Inspection on 08/01/08 for Anvil Close

This inspection was carried out on 8th January 2008.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Anvil Close 24/09/09

Anvil Close 17/07/06

Anvil Close 19/10/05

Anvil Close 11/11/04

Anvil Close 09/06/04

Anvil Close 10/11/03

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 Anvil Close 21-24 Anvil Close Nr Eastwood Street Streatham London SW16 6YA Lead Inspector Davina McLaverty Unannounced Inspection 8th January 2008 10:00 Anvil Close DS0000010164.V355100.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 Anvil Close DS0000010164.V355100.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. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anvil Close Address 21-24 Anvil Close Nr Eastwood Street Streatham London SW16 6YA 020 8677 4714 020 8677 8713 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) www.macintyrecharity.org MacIntyre Care Mrs Edith Uche Aganoke Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home can admit one named service user over the age of 65 years of age. 17th July 2006 Date of last inspection Brief Description of the Service: Anvil Close is a home for twelve adults with learning disabilities, some of whom also have a physical disability. The property is purpose built and has been fully adapted for use by service users with wheelchairs. The home is on two floors and is divided into four flats, each with their own kitchen/dining room, lounge, toilet and bathroom, adapted shower room and sensory room. All bedrooms are single occupancy, with four bedrooms having ensuite facilities. Shared facilities include the lift, laundry room and a large garden. The home is situated at the end of a cul-de-sac in a quite part of Streatham, but is within easy reach of local shops, community facilities, bus and rail links. Parking is available. Further information concerning the service can be found on the organisations website at www.macintyre-care.org. At the time of this inspection the manager of the home reported that the fees per year range from £54,000 - £60,000. Additional charges are made for some outings and holidays. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service included an unannounced visit to the home on 8th January 2008, by one regulation inspector, and an ‘expert by experience’. The expert by experience, is a person who because of their knowledge of services visits a home with the inspection team to help us get a picture of what it is like to live in the service. The manager was available for discussions about the service. We also spoke to some staff and residents. The manager and staff were welcoming and helpful throughout the inspection and the inspection team wishes to thank residents and staff for their help. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety documentation. We also looked at the premises. Prior to this inspection taking place the Manager completed an Annual Quality Assurance Assessment (AQQA) and evidence from this was used to help form some of the judgements in this report. We also sent fifteen surveys to the home prior to the visit for staff to complete, of which six were returned. Twelve questionnaires were sent to the home for them to distribute on behalf of CSCI to relatives of which three were returned. All twelve questionnaires sent to the home for residents were returned however, all residents had been supported by staff to complete them. Feedback from the surveys, both staff and residents at the time of inspection was positive about life in the home. One visiting relative was also spoken to during the inspection. What the service does well: The management approach ensures that the service is run in the best interest of the people who reside there and that they are supported in developing independence skills. Staff have a good awareness of people’s needs and are committed to providing a person centred service. Individuals where able, are encouraged to participate in activities of their choosing. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Assessments are completed before people move into the home, in order to make sure that their individual needs can be met. Visits to the home are encouraged and readily facilitated. EVIDENCE: There is a comprehensive assessment procedure in place, which includes several visits to the home for the prospective person and their representative. Examination of the newest resident to the home evidenced that a gradual introduction had taken place to ensure that the person’s needs could be met, as well as providing the person and their advocate the opportunity to decide that Anvil Close was the right home for them. Sufficient information was seen on file regarding the assessment of the persons care and support needs, including reports from various professionals involved with the person. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 9 Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Good care plans and Person Centred plans are in place and staff work with individuals to identify goals that are important to them. People are encouraged to make decisions and take risks. Risk assessments were in place. EVIDENCE: The organisation is currently looking at its documentation to see how it can be improved upon and new documents are being introduced, which aims to seek the views of residents. Documents seen on files included, “listen to me workbook” and “listen to me booklet”. In discussion with the manager, she reported that these documents are to try to improve the quality of care by key workers asking direct questions from residents (where able), regarding life in the home detailing what they are happy about, and what they would like to change. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 11 These documents are supplementary to the care plans, which details support needs, communication, health and medication, money, keeping safe, activities, family contact. There is also a Person Centred plans in place, which supplements the care plan and includes goals and aspirations. These varied, depending on the residents communication needs, e.g. one seen was pictorial with minimal text. Three files were examined and all contained a lot of information regarding the person’s needs. Consideration should however, be given to reducing the volume of paperwork on the files and ensuring that what is available is current. Risk assessments are in place and include appropriate responses to minimise risks without denying the person the activity they wish to participate in. Risk assessments were dated and signed by the individual, their key worker and other people involved in the decision-making. People spoken with clearly are involved in making decisions about how they live their lives. This is carried out through individual chats with staff and through the monthly meetings. Where residents are not able to verbalise what they want, staff will advocate on their behalf, although family members are encouraged to support and be directly involved in their relative care if they wish. One visiting relative spoken with said, she was very happy with her son being at Anvil close, as she knows he is well cared for and is happy there. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who live at the home are given lots of opportunities to take part in a range of activities at the home and in the community. People are supported to stay in contact with friends. Individuals rights are respected in their daily lives be they cultural or religious. Routines in the home are flexible. Residents enjoy the food provided by the home and where able, are involved in planning the menu. EVIDENCE: On the day of the inspection, individuals were carrying on with their daily lives at their own pace and with the support of staff on duty. Individuals were in and out of the home participating in activities of their choice. One person spoken with said that they chose not to go to their day service, as they did not feel like it. Another was seen to be supported by a staff member to access the Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 13 community. Another resident spoken to said that they were happy being at the home and just wanted to stay home today. As stated earlier, residents receive good support to access a range of opportunities. Some residents use local resources centres and colleges, whilst others choose not to use formal day care services. Some residents travel independently and use public transport to access the community. Some residents make use of the local shops, cafes and restaurants. Evidence was seen in residents’ files and from discussion with staff. The home arranges regular trips to places of interest and individual/ small group activities are encouraged. Some residents receive support from Odyssey’s Community Access Team (CAT). The ‘expert by experience’ spoke to two residents and one said he went to his club a lot, but chooses not to go as much now. This person also said that they helped in the garden and also goes out to eat with friends sometimes. The resident went on to say that they could have friends in their room if they wanted to, but chose not to. They also said that if they wanted time on their own they could go to their room if they wished. The ‘expert’ asked a resident if there was anything he would like to do, but was not doing now? The resident said that there was no more that they wanted to do. Another resident told the ‘expert’ that they liked to take things apart and was actively engaging in this activity. One resident told the ‘expert’ that they attended a local church and that residents meeting are held every Tuesday when they can discuss how they feel. Staff were observed to interact appropriately with residents and the ‘expert’ by experience observed a member of staff kneel down to a resident in a chair to speak to him. The member of staff was able to communicate with the resident and feedback his answers to the ‘expert’. Several residents have regular contact with their families. Where relatives live some distance away and if the person wants contact them, the home will support residents to visit. One resident visits their family independently. Another receives regular visits in the home and goes home most weekends; whereas another receives family visits from their father at their day centre. Relationships are encouraged and one resident spoke of his girlfriend, whom the home was supporting him to see, as she was unwell and therefore not able to attend the day service where they usually spent the day together. The ‘expert by experience’ was informed by a staff member that four residents each had their personal telephone line in their rooms and were able to make calls to their family and friends when they choose. Other residents were able to use the hands free telephone if they wished, at any time. All residents were able to make and take calls. Interaction between staff and residents was positive during the inspection. Staff were seen to use appropriate forms of address when speaking to residents. Resident’s needs and rights and responsibilities are recognised in their daily live. Staff in the home have received training in the Mental Capacity Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 14 Act and the home is due to start looking at decision making of individuals where capacity may be an issue. Residents said that they enjoyed the food provided at the home and that they can ask for dishes to be included on the menu. They also said that they can have alternatives to the menu if they wish. Residents who are able, can help themselves to snacks and drinks when they wish and are encouraged by staff to participate in the preparation of some meals. Staff were seen by the ‘expert’ cooking dinner on the ground floor for the residents who returned from day centre. A member of staff was also observed making a cup of tea /coffee with a resident. The fridges in all four units were observed by the ‘expert’ to be fully stocked and fruit was seen in all units. One staff member informed the expert that they labelled food items and would throw away food that is out of date. However, the ‘expert’ observed a staff member giving a resident biscuits from a locked cupboard on the first floor. The resident was observed to take biscuits and gave some to another resident. The cupboard was then locked. It was not clear why the cupboard was locked. Residents should have access to biscuits. If they can’t, the reason should be recorded in their care plans. One resident informed the ‘expert’ that they had a choice when they have something to eat. Anvil Close DS0000010164.V355100.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 & 20 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home supports residents to maintain good health, Any changes in residents’ needs are effectively identified and addressed. Residents medication is appropriately stored and is usually appropriately recorded. EVIDENCE: Staff were observed to treat people in the home with respect. People are able to make choices about how they prefer to live and receive support for example, on how they have their rooms and what time to get up and go to bed. The staff team reflects the cultural background of people who live there. The ‘expert by experience’ was informed by a resident that they were able to have a shower when they chose, and that if they could not wash themselves, then they was able to have a member of staff help them if they wished. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 16 All people are registered with a local GP, optician and dentist and are supported as required to attend appointments. One resident informed the ‘expert by experience’ that they had a different Doctor from the other residents but that all residents shared the same dentist. As already stated, the home has input from Wandsworth Community and Assessment team and work very much in partnership with various professionals to best meet the assessed needs of the people living in the home, some of whom have quite complex needs. Reports seen on files provided evidence that the home liaises well with health care professionals when necessary and responds appropriately to any changes in residents’ needs. Guidelines for the delivery of individual care are in place, which staff follow. Some staff have also received training in areas where residents have specific needs e.g. autism, and the manager said that specialist training is on-going within the home. All staff received training in the administration of medication, although details of training must be more clearly evidenced in staff training and development plans. An appropriate medication policy and procedure is in place. Medication is stored appropriately in a locked cabinet. Administration records showed a couple of gaps in relation to recording prescribed food supplements. Two notifications had regarding medication errors had been sent to the Commission and appropriate action was seen to have been taken by the home when identified. The manager stated that she now includes discussion of medication at staff handover meetings to ensure that any errors are minimised. Anvil Close DS0000010164.V355100.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 & 23 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff are well informed about adult abuse issues, which helps to protect people living in the home. Staff listens to resident’s views. EVIDENCE: The home has an appropriate complaints procedure and whistle –blowing policy, which enables staff to report any concerns they have about poor practices. Two complaints had been made since the last inspection and both were seen to have been appropriately addressed. Two residents said that they knew who to speak to if they were unhappy about something at the home and feel confident about raising concerns with staff. The expert observed that in each unit there was a complaint procedure printed in picture text in large letters. There were suitable policies and procedures in place for the protection of vulnerable adults. A copy of the Local Authorities inter-agencies procedures was available in the home. Staff spoken to were knowledgeable of the procedure. Team meeting minutes demonstrated that the manager used this forum to remind staff of their responsibilities regarding the protection of vulnerable adults and of the availability of the whistle blowing procedure. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27,28, & 30 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home presents as homely for residents. However, a more robust system must be put in place to ensure that repairs are carried out more quickly. EVIDENCE: The premises blend into the local housing and have good access to local community facilities, and public transport. The home is divided into four self-contained units each with their own lounge, kitchen and bathroom facilities. Three residents reside in each unit. The ‘expert’ raised a number of premises issues, firstly they were concerned at the lighting throughout the home, which they felt was poor. They found that some Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 19 areas of the home had no lights on and in one area on the top floor, they were unable to find a light switch. In discussion with the manager she reported that energy efficient bulbs were used and this may be a contributory factor, which can be reviewed. The ‘expert’ also noted that on the top floor in one of the units there was a broken doorbell hanging off the wall. They also observed that in all four units the cooker hobs had no guards to prevent residents touching while in use. The inspection team observed kitchen cabinets with doors broken and/or removed. Whilst this had been reported, the delay was for repair seemed excessive. Brooms and buckets should be placed in store cupboard. The expert’ also noticed that there were no pictures on doors telling residents what is behind the doors apart from the number. The inspector raised this issue with the manager, who said that the home did not want photos on doors of residents unless it was the residents choice, but that the home could look again at signage within each unit as some bathrooms had signs on and others did not. On the day of the inspection, the inspector was informed that the home had problems with the heating, which had been on - going well before Christmas. Residents had been given portable heating to ensure their well-being, but this issue still was not resolved despite active input from the manager. The ‘expert’ also observed that there was no fire escape from the main entrance in and out of the unit. This concerned the expert asking if there was a fire in front of this main entrance door, how would the residents and staff exit safely? This was raised with the manager who confirmed that a fire risk assessment was in place, fire equipment and systems are regularly checked, also residents who reside upstairs, know that in the event of a fire by the staircase that they are to remain behind the fire doors until the fire brigade gets to the home. There is a shared laundry room on the ground floor with industrial machines, which is used by staff for soiled linen. Washing machines are located in the kitchens in all four units and residents, where able, are supported to do their own laundry. All four units are quite different, reflecting residents needs. All four units were found to be homely in appearance and in the inspector’s opinion took account of resident’s individual needs. Communal areas in all four units were seen to be clean with no offensive smells. The inspector saw three bedrooms, two of which were highly personalised and reflected individual tastes and preferences. One resident chooses to spend most of their time in their bedroom, which is his choice. Staff reported that the person valued their privacy and their own space. One resident told the expert that they had chosen the colour of their room. Bathroom facilities seen contained appropriate hoists and specialised baths to meet residents needs. However, several staff stated that the repair of equipment took quite a while and impacted on the delivery of care e.g. the rail Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 20 hoist from two of the residents bedrooms was not working and staff had to use a free standing hoist to bath residents. The expert also observed that there were no signs of handrails in any of the bathrooms. A lift is available to allow residents from the ground floor, who may have mobility needs, to go upstairs for parties. Anvil Close DS0000010164.V355100.