Inspection on 07/03/08 for Aspinden Wood Centre

This inspection was carried out on 7th March 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aspinden Wood Centre 27/10/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Aspinden Wood Centre 1, Aspinden Wood Road London SE16 2DR Lead Inspector David Halliwell Key Unannounced Inspection 7th March 2008 09:30 Aspinden Wood Centre DS0000007058.V358189.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.V358189.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.V358189.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.V358189.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 23rd June 2006 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 and pretty 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.V358189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means people use this service experience adequate quality outcomes. This was an unannounced inspection visit that took place over 1 day and was undertaken by the Inspector responsible for Aspinden Wood. The Inspection covered all the key standards and involved a tour of the premises, a review of the homes records and formal interviews with 2 staff and the Manager and a number of the residents. Informal interviews were conducted with other residents as a part of the inspection of the home. 9 requirements were made as a result of this inspection and 5 good practice recommendations. 2 of these requirements are repeat requirements and enforcement action may be taken if the new timescales are not met. This inspection found a good deal of very positive work has been done by both the Manager and the staff group to meet the problems / issues that were identified in the 12 requirements and 4 recommendations that were made at the last inspection. Since then new procedures and processes have been drawn up and are now in the process of being implemented. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. What the service does well: What has improved since the last inspection? There has been positive progress identified in a number of areas at Aspinden Wood. These are discussed in this report, they are in summary: 1. The care planning process has been developed to include individual support plans including activities, aims and objectives. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 6 2. Risk assessments have been undertaken for each of the residents and staff have received training in this process and in the care planning process. 3. Complaints are better recorded and investigated. 4. Light cords in the bathrooms and toilets have been replaced. 5. Hot water temperatures are now regularly recorded and come within the acceptable ranges. 6. Provision of food has been greatly improved and there is now a permanent Chef in place. 7. The Manager told the Inspector that all COSSH legislation has been reviewed and new practices established. This was borne out in the inspection process so residents should now be better protected. What they could do better: Specific areas identified in this inspection report are as follows: 1. The Manager must ensure that the service user guide is updated to 2008 and reviewed and maintained annually. 2. 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. 3. Medication records / MAR sheets must be signed by staff authorised to administer medication, after residents have been given their medication and reasons provided if residents refuse or are not present to take their medication. Enforcement action will be taken if the new timescale for this requirement is not met. 2 previous requirements have not been met. 4. The Manager must now ensure that more effective external training from a recognised provider is provided to staff around the policies and procedures for this unit to do with the safe handling of medications. All staff who administers medication must receive this training. 5. The Manager must ensure that clear guidance for each resident is made available with the MAR sheet records where PRN medication is being used. 6. The Manager must ensure that the unit’s complaints policy be updated. 7. The Manager must 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. 8. An inventory for resident’s valuable belongings should be 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 and is therefore strongly recommended. 9. The shower room on the first floor needs some tiles to be replaced as they are loose and the ingress of water could present a health hazard to residents. 10. All staff files should include certificated evidence for all training undertaken by staff. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 7 11. Documentary evidence must be gathered for all the staff members as described under Standard 34 and be held on the staff files for review and inspection. 12. The Manager must ensure that there are accurate, up to date and comprehensive staff training records. 13. The Manager should apply to the Commission for Social Care Inspection for registration as the Manager at Aspinden Wood. 14. The registered person must ensure that there is a quality monitoring system that is analysed and reported on annually. 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.V358189.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.V358189.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. People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Prospective residents do not have up to date information that they need to make a decision about living at Aspinden Wood. However their needs are being assessed and their aspirations are taken into account in the assessment process. EVIDENCE: Standard 1 – At the last inspection a recommendation 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. A service user guide was produced however it stated it had been updated in June 2004. People living in the home were unaware of the guide. This means that people who are using or who may wish to use these services provided at Aspinden Wood may not have the information that they need to be fully informed about these services. It is a requirement therefore that the Manager ensure the guide is updated to 2008 and reviewed and maintained annually. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 10 Standard 2 – Over the course of the inspection the Inspector spoke to residents and staff and inspected 3 of the 24 resident’s files. He found 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 staff’s own assessment of the persons needs. The assessment 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 resident’s 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.V358189.