. This included care plans, guidelines, assessments, medication records, complaints, menus, activities books, appointment books, communication book, meeting minutes, visitors book, fire book and health and safety documentation. A range of health and safety documentation was seen and was found to be in good order. This included fire records, health and safety checks, risk assessments, clinical waste contract, fire alarm certificates, gas safety certificate, water temperature checks, and COSHH and RIDDOR records. The five yearly electricity safety certificate could not be found and a copy must be supplied to CSCI by the Registered Provider. The small electrical appliances annual test had been due on 14th March 2006 but not carried out, however the manager said that the Housing Officer had arranged for the company to visit the home and this should be confirmed to CSCI. (see Requirement 3). DS0000022718.V291260.R01.S.doc Version 5.1 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 2 2 4 3 3 4 3 5 X 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 3 X 3 2 X DS0000022718.V291260.R01.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(c) Schedule 1 (14) Requirement Timescale for action 30/08/06 2 YA24 23(2)(b) 3 YA26 23(2)(p) 4 YA42 12(1)(a) The Registered Person must ensure that the Statement of Purpose contains the arrangements made for dealing with complaints, and states the correct age group for which the home is registered. The Registered Provider must 30/09/06 ensure that the double gate that forms the entrance to the house is sufficiently solid to provide security and safety for service users. The Registered Provider must 04/05/06 ensure that access to radiator thermostats is facilitated for any service users who are admitted with the requisite cognitive ability and manual dexterity to make use of them. The Registered Person must 30/06/06 send CSCI a copy of the five yearly electricity safety certificate and a copy of the small electrical appliances annual test. DS0000022718.V291260.R01.S.doc Version 5.1 Page 27 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 3 4 Refer to Standard YA1 YA24 YA24 YA26 Good Practice Recommendations The Registered Person should ensure that the information about complaints process/Quality Officer in the Tenant’s Handbook is updated and accurate. The Registered Person should consider employing a gardener to develop and maintain the garden areas. The Registered Person should ensure that the sensory garden is completed. The Manager should carry out risk assessments and provide guidelines on how to determine whether service users are warm/cool enough in their bedrooms. DS0000022718.V291260.R01.S.doc Version 5.1 Page 28 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.V291260.R01.S.doc Version 5.1 Page 29 - 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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