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): 32,33,34,35 & 36 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There are usually enough staff to meet residents’ needs, but permanent staff need to be recruited to ensure consistency of care in the long term. An appropriate recruitment and selection procedure is in place. Staff have access to training appropriate to their roles and receive good supervision and support. EVIDENCE: The home operates with two staff upstairs and four downstairs. The manager stated that in her view staffing levels were adequate, although at times shifts can be busy, but staff were aware of the importance of team working and will support where they can. Staff described the manager as “hands on” as when staffing has been an issue e.g. when there is sickness and during holiday periods the manager has stepped in. Relief staff are used, but at times, shifts have operated below their minimum levels. The manager stated that the organisation has found it difficult to recruit permanent staff. Even when they do, staff do not always stay due, she feels, to the needs of the residents, in particular on the ground floor, where residents are all totally depended on staff Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 22 for their total care. The manager stated that following the recent recruitment drive, three permanent staff and two relief had been recruited. She is hopeful that they take up their positions once all the checks are in. All prospective staff visited the home and meet the residents, in particular those on the ground floor prior to or after interview. Staff have explained to them the needs of the residents, so that they are fully aware when accepting the position, what the job will entail. The manager hopes that this recruitment drive, and the appointments will provide a degree of stability for the home and for the residents. Staff on duty said that they worked well as a team and spoke positively about their work at the home. Staff also said that they have individual supervision regularly and access to training appropriate to their roles. Staff meetings take place monthly and notes seen of these meetings demonstrated that they are used effectively to address important issues within the service, such as changes in residents needs and awareness of the organisation’s policies and procedures. The expert observed relationships between the staff and residents to be very friendly. Staff was seen to be available at all times throughout our visit and would be seen taking and interacting with residents. The manager who showed us around was very nice and knew the residents very well. Staff records for the most recently recruited staff was seen and the inspector saw that the organisation carries out appropriate pre-employment checks, including references and Criminal Bureau disclosures. However, the manager should complete the checklist form confirming that all checks have been carried out. The manager was in the process of updating all staff “mandatory” training and records were available to evidence this. As stated, staff spoken to and from the questionnaires received, were all positive about training. There is an organisational staff appraisal system in place. Anvil Close DS0000010164.V355100.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 and 42 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home has an experienced and committed manager. A quality assurance system is in place but should be collated with the homes findings and improvement plan. Systems are in place to ensure the health and safety of residents and staff. EVIDENCE: The manager has been in post over four years, is committed and has NVQ level 4. All staff spoke positively of her management style, stating that she was Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 24 “very thorough”, “approachable”, and “hands on” with “high standards, who leads by example”. There is a commitment to running the home in the residents ‘best interests’ and to seeking their views about how the home is run. Residents meetings are held in the upstairs unit. These meetings are used to seek residents’ views regarding activities \outings and to raise any concerns that residents may have. Monthly regulation 26 visits are taking place, with copies of the reports being sent to the Commission. A quality assurance system is in place, which seeks the views of residents, relatives and other stakeholders. Questionnaires are sent out annually, collated and acted upon. However, the home must consider formally analysing and writing a report on the collation of the questionnaires that is available to stakeholders and relatives. The manager stated that the organisation have introduced “the big respect”, which also forms part of the quality assurance system. The Big Respect involves a senior staff member from the organisations head office spending a day in the home, talking to residents and staff regarding the operation of the home. A copy of this visit was seen, which was carried out March 07. Records showed that staff make regular checks on the building and equipment in the home and that the health, safety and welfare of residents are promoted and protected Sample records seen included the fire system, fridge and freezer temperature, fire drills and testing of the alarms, lift servicing records, annual gas record as well as the 5 year electrical test. All records seen were in order. Anvil Close DS0000010164.V355100.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 X 2 X 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 2 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 26 NO 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 2 Standard YA9 YA39 Regulation 13(3) (4) 24 (2) Requirement Risk assessments must include electric hobs in the units. The quality assurance system in place must be evaluated and a written report produced which evidence the action taken. The home must put in place a system that leads a clear audit trail as regards referring and following up of repairs. The home must ensure that there is appropriate storage of mops and buckets within the home. Timescale for action 28/02/08 30/08/08 3. YA42 13(4) 28/02/08 4 YA42 13(4) 28/02/08 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 YA24 YA29 Good Practice Recommendations A review of the lighting system within the home should take place. The manager should consider having the bathroom areas assessed by an occupational therapist to ensure that appropriate support aids are in place. DS0000010164.V355100.R01.S.doc Version 5.2 Page 27 Anvil Close 3 YA34 The home should complete their staff checklist to clearly evidence that all the required checks have been carried out. Anvil Close DS0000010164.V355100.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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