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, 8 and 9. People who use this 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 Aspinden Wood should know that the home has a good care planning system in place that reflects their needs and personal goals. Residents are assisted to make decisions about their lives as they are able. Residents are also supported to take risks as part of their independent lifestyle. EVIDENCE: Standard 6 – 3 different residents files were inspected at this inspection and on each was found an up to date care plan. The Manager told the Inspector that every resident’s care plan is reviewed monthly and the care plan objectives updated accordingly. This was borne out by those files inspected. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 12 Generally the resident’s files were in good order and the information was set out in logical sections that made finding the information easier. The 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. However at the last inspection it was clear to the Inspector from speaking to staff that although they were knowledgeable about resident’ wishes and needs it was not reflected in the documentation. The Inspector discussed with the Manager how this important element of the care planning process still needs to be included. It was agreed 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. The Manager agreed to include this information in the care plans for all residents in future, this is a new requirement. Some improvement was seen in the support/care plans that do now detail more fully in more areas what support is needed. Resident’s files for the 2 most recent admissions to Aspinden Wood were inspected and their files both contained an up to date care plan. Care plans were seen to be more detailed and outlined resident’s 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. Residents should be provided with a copy of their care plans within their service user guides. 2 previous requirements made at the last inspection have now been met. The Manager explained to the Inspector that recent training has been provided for all staff on care planning and risk assessment 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 the Inspector 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 the most recent meetings. The Inspector was provided with the resident’ meetings minutes book and this showed that these meetings were minuted and held regularly with the residents. Residents also told the Inspector that they find these meetings helpful as it provides a good arena for discussion, decisions can be made that are generally implemented as a result. All of this Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 13 enables residents to make decisions about their lives with assistance as needed. Standard 8 – At the last inspection a requirement was made that the Manager must ensure that residents’ care plans include statements of how each individual service user will be offered opportunities to be involved in the activities of the day to day running of the home, and that there are adequate monitoring and recording systems in place to demonstrate that these opportunities are being offered, taken up or refused. The Manager explained that all activities are now recorded in the care plans and activity plans were seen on each of the resident’s files inspected. This requirement has therefore now been met. Standard 9 – At the last inspection concerns were raised by the Inspector that there were no risk assessments on residents’ files. This meant that people’s 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 the Inspector that as part of the care planning system risk assessments are now undertaken by the staff. The Manager also explained to the Inspector that in February 2008 training was been provided for all staff on care planning and on undertaking risk assessments for residents. The Inspector was told by the 3 staff who were interviewed that they had attended this training. Examination of 2 of the resident’s files showed that risk assessments were in place and that they cover a wide scope of a resident’s 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. At this inspection it was clear that there is much challenging behaviour amongst the residents and so these risk assessments are very important for the protection of residents and staff alike. Risk assessments and action strategies help to minimise risk for service users and staff. Aspinden Wood Centre DS0000007058.V358189.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, 16 & 17. People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Residents are more likely to be able to take part in appropriate activities within the unit. They will be supported in maintaining and developing appropriate relationships and that their rights and responsibilities will be respected in their daily lives. Residents are also assured that they will be offered a healthy, varied and nutritious diet. EVIDENCE: Standard 12 – At the last inspection concerns were raised by the Inspector to do with the range and scope of activities being offered to and being taken up by the residents at Aspinden Wood. At this inspection the Manager explained a number of activities now being offered to residents as part of their individual activity programmes. It was also explained how residents have the opportunity to express their wishes and preferences about different activities Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 15 through the care planning and key working process, as well as via the regular resident’s meetings that are held every 2 weeks. Another member of staff also explained in detail many of the activities being provided at Aspinden Wood and how that an individual activities programme has been drawn up for each of the residents in connection with their care plan objectives as well as what residents have said they want to do. Examples were described to the Inspector to do with the last two year’s holiday choices. Last year residents chose to go to Blackpool for their summer holidays and this year they have decided to go to Ireland. The Manager explained that support staff will go with residents and that residents have asked if they could be