Inspection on 27/10/08 for Aspinden Wood Centre

This inspection was carried out on 27th October 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aspinden Wood Centre 07/03/08

Aspinden Wood Centre 23/06/06

Aspinden Wood Centre 08/12/05

Aspinden Wood Centre 21/06/05

Aspinden Wood Centre 25/01/05

Aspinden Wood Centre 13/07/04

Aspinden Wood Centre 25/03/04

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOME ADULTS 18-65 Aspinden Wood Centre 1, Aspinden Wood Road London SE16 2DR Lead Inspector David Halliwell Unannounced Inspection 27th October 2008 09:30 Aspinden Wood Centre DS0000007058.V373145.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 Aspinden Wood Centre DS0000007058.V373145.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. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspinden Wood Centre Address 1, Aspinden Wood Road London SE16 2DR 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) 0207 237 0331 jennipher@awc.equinoxcare.org.uk Equinox None Care Home 24 Category(ies) of Past or present alcohol dependence (16), Past or registration, with number present alcohol dependence over 65 years of of places age (8) Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. eight of the service users may be over 65 years of age Date of last inspection 11th February 2008 Brief Description of the Service: Aspinden Wood Centre is a care home providing accommodation and personal care to 24 people with past or present alcohol dependence. The home is part of Equinox Care, a voluntary organisation. The home is a detached, two-storey building with off street parking at the front, and a small, well maintained garden at the back. It is in Bermondsey, South London, close to local shops, social and leisure facilities, and public transport links. All service users have single rooms with sinks, and there are ample communal spaces including a dry and a wet lounge, a service users kitchen and a large pleasant dining room and conservatory. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The stars quality rating for this service is adequate. This means that people who use these services experience adequate quality outcomes. They said that they like to be called residents. A completed AQAA was received prior to the inspection. No enforcement activity has occurred since the last inspection. This was an unannounced inspection visit and was carried out over 1 day. The Inspection covered all the key standards in the National Minimum Standards for Younger Adults. The inspection involved a tour of the home, a review of all the homes records and formal interviews with 2 staff and the Manager. 4 residents were spoken with formally and more informal interviews were conducted with 2 other residents as a part of the tour of the home. 4 staff and 4 residents files were inspected as was the policies and procedures manual for the home. 8 requirements including 4 repeat requirements have been made as a result of this inspection and 7 new recommendations have also been made. Feedback on the requirements and recommendations was given verbally to the Manager at the end of the inspection visit. The residents and staff were very helpful and they are to be thanked for their assistance over the course of this inspection visit. The agencies Registration Certificate with the Commission for Social Care Inspection was seen displayed appropriately in the hall just outside the main office. There have not been any changes in the ownership or management of Aspinden Wood since the last inspection. What the service does well: The home strives to provide good quality care for a group of service users with multiple and complex needs. There is accessible information on the service and thorough assessments before people come to the home, to ensure their needs can be met. The home is comfortable and homely and support is offered by a stable, enthusiastic staff group. Service users are able to live as they wish, with all necessary support and encouragement where needed, to modify harmful behaviour. Their health care is monitored and systems are in place to protect them from abuse or neglect. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Manager must ensure that new residents files are drawn up that contain in logical sections, current information relating to the resident concerned. This should assist people to find information easier. The care planning format needs to be developed to include a section where residents are able to record their comments and wishes to do with each care plan objective. The requirement is a repeat requirement, enforcement action may be taken if this is not met with the new timescale. All residents meetings should be minuted, kept up to date and with copies held on file. The Manager must ensure that training to do with the safe handling of medications is certificated with copies held on staffing files. Staff have not yet been asked to sign to say that they have read and understood the policies and procedures. The requirement is therefore repeated, enforcement action may be taken if this requirement is not met within the new timescale. It is important and therefore strongly recommended that the Complaints Policy contains all of the relevant and necessary information and is readily available to the people who live at Aspinden Wood, their relatives and other visitors. The Manager should ensure that any staff who have not done so enrol on POVA training in the near future. Certificated evidence will be required to be seen. The Manager must ensure that all staff receive infection control training. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 7 The Manager must ensure that all staff files should include certificated evidence for all training undertaken by staff. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. It is required that Equinox and the Manager at Aspinden Wood provide the information required under this Standard 34 so that the residents are seen to be being supported and protected by the homes recruitment policy and practices. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. The Manager should ensure that all members of the staff team have received a basic level of training in the areas already identified. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. The Manager should ensure that a detailed record of induction training is made available that indicates how the induction programme is structured, what was covered in it, when it was carried out or that it had been completed to the satisfaction of the Manager and the person receiving this training. It was recommended to the Manager that a new staff training matrix would be helpful as a management tool that identifies future staff training needs and that logs training already undertaken by staff. It is a requirement that is now repeated here that a quality assurance system be put in place at Aspinden Wood that enables a level of self-audit and monitoring that may inform improvements and development targets for the home. This should enable the key stakeholders to be confident that their views underpin all self-monitoring, review and development at Aspinden Wood. Enforcement action may be taken if this is not addressed within the timescale provided. Fire alarm tests should be carried out weekly; records seen showed that this was last completed on 7.7.08. The Manager needs to ensure these tests are carried out as required to ensure the safety of both staff and residents alike. 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. Aspinden Wood Centre DS0000007058.V373145.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 Aspinden Wood Centre DS0000007058.V373145.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): Standards 1 & 2 were inspected at this inspection. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective service users may be assured that their needs are assessed and that their individual aspirations. EVIDENCE: Standard 1 - At the last inspection a requirement was made that the service user guide be kept up to date with information about the service. The Manager explained to the Inspector that some work has been done on updating the guide but no evidence of this was seen. At this inspection the Manager told us that the service user guide has now been updated and a copy of the new guide was provided. The information in this guide is sufficiently comprehensive enough for people who are using or who may wish to use the services provided at Aspinden Wood have the information that they need to be fully informed about these services. The previous requirement has therefore now been met. Standard 2 - Over the course of the inspection we spoke to 4 residents and 4 staff and inspected 4 of the residents files. On each file an assessment of needs had been carried out by the home. These assessments have been based on information supplied by the referring professionals, usually care managers, and by the staffs own assessment of the persons needs. The assessment Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 10 format includes the assessment of social care needs, health, personal care, mobility, practical needs, communication and dietary needs. This should help ensure that all a persons needs are assessed and addressed in the care plans. The assessment tool provides a useful way of ensuring all of the residents or prospective residents needs are taken into account at the assessment stage. Inspection of the files showed that each resident has a care plan. Both the needs assessments and the care plans are signed by the residents in agreement to the contents of these plans. Aspinden Wood Centre DS0000007058.V373145.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): Standards 6, 7, & 9 were inspected at this inspection. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents may be assured that their assessed needs and personal goals will be reflected in their care plans. They may also be assured that they will be able to make decisions about their daily lives and be enabled to take risks as part of developing a more independent lifestyle with support, as they need it. EVIDENCE: Standard 6 - 4 of the residents files were inspected at this inspection and on each file except for one we found an up to date care plan. The Manager told us that every residents care plan is reviewed monthly and that the care plan objectives are updated accordingly. This was borne out by those 4 files inspected. Generally the residents files were not in good order. The information was not set out in chronological order and although there were file sections, Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 12 information had not been filed into the correct sections. A good deal of information currently held on the residents files should be archived. It is strongly recommended therefore that the Manager ensures new files are drawn up that contain in logical sections, current information relating to the resident concerned. This should assist people to find information easier. Care plans were seen to give a good level of information on the individual and objectives were in place with regard to the care input planned. There was some evidence of resident involvement in the care planning process as the care plans were signed off by the residents. At the last inspection it was required that the care planning format needs to be developed to include a section where residents are able to record their comments and wishes to do with each care plan objective. No evidence was available at this inspection that demonstrates that the views and wishes of the residents’ particular to each care plan objective has been taken into