helped to make links with some of their family members who they have not seen for a long time but who are living in Ireland. Records seen by the Inspector evidence this statement and discussions both with staff and the residents also confirmed this. This means that residents at the home are taking part in a range of social activities that they have chosen or have been asked about. Residents were reticent to discuss social events in the home and what they enjoyed doing during the day however the impression gained by the Inspector was that residents at Aspinden Wood are able to take part in appropriate activities. A previous requirement has now been met. Standard 13 – The Manager explained to the Inspector that neighbours and other local services have a positive regard for the residents and what they are trying to achieve. Those residents who do go out of the home and who were interviewed by the Inspector said that they get out and about to go shopping or to see their friends and sometimes their families. 3 members of staff confirmed this in discussions they had with the Inspector and some residents said that they do go to church and make use of day centre provision in the local area. The Manager informed the Inspector that all residents are registered to vote and are encouraged to use their votes. Service users and members of staff confirmed with the Inspector that they 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 service users and their visitors. However visitors can come after those hours and stay overnight, after consultation with staff. The Inspector was 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 the Inspector was asked to sign the record on the days of the inspection. Residents were seen to be a part of the local community. Standard 16 - Policies seen by the Inspector to be established within the home ensure that resident’s rights to privacy, respect and dignity are respected. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 16 Residents who were interviewed confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. The staff induction process was reviewed by the Inspector and was seen to include the core standards of recognising and meeting the resident’s rights to: • Privacy • Dignity • Independence • Rights • Fulfilment • And choice. These core standards are also included in the Unit’s Statement of Purpose. There is a specific area allocated to smokers. Residents spoken to told the Inspector that they liked living at the home and could choose what they wanted to do during the day. Members of staff interviewed by the Inspector also said that residents are able and do choose what they want to do during the day and that respecting resident’s rights is paramount. From observation during the day, residents were seen making choices about where they spent their time. Interaction between residents and staff was seen and heard to be friendly and respectful. Standard 17 – The Manager explained to the Inspector that since the last inspection the home now has a new chef who has worked to bring in a new menu and consultation process with the residents that they seem to be happy with. All meals are provided for the residents at Aspinden Wood, breakfast, lunch and dinner. As part of the Inspection the Inspector met the Chef who said that there is a 4 week rolling menu in place. The menu sheets were seen by the Inspector and the Chef explained that she regularly meets with the residents both individually and at the residents meetings to ascertain their likes and dislikes in terms of food. The Chef has drawn up a profile for each of the residents that includes this information as well as any specific dietary requirements that they may have. Members of staff spoken to by the Inspector confirmed that residents do choose what they want to eat and what is placed on their menus. Staff explained that residents are good at choosing healthy and nutritious options on their menus but that staff will help residents by providing information on healthy and nutritious food if they are asked to do so by the residents. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 17 Residents spoken to by the Inspector were much more positive about the food than at the last inspection. It was observed that mealtimes are flexible and allow for residents to go out of the home and come back to have a late lunch. Food menus shown to the Inspector were varied, choices are provided and the Manager and the Chef both told the Inspector that resident’s assist in the drafting of the food menus. No complaints about the meals arose during the inspection in fact all those residents interviewed said that like the food provided at Aspinden Wood. It was noted that a wide range of meals were listed which cater for the multicultural needs and wishes of the residents. The Inspector 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 but not as a general rule. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 18 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. People who use this service receive adequate quality in this outcome 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 that they prefer and require and that their physical and emotional needs will be met. Service users cannot rely on the home providing a well-managed service with regards to medication. EVIDENCE: Standard 18 – The Manager explained to the Inspector that residents can choose when they get up each morning. The residents 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 Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 19 raise any concerns with the Inspector about their key workers in fact their comments 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 the Inspector 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 the Inspector 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 resident’s own decision but staff will encourage residents to use this service if required. Residents who spoke with the Inspector said that they go to see their GPs as and when necessary. Standard 20 - The Manager told the Inspector that all the permanent staff administer medication to the residents and that staff have recently received training to do with the safe handling of medicines. Staff when interviewed said that they had received medication training and had found it helpful. The Manager informed the Inspector that none of the residents self-administer their medication. An