account in the process. The requirement has not been met and is therefore repeated here. One residents file for the most recent admission to Aspinden Wood was inspected and the file contained an up to date care plan and was signed off by the resident. Care plans were seen to be more detailed and outlined residents social, mental health, physical needs and objectives. Records showed that these are generally kept under review. A care plan/goal monitoring form is in place and these were seen to contain valuable and objective information. This means that residents know that their assessed and changing needs are better reflected in their care plans. Standard 7 - Inspection of the records in the care planning system evidenced that residents are able to make decisions regarding their lives. This was seen to include, for example, choices on how they spend their time and if they wish to be alone. The Manager told us that residents have regular meetings every 2 weeks where a variety of issues relating to life within the home are discussed. Menu planning and holidays are amongst the topics discussed at these recent meetings. The Manager provided some of the resident’s meetings minutes. This showed that these meetings had been held and were minuted up to 30.6.08 but not beyond this date. The Manager assured us that the meetings had been held but the minutes had not been minuted. It is recommended that all meetings are minuted with copies held on file. Residents told us that they find these meetings helpful as it provides a good arena for discussion where decisions can be made that are generally implemented as a result. One resident said, We regularly discuss the menus and our preferences are taken into account by the Chef when the menus are Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 13 put together. Another resident told us, Theres much better food here now, it was awful before we had this cook. She listens to us. All of this enables residents to make decisions about their lives with assistance as needed. Standard 9 - At the last inspection concerns were raised by us that there were no risk assessments on residents files. This meant that peoples individual areas of risk, in terms of sensory impairment or schizophrenia, were not being looked at nor were strategies devised to minimise risk. At this inspection the Manager told us that as part of the care planning system risk assessments are now undertaken by the staff. The Manager also explained to us that in February 2008 training was provided for all staff on care planning and on undertaking risk assessments for residents. Examination of the residents files showed that risk assessments were in place and that they cover a wide scope of a residents life. It is clear that residents are more able to undertake community and home activities that contain a level of risk and that may help them achieve greater levels of independence. Management systems were seen to be in place that would reduce the risk. Community risk assessments were seen to be in place and were appropriate for the individual residents. Any restrictions were explained in detail and reviews were evident. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 15, 16 & 17 were inspected at this inspection. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users may be assured that they will be able to take part in appropriate activities, some of which will be based in the local community. That they will be supported to maintain appropriate personal relationships with family and friends; and that their rights will be respected and their responsibilities recognised in helping them to construct an appropriate programme of activities in their daily lives. Residents were seen to be offered a healthy, nutritious and varied diet according to their needs. EVIDENCE: Standard 12 - The Manager told us that staff at Aspinden Wood do place a strong emphasis on community presence and encouraging the involvement of the residents. Records and observation showed that residents are offered some Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 15 choices of activities and are supported to engage in their preferred interests and hobbies. Residents are provided with daily activity plans that are flexible so that daily programmes can alter if residents wish to do something different. Staff who were interviewed told us how they actively support residents doing the activities both that they choose and that relates to their care plans. One member of staff told us, I look at the residents support plan, their daily schedule and I ask the residents what activities they wish to do. Another member of staff said, a lot of activities are arranged for the residents according to their needs, however some activities are not always taken up by some residents. We were told that this year 4 of the residents went on a holiday to Cornwall. One resident who we asked said, I loved the holiday in Cornwall, it was good to get away from here. Another said, I went to Cornwall this summer, staff were helpful. Residents do seem to be able to take part on appropriate activities and are supported appropriately by staff. Standard 13 - The Annual Quality Assurance self Assessment for Aspinden Wood says, We encourage and support service users to integrate, access facilities and services that enables them to feel part of the community by involving them in all community and cultural events. The Manager informed us that all residents are registered to vote and are encouraged to use their votes. Residents and members of staff confirmed to us that the residents are supported and enabled to vote. There are restricted visiting times 9am - 9pm and the Manager said that this was because of disruption in the evening from residents and their visitors. However visitors can come after those hours and stay overnight, after consultation with staff. We were told that friends and families are encouraged by the Manager and staff to attend the home. A record of visitors is kept in the main hall and we were asked to sign the record on the days of the inspection. Standard 15 - The Manager told us that residents do keep in regular contact with their families and friends. Staff encourage the residents to keep and maintain contacts with family and friends so that they do benefit from having appropriate relationships. Standard 16 - Policies seen by us to be established within the unit ensure that residents rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. We observed staff to be interacting with residents in a friendly and respectful manner. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 16 Standard 17 - Food menus shown to us indicate that menus are well balanced, nutritional and cater for the varying cultural and dietary needs of the residents. Menu choices are provided and the Manager told us that the drafting of the food menus is regularly discussed at the residents meetings. Minutes of these meetings support this. The Chef explained that a 4 week rolling programme is used within the home. No complaints about the meals arose during the inspection in fact those residents interviewed said that they like the food provided. One resident said, “I like the food here, another told us, the food is good and we can choose what we want to eat. It was noted that a wide range of meals were listed which cater for the multicultural needs and wishes of the residents. We asked the Manager if a dietician is used to advice on the menu planning in order to ensure that the food provided is always healthy and nutritious. The Manager said that a dietician is used in some cases where there is a specific need and that training is also offered to staff and residents on menu planning. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 17 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): Standards 18, 19, & 20 were inspected at this inspection. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users may be assured that they will receive personal support in the way they prefer and require, they may also be assured that their physical and healthcare needs will be appropriately met. Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Standard 18 - The Manager explained that residents can choose when they get up each morning. The residents we interviewed at this inspection said that they do choose when to go to bed, when to have a bath, what they wish to wear and what activities they do during the day. Residents do not have a choice of their allocated key worker however the Manager said that they have a chance to discuss any issues they may have or which arise subsequent to the allocation of their key workers. Residents did not raise any concerns with us about their key workers in fact their comments Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 18 reflected a positive view of key work support. This means that residents receive personal support in the way they prefer and require. The Manager said that residents at Aspinden Wood continue to receive regular input from their Community Psychiatric Nurses and from other professionals in their clinical teams. Standard 19 - With regards to the health care of the residents the Manager informed us that all residents are supported to keep well through accessing appropriate healthcare support. All residents are signed up with local GP surgeries and some are registered with local dentists. The Manager told us that annual health checks take place at the GP surgeries and residents attend there. The Manager said that whether or not a resident uses the dentist is left up to the residents own decision but staff will encourage residents to use this service if required. Residents who we spoke to said that they go to see their GPs as and when necessary. Standard 20 - The Manager told us that all the permanent staff administers medication to the residents and that staff have received training from Boots the Chemists to do with the safe handling of medicines. Staff when interviewed also said that they had received medication training and had found it helpful. However there was no certificated evidence available to confirm this. The Manager must now ensure that training for staff around the policies and procedures for this unit to do with the safe handling of medications is certificated with copies held on staffing files. This is a requirement. The Manager informed us that none of the residents self-administer their medication. An inspection of the medication records MAR sheets was undertaken together with the Deputy Manager, the requirement made at the last inspection has now been met. Photographs of the residents were attached to most of the MAR sheets, which helps to ensure that staff administers medications to the right resident. We did a spot audit check on the stock control system and this proved satisfactory with the levels of medications being as stated on the control sheets. A check on the storage facilities for the medication was seen to be appropriate. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 19 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): Standards 22 & 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may now be assured that their views are listened and acted on. Also that that they will be protected from abuse within the home. EVIDENCE: Standard 22 - The Manager told us that the complaints procedure has recently been updated so as to ease access to it by all residents. However inspection of the procedure did not support this. The Manager was unable to find the updated copy of the policy and procedure and so it cannot be confirmed that information in the Complaints Policy is up to date and appropriate. It is important and therefore strongly recommended that the Complaints Policy contains all of the relevant and necessary information and is readily available to the people who live at Aspinden Wood, their relatives and other visitors. A log of complaints is being kept in a book that the Manager showed to us. One complaint had been made about the home since the last inspection, this had been dealt with appropriately. Residents interviewed said they are aware of who to go to if they feel unhappy and are provided with the necessary support to air their views or concerns. This means that residents can now feel that their views are being listened to and acted upon appropriately. Standard 23 - The Manager advised us that the policy for the Protection of Vulnerable Adults is in place and is aligned with the London Borough of Southwarks own procedure. She said that most of the staff team have been Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 20 provided with training and guidance about what actions they need to take if the need arises. On inspection of 4 of the staffing files there was evidence that 2 of the 4 staff members had attended POVA training in the last 3 years. The Manager told us that 1 member of staff is to be enrolled on POVA training and another will also need to do the training. It is important that all Aspinden Woods staff team receive this training at least once every 2 or 3 years. It is therefore recommended that the Manager ensure that those staff who have not done so, enrol on POVA training in the near future. Certificated evidence will be required to be seen. This will help ensure that all staff are up to date with the policies and procedures and other issues to do with the protection of vulnerable adults at Aspinden Wood. We saw the policy in the Units policies and procedures file, the procedures are robust for responding to suspicion or evidence of abuse or neglect and they include a whistle blowing procedure for staff. The Manager told us that no allegations of abuse had been made at the home since the last inspection. At the last inspection a requirement was made that a new process is implemented by the Manager that assists staff to know and understand the homes key policies and procedures including the Whistle blowing policy and procedure. It was intended that this should include discussion in supervision sessions of these policies and procedures with staff signing to say that they have read, understood and had a chance to discuss them with their supervisor. We asked the Manager whether this process is now in place. The Manager explained that while understanding the policies and procedures is a part of the staff induction process, staff have not yet been asked to sign to say that they have read and understood the policies and procedures. The requirement is therefore repeated, enforcement action may be taken if this requirement is not met within the new timescale. We asked the Manager whether an inventory for residents valuable belongings is drawn up and maintained and kept up to date by key workers for all residents belongings that are kept in their bedrooms. This is an important method of helping to protect residents and staff. The Manager told us that this has now been carried out. Evidence was seen on each of the 4 residents files inspected. Inventories were signed and dated by the residents concerned in agreement to the contents. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 21 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): Standards 24 & 30 were inspected. People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents at Aspinden Wood live in a homely, comfortable and safe environment. The home is also clean and hygienic. EVIDENCE: Standard 24 - As a part of this inspection we looked at all areas of the home to assess the quality of the environment and décor. Generally the home was found to be clean and hygienic. At the last inspection some repairs were identified as required for the shower room on the first floor. A completely new shower unit has now been fitted that meets the requirement. The Manager explained that Equinox now have a new arrangement with the landlords Hexagon Housing for small repairs to be carried out to the house. Equinox will arrange directly with the appropriate contractors for small repairs and maintenance issues to be carried out, rather than as before going via Hexagon. It is reported that this caused considerable delays in the process and Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 22 the hope now is that where there are maintenance issues and repairs that are non structural they can be remedied more quickly. 5 residents bedrooms were inspected with the permission of those residents. They all told us that they are happy with their rooms and that they like living at Aspinden Wood. This means that residents do live in a homely and comfortable environment. General maintenance throughout the home was seen to be good. The home has a maintenance man who works 4 hours a day. The home has a large rear garden with a patio and this is mainly laid to lawn with a shrub border and some small trees. It is nicely enclosed and affords the residents some privacy. The home was seen to be clean and no odours were noted. Standard 30 -The home has an infection control procedure in place. A review of 4 of the homes staffing files and other training information indicated that only 1 member of these 4 staff have received training to do with infection control in February 2008. It is strongly recommended that the Manager ensures that all staff receives this basic training. This is seen as important so that staff know the required standards and what measures and controls need to be in place to achieve the standards. As has already been stated, at the time of this inspection the home was seen to be clean and tidy, hygienic and free from offensive odours. Systems are in place to ensure that the spread of infection is controlled and minimised. Laundry facilities are sited so that soiled articles are not being carried through the kitchen and hand washing facilities are appropriately provided to ensure staff can use them where appropriate. This helps to ensure the protection of the residents health and to ensure that the home is clean and hygienic. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 23 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): Standards 32, 34, 35 & 36 were inspected. People using this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users may benefit from the clarity of staffing roles and responsibilities. Considerable improvements are required as detailed in this and previous reports before they may be assured that they are supported by a competent, appropriately trained, qualified and supervised group of staff. The homes recruitment policy and procedures do not at present help protect the residents. EVIDENCE: Standard 32 - We inspected a range of the homes staffing records and 4 staffing files were inspected including a recently appointed member of staff, the others having been chosen at random. The Manager told us that all the staff group except for 1 person hold an NVQ qualification or equivalent although as at the last inspection no certificated evidence was available for inspection. The Manager said that some of the care staff have achieved their level 3 NVQs and senior staff their level 4 NVQs. The recently completed AQAA tells us, 80 of staff at Aspinden Wood Centre have accomplished NVQ3. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 24 The manager said she has completed the Registered Managers Award and NVQ level 4 and that the Deputy Manager is working now to complete the Registered Managers Award and NVQ level 4. No certificated evidence was available for inspection. Staff interviewed confirmed with the Inspector that they are completing their NVQ training but no evidence of NVQ training certificates was seen in the office records. It is required that all staff files should include certificated evidence for all training undertaken by staff. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. Standard 34 - The home has recruitment polices and procedures in place. 4 staff files were checked at random. As at the last inspection very little of the required documentation was seen to be held on any of these 4 staff files. Files on the new staff and for those staff members longer in place at Aspinden Wood do not meet the required standards expected under the National Minimum Standards not of the associated regulations. Information that was on file was not logically ordered and the Manager found it very difficult to find any specific information when asked to do so. In the last inspection report the specific information required to be held on file in the homes office was detailed. It was fully explained to the Manager and was also made the subject of a requirement. Again and as at the last inspection evidence of CRB clearances was not held on the staffing files as is required. The Manager was asked to provide information and was able to get an email from the head office of Equinox that provided assurances of satisfactory CRB checks for the staff working at Aspinden Wood. It is required that Equinox and the Manager at Aspinden Wood provide the information required under this Standard 34 so that the residents are seen to be being supported and protected by the homes recruitment policy and practices. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. Standard 35 - As at the last inspection concerns were raised with the Manager to do with staff training. Training records show that there are shortfalls in relation to statutory training and the Manager needs to address this if she is to ensure a competent and appropriately trained staff team able to best meet the needs of the residents at Aspinden Wood. As already indicated in a previous section of this report it is said that most staff have completed their NVQ training although no certificated evidence was available for inspection. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 25 As well as NVQ training, essential training for staff should include the following areas. This inspection revealed that for: Safe handling of medications - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. Fire safety - the Manager said that 3 of the 4 staff members had received this training in May and June 2008 although no certificated evidence was available. Manual Handling - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. Health and safety - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. Managing aggression - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. Communication - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. POVA 1st Aid - evidence on only 1 of the 4 staff files inspected that this has been received since the last inspection. Infection control - evidence on only 1 of the 4 staff files inspected that this has been received since the last inspection. Food hygiene - no evidence on any of the 4 staff files inspected that this has been received since the last inspection. Inspection of staffing records did not evidence that staff have yet received the full level of training referred to above as being necessary. Discussion with the Manager indicated that staff actually do receive more training than the records demonstrate although the evidence does not exist in certificated form. It is therefore required that the Manager ensures that all members of the staff team have received a basic level of training in the areas already identified. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. The Manager informed us that a structured induction programme is offered to new staff however documentary evidence of this was not available to be seen for the new staff member employed since the last inspection. That person did say that they had received induction training and they said that it had been helpful to them to better understand their roles and functions at Aspinden Wood. However no detailed record was available that indicated how the induction programme is structured, what was covered in it, when it was carried out or that it had been completed to the satisfaction of the Manager. This is a requirement. As at the last inspection it is again suggested that the Manager draw up new files for each member of staff that identifies what training that individual has achieved and when; what their training needs are that need to be met and evidence of the training courses attended. It was agreed with the Manager that a new staff training matrix would be helpful as a management tool that identifies future staff training needs and that logs training already undertaken Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 26 by staff. This is a useful tool in that it will easily inform the Manager what training the staff team have received and where the gaps in training exist. This is a recommendation. This is important so that the Manager has an accurate overview of what staff have covered in skills training and where the gaps are so that they may be addressed effectively. Standard 36 - 4 staff files were inspected in relation to staff supervision and records were seen to show that this takes place on a fairly regular basis. 2 staff interviewed said that their supervision happens every 6 - 8 weeks. Staff are asked to sign their supervision records as was evidenced by the inspection of these records and staff confirmed that they find this support very helpful and that they are given a copy of the minutes for their information. Staff spoken to said that the following issues are discussed at their supervision sessions as a standard format: Key work with residents Training needs Personal issues. Staff told us that they felt well supported in the home and felt that the management team were helpful when they had concerns or problems arising in their work. Residents should be able to benefit from well-supported and supervised staff. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 27 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): Standards 37, 39, & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users may be assured that they benefit from a well run home. When a quality assurance system is implemented stakeholders will be able to be confident that their views underpin all developments in the home. They should also be assured that their health, safety and welfare will be promoted. EVIDENCE: Standard 37 - The Manager is an RGN. She has 6 years experience in managing the centre and was a deputy manager for 9 months before that. She said she has achieved her NVQ 4 in management, although as with other training certification, no certificated evidence was made available for inspection. The Manager is not yet registered with the Commission for Social Care Inspection. This is a requirement and must be addressed immediately. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 28 There is an experienced and enthusiastic deputy at Aspinden Wood who the Manager said has now completed her NVQ level 4 and Registered Managers award. Standard 39 - With reference to a quality assurance process at Aspinden Wood we were told, that a survey has recently been started with the residents, that the visitors evaluation forms have been re-introduced and that that the equal opportunities evaluation form as a part of the recruitment process is being looked at. However no completed forms were available nor was any analysis of the information gathered through these processes available to be seen. It would seem therefore that very little progress has been made since the last inspection with developing a specific quality assurance tool / process in place for the Aspinden Wood Centre. A quality assurance process for Aspinden Wood needs to be addressed so that service users and other stakeholders can be confident that their views underpin the self-monitoring and development of this home. Some discussion was again had with the Manager as to what elements could be used to inform the process, some suggestions included were: Questionnaires for residents, relatives and referring professionals seeking their feedback on different aspects of the service. For instance residents might be asked for their views on the environment within the home, the effectiveness of the care support they receive etc. Professionals who have referred people to Aspinden Wood could be asked about the effectiveness of the service in meeting the Care Programme Approach care plan objectives. Relatives and families could also be asked for their views on different elements of the service and how their relative is being served by it. A review of any complaints made over the pperiod could be assessed for any emerging themes or trends. A review of any accidents that have occurred. Issues raised by residents at community meetings. Issues raised by staff at staff meetings. Commission for Social Care Regulatory inspection report feedback. A summary and analysis of the key points arising from the above could then be used to inform an annual development plan for the home. Different areas or themes could be targeted on an annual basis that over a longer period would inform all the key areas of service provision. It is a requirement that is now repeated here that a quality assurance system be put in place at Aspinden Wood that enables a level of self-audit and monitoring that may inform improvements and development targets for the home. This should enable the key stakeholders to be confident that their views underpin all self-monitoring, review and development at Aspinden Wood. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 29 Enforcement action may be taken if this is not addressed within the timescale provided. Standard 42 - We were shown information to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. Up to date and satisfactory pass certificates were seen for: Boiler & Gas - 31.3.08 Fire alarms - 9.9.08 Emergency lights - 9.9.08 Fire equipment - 1.08 The electrical installation test - 31st January 2005 PAT testing - 30.7.08 Lift - 9.9.08 Legionnaires water tests - 10.4.08 Fire alarm tests should be carried out weekly; records seen showed that this was last completed on 7.7.08. The Manager needs to ensure these tests are carried out as required to ensure the safety of both staff and residents alike. Records were seen by us that confirmed regular tests had been carried out for the: Fire extinguishers - weekly Emergency lighting - 6 monthly Fridge and freezer temperatures records were checked and records indicate that they came within the acceptable ranges. Accident records were checked - none had been noted. Hot water temperatures were also checked and records indicated that they also came within the acceptable range. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. A fire risk assessment had been carried out by the Manager on 21st October 2008. Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 30 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 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 2 X 2 X 1 X X 3 X Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 Requirement Timescale for action 28/02/09 2. YA20 13 3. YA23 13 4. YA32 18 The care planning format needs to be developed to include a section where residents are able to record their comments and wishes to do with each care plan objective. The requirement is a repeat requirement; enforcement action may be taken if this is not met with the new timescale. The Manager must ensure that 31/01/09 training to do with the safe handling of medications is certificated with copies held on staffing files. Staff have not yet been asked 23/12/08 to sign to say that they have read and understood the policies and procedures. The requirement is therefore repeated, enforcement action may be taken if this requirement is not met within the new timescale. It is required that the Manager 23/12/08 ensures that all staff files should include certificated evidence for all training undertaken by staff. This is a repeat requirement which if not met within the new DS0000007058.V373145.R01.S.doc Version 5.2 Aspinden Wood Centre Page 32 5. YA34 19 6. YA35 18 7. YA35 18 8. YA39 10 timescale provided in this report, enforcement action may be taken. It is required that Equinox and the Manager at Aspinden Wood provide the information required under this Standard 34 so that the residents are seen to be being supported and protected by the homes recruitment policy and practices. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. It is required that the Manager ensures that all members of the staff team have received a basic level of training in the areas already identified. This is a repeat requirement which if not met within the new timescale provided in this report, enforcement action may be taken. It is required that the Manager ensures that a detailed record of induction training is made available that indicates how the induction programme is structured, what was covered in it, when it was carried out or that it had been completed to the satisfaction of the Manager and the person receiving this training. It is a requirement that is now repeated here that a quality assurance system be put in place at Aspinden Wood that enables a level of self-audit and monitoring that may inform improvements and development targets for the home. This should enable the key stakeholders to be confident that their views underpin all DS0000007058.V373145.R01.S.doc 23/12/08 31/03/09 23/12/08 28/02/09 Aspinden Wood Centre Version 5.2 Page 33 self-monitoring, review and development at Aspinden Wood. Enforcement action may be taken if this is not addressed within the timescale provided. 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 YA6 Good Practice Recommendations The Manager must ensure that new residents files are drawn up that contain in logical sections, current information relating to the resident concerned. This should assist people to find information easier. All residents meetings should be minuted, kept up to date and with copies held on file. It is important and therefore strongly recommended that the Complaints Policy contains all of the relevant and necessary information and is readily available to the people who live at Aspinden Wood, their relatives and other visitors. The Manager should ensure that any staff who have not done so enrol on POVA training in the near future. Certificated evidence will be required to be seen. It is strongly recommended that the Manager ensures that all staff receive infection control training. It was recommended to the Manager that a new staff training matrix would be helpful as a management tool that identifies future staff training needs and that logs training already undertaken by staff. Fire alarm tests should be carried out weekly; records seen showed that this was last completed on 7.7.08. The Manager needs to ensure these tests are carried out as required to ensure the safety of both staff and residents alike. 2. 3. YA7 YA22 4. 5. 6. YA23 YA30 YA35 5. YA43 Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Aspinden Wood Centre DS0000007058.V373145.R01.S.doc Version 5.2 Page 35 - 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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