inspection of the medication records MAR sheets was undertaken together with the Manager. Several unexplained gaps for a number of residents were found where staff signatures were missing or where reasons why the medication was not taken or had not been received had not been written down. The Inspector asked the Manager about this and she explained that residents may not have been present in the home to take their medication. The Inspector explained that whatever the circumstances some explanation must always be recorded on the MAR sheets. It is therefore a requirement that medication records / MAR sheets are signed by staff authorised to administer medication, after residents have been given their medication and that reasons be provided if residents refuse or are not present to take their medication. Enforcement action will be taken if the new timescale for this requirement is not met. 2 previous requirements have not been met. The Manager must ensure that there are no gaps in these records in future so that the individual residents’ pattern of medication administration is known and is accurate. Where residents refuse to get up in the mornings to take their medication staff should discuss this problem with the prescribing doctor in order to find a satisfactory solution. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 20 The Manager told the Inspector that all staff had recently received training to do with medication, however this has clearly been unsuccessful. The Manager must now ensure that more effective external training from a recognised provider is provided to staff around the policies and procedures for this unit to do with the safe handling of medications. All staff who administer medication must receive this training. This is a requirement. As part of this inspection a check on the stock of medication held in the home was carried out and records kept were inspected. In a number of cases medication records did not match the actual stock held. On closer investigation the reason for this seemed to be that medications had probably been given out but because of the MAR sheet gaps this was not recorded and so a disparity exists between the records and the actual stock levels. This will be addresses when MAR sheet records are properly maintained. An appropriate medication cabinet was seen in the office bolted to the wall. Some residents receive PRN medication and it is recommended now that the Manager ensures clear guidance for each resident is made available with the MAR sheet records where PRN medication is being used. This information should be readily accessible for staff and residents alike when PRN medication is needed. The guidance should set out clear individual information. It could include when or when not to take the PRN medication, what the potential side effects are and this should be done in conjunction with the resident’s GP. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 21 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. People who use this service receive good quality in this outcome area. 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 – At the last inspection a requirement was made for all complaints to be recorded and investigated. The Manager informed the Inspector that since the last inspection a new record is now being kept of any complaints received by the unit. This record was inspected showing that there were 2 complaints made in 2007 and 1 in 2008. These complaints were recorded appropriately and investigated according to the home’s policy and procedure. This means that residents can now feel that their views are being listened to and acted upon appropriately. It is recommended that the unit’s complaints policy be updated. Contact details should include those for the Commission for Social Care Inspection. Standard 23 – The Manager advised the Inspector that the policy for the Protection of Vulnerable Adults is in place and is aligned with the London Borough of Southwark’s own procedure. She said that most of the staff team have been provided with training and guidance about what actions they need to take if the need arises. On inspection of 3 of the staffing files there was evidence that 2 of the 3 staff members had attended POVA training. It is Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 22 important that all Aspinden Wood’s 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. The Inspector saw the policy in the Unit’s 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 the Inspector that no allegations of abuse had been made at the home since the last inspection. The Inspector asked the Manager whether there is a process in place to help staff understand the policies and procedures of the home. The Manager explained that while understanding the policies and procedures is a part of the staff induction process, staff are not asked to sign to say that they have read and understood the policies and procedures. It is required therefore that a new process is implemented that assists staff to know and understand the home’s key policies and procedures including the Whistleblowing policy and procedure. 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. The Inspector 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 and is therefore strongly recommended. The Manager told the Inspector that this has not been done hitherto but will be implemented straight away. Evidence will need to be seen at the next inspection that this has been carried out. Inventories should be signed and dated by the residents concerned in agreement to the contents. This should add to the measures already in place to ensure the protection of the resident’s property. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 23 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 - People who use this service receive good quality in this outcome area. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents do live in safe and comfortable surroundings and said that they are happy living in this environment. Residents may be assured that the home is clean and hygienic. EVIDENCE: Standard 24 – Together with the Manager, the Inspector reviewed all areas of the home to assess the quality of the environment and décor. Generally the home was found to be clean and hygienic. The shower room on the first floor needs some tiles to be replaced as they are loose and the ingress of water could present a health hazard to residents. The Manager explained this would be reported to the landlords, Hexagon Housing for repairs to be carried out. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 24 5 resident’s bedrooms were inspected with the permission of those residents. They all told the Inspector 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. The last environmental health officers’ report dated 25th April 2007 was also seen by the Inspector. The Manager explained that this made 1 requirement – implementation in the kitchen of a critical control point hazard analysis. The Manager said that this has subsequently been met and the Inspector saw evidence of this being in place when discussing matters with the Chef. The Manager showed the Inspector evidence that the electrical wiring safety check was carried out successfully in January 2005 and this is understood to be valid for 5 years. The Inspector asked to see the records for checks on water temperatures and the Manager provided the homes records for this. They revealed that these tests have been carried out each week as is required. Tests carried out all indicated that the hot water temperatures were within the prescribed limits. Maintenance certificates were seen for the following areas that confirmed they have been serviced and passed as satisfactory by professional expert contractors: • Fire alarm – February 2008 • Emergency lighting – February 2008 • Fire extinguishers – February 2008 The Manager told the Inspector that the fire alarm points are tested weekly and the Inspector was shown records that confirmed this. The records indicated that the last test was carried out on 25th February 2008. These measures all help to ensure that the residents live in a safe environment. Standard 30 – The Manager showed the Inspector the home’s infection control procedure, which seems to be working effectively. This means that the residents live in a clean and hygienic home. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 25 The laundry area is well laid out and there is an impermeable floor laid down to prevent water ingress and easy cleaning. Laundry is not taken through areas where food is prepared. The home has appropriate sluicing facilities and these were seen by the Inspector to be appropriate. At the last inspection a requirement was made for all the lighting cords to be replaced. Inspection of the premises at this inspection confirmed this has been carried out as required. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 26 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. People who use this service receive adequate quality in this outcome area. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents benefit from clarity of staff roles and responsibilities but they cannot be fully assured that they are supported by a competent and qualified staff team given the problems with staff training. Recruitment procedures need to be improved so as to help protect residents and ensure that they are supported appropriately. Improvements in staff supervision should mean that residents can be more assured that they will benefit from well-supported and supervised staff. EVIDENCE: Standard 32 – The Manager showed the Inspector staffing records and 3 staffing files were inspected, having been chosen at random. The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. Evidence of this was seen by the Inspector on staff files and from discussions with staff interviewed. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 27 The Manager told the Inspector that all staff hold an NVQ qualification or equivalent although 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. In addition to this the majority of the staff have attended training in fire awareness and medication training as well as POVA training in 2006. 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 insufficient 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. Standard 34 – The home has recruitment polices and procedures in place. Three staff files were checked at random. Very little of the required documentation was seen to be held on these staff files. The Manager explained that this is because the main HR function is carried out at head office. However the Inspector explained that under Standard 34 of the National Minimum Standards it is a requirement that documentary evidence be gathered for all the staff members in the following areas and be held on the staff files for review and inspection. This will help to ensure that recruitment practices meet the required standards. The specific information needed was identified with the Manager and is as follows: 1. An application form that contains health and work histories, 2. 2 written references, 3. Evidence of satisfactory enhanced CRB checks, 4. Induction, 5. Confirmation of the staff member’s identity, 6. Certificated evidence of qualifications and training, 7. Supervision and appraisal notes, 8. An employment contract. It is suggested that the Manager use a file checklist system that may help to address any delays that may occur and to ensure documents are available for inspection. Since 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. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 28 Standard 35 – At this inspection concerns were raised with 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. A list of training that staff have received over the period 2006 – 2008 was provided for the Inspector. This showed that not all staff have attended the core training necessary. Shortfalls relate to: • First aid (only 3 staff attended a course in 2006 with no certificated evidence seen) • Dual diagnosis – alcohol misuse and mental health • Fire safety (3 staff attended in 2008 and 1 in 2006) • POVA (3 staff attended in 2006). Lack of attention to this part of the staff training can affect competency at the home”. As well as NVQ training, essential training for staff should include: • Safe handling of medications • Fire safety • Manual Handling • Health and safety • Managing aggression • Communication • POVA • 1st Aid • Infection control • Food hygiene. 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 receive more training than the records alone demonstrate, so it is important that staffing records for training received are clear, up to date and inclusive. The Manager informed the Inspector that a structured induction programme is offered to new staff however documentary evidence of this was not available to be seen by the Inspector. Staff at interview 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. It is suggested that the Manager either draw up training files for each member of staff or a single training file 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. 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. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 29 Standard 36 – 3 staff files were inspected in relation to staff supervision and good records were seen to show that this takes place on a regular basis. 3 staff interviewed said that their supervision happens every 4 - 6 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: • Keywork with residents • Training needs • Personal issues. They told the Inspector 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 therefore benefit from wellsupported and supervised staff. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 30 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. People who use this service receive adequate quality in this outcome area. 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 told the Inspector that she has since the last inspection completed and gained her NVQ 4 in management, although no certificated evidence was made available for inspection. The process of inspection showed that she is competent to run the home however she is not yet registered with the Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection. This is a requirement and must be addressed immediately. There is an experienced and enthusiastic deputy at Aspinden Wood who the Manager said is near to completing her NVQ level 4 and Registered Managers award. Standard 39 – The Manager told the Inspector that at present there is no specific quality assurance tool / process in place at Aspinden Wood that monitors all it’s service areas and this was reflected at the last inspection where a requirement was made that has still not been met. The Manager said that Equinox has a generic quality assurance process that provides feedback to Aspinden Wood and the Manager on certain areas and that developmental targets are set in the Agencies Business Plan 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 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. • 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 a quality assurance system is 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.V358189.R01.S.doc Version 5.2 Page 32 Standard 42 – The Inspector was 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 by the Inspector for: Boiler & Gas – 20th April 2007 Fire alarms – 25th February 2008 Fire equipment – 25th February 2008 The electrical installation test – 31st January 2005 Lift – 20th February 2008 Pull cord alarms – 25th November 2007 Legionnaires water tests – November 2003. Records were seen by the Inspector that confirmed regular tests had been carried out for the: Fire alarm - weekly 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 – a previous requirement has now been met. The Manager told the Inspector that all COSSH legislation has been reviewed and new practices established. This was borne out in the inspection process so residents should now be better protected. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 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 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 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 2 X 2 X 2 X X 3 X Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 34 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 YA1 Regulation 5 Requirement Timescale for action 01/04/08 2. YA6 15.1 3. YA20 13.2 4. YA20 13.2 The Manager must ensure that the service user guide is updated to 2008 and reviewed and maintained annually. The care planning format needs 01/04/08 to be developed to include a section where residents are able to record their comments on each care plan objective. Medication records / MAR sheets 01/04/08 must be signed by staff authorised to administer medication, after residents have been given their medication and reasons provided if residents refuse or are not present to take their medication. Enforcement action will be taken if the new timescale for this requirement is not met. 2 previous requirements have not been met. The Manager must now ensure 01/04/08 that more effective external training from a recognised provider is provided to staff around the policies and procedures for this unit to do with the safe handling of medications. All staff who DS0000007058.V358189.R01.S.doc Version 5.2 Aspinden Wood Centre Page 35 5. 6. YA32 YA34 7. YA35 8. YA37 9. YA39 administer medication must receive this training. 18 All staff files should include certificated evidence for all training undertaken by staff. 19 Documentary evidence must be gathered for all the staff members as described under Standard 34 and be held on the staff files for review and inspection. 18 The Manager must ensure that there are accurate, up to date and comprehensive staff training records. 8 The Manager should apply to the Commission for Social Care Inspection for registration as the Manager at Aspinden Wood. 24(1)(a)(b) The registered person must ensure that there is a quality monitoring system that is analysed and reported on annually. 01/04/08 01/04/08 01/04/08 01/04/08 01/06/08 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. 3. Refer to Standard YA22 YA23 YA23 Good Practice Recommendations The Manager must ensure that the unit’s complaints policy must be updated. The Manager must 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. An inventory for residents valuable belongings should be 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 and is therefore strongly recommended. The shower room on the first floor needs some tiles to be replaced as they are loose and the ingress of water could DS0000007058.V358189.R01.S.doc Version 5.2 Page 36 4. YA23 Aspinden Wood Centre 5. YA20 present a health hazard to residents. The Manager should ensure that clear guidance for each resident is made available with the MAR sheet records where PRN medication is being used. Aspinden Wood Centre DS0000007058.V358189.R01.S.doc Version 5.2 Page 37 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.V358189.R01.S.doc Version 5.2 Page 38 - 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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