Inspection on 09/01/07 for Athol House, London Cheshire Home

This inspection was carried out on 9th January 2007.

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

Athol House, London Cheshire Home 09/11/07

Athol House, London Cheshire Home 03/11/05

Athol House, London Cheshire Home 26/04/05

Athol House, London Cheshire Home 18/01/05

Athol House, London Cheshire Home 02/08/04

Athol House, London Cheshire Home 17/03/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Athol House, London Cheshire Home Athol House 138 College Road London SE19 1XE Lead Inspector Sean Healy Unannounced Inspection 9th January 2007 10:00 DS0000007004.V326162.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 DS0000007004.V326162.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. DS0000007004.V326162.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Athol House, London Cheshire Home Address Athol House 138 College Road London SE19 1XE 020 8670 9279 020 8761 7830 a.hardy.lk@lc-uk.org 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) Athol House, London Cheshire Home Miss Allison Jayne Hardy Care Home 21 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0) of places DS0000007004.V326162.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: As at last inspection, due to the size and environmental limitations of the building the organisation has decided to reprovide the service. The timescale for reprovision is unclear, the organisation currently prioritising the reprovision of other London based services. Athol House is a care home providing personal care and accommodation for 21 people with a physical disability. The building is leased; the service set up and managed by The Leonard Cheshire Foundation, a voluntary organisation. The home is located on the outskirts of Dulwich and Crystal Palace. Accessible bus routes, train services and shops are close by. The home has its own vehicles and now has more drivers available. The home has a number of wheelchair-adapted vehicles. The home consists of a two-storey building, bedrooms provided over both floors. All the bedrooms are single. There is a passenger lift between floors. The home has a garden to the rear. 20 of the 21 service users are funded by social services and one resident is privately funded, paying the same fees and charges as all other service users. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The most recent CSCI report is currently kept at the home, with a copy open for viewing at the reception area. At 9th January 2007, the homes fees are set at between £917.21 and £1,300 per week for accommodation and support. The majority of these costs are met by the referring social services authorities from Lambeth, Lewisham, Bromley and Waltham Forest. The fees include food laundry, activities and some transport costs. Residents have to pay for other personal expenses such as hairdressing and personal shopping, with a small per mile mileage charge for using the homes transport. The provider’s email address is: a.hardy.lk@lc-uk.org DS0000007004.V326162.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day in January 2007. The inspection was unannounced, and was facilitated by the Registered Manager. The inspector spoke with four service users who were in the home, and examined five service users planning files. Three support staff were spoken to and four staff files were examined to see recruitment and training records. The inspection included examination of records and policies and procedures, and a tour of the building. The inspector found that two of the four requirements made at previous inspections had now been met, and the remaining two were partially met or being addressed. Generally service users said they were very happy at this home. The atmosphere was relaxed and friendly and staff involved service users and spoke with them regularly. They also said that the food was good and they feel safe in the home. There were comments made by them, which suggested that they should be more involved in developing their care plans. What the service does well: What has improved since the last inspection? The homes manager has been registered with the Commission for Social Care and inspection, and is knowledgeable about the standard of care that needs to be provided to service users. Transport at the home has improved, and there are now three wheelchair accessible buses available for service users to use with an increased number of drivers also now available. DS0000007004.V326162.R01.S.doc Version 5.2 Page 6 Service users who were concerned about some damage being done by wheelchairs have been listened to and the home has employed a part time Physiotherapist to make sure that the service users and the fabric of the home is best protected. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000007004.V326162.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000007004.V326162.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users individual needs have not been fully assessed, which may result in their needs not being met. Some information regarding charges and what is included needs to be updated in service users contracts/statements of terms and conditions. EVIDENCE: Five service users’ files were inspected. The referring agencies always provide written assessments for publicly funded service users. Some assessments are also carried out by the Registered Manager or Care Co-ordinator, assisted by the Team Leader in the home. There is evidence of good assessments addressing a full range of service users’ support needs and these assessments include HALO assessment and a separate behavioural assessment. However, for some privately funded service users a complete assessment system was not applied and as they are privately funded there were no social services assessments as is to be expected. The home must ensure that all service users including those privately funded have a full assessment of needs in place before admission. (Refer to requirement YA2.) All service users have a contract in place between the provider and the resident. These documents show the service to be expected with some reference to the cost for individual service users, and also states who pays the DS0000007004.V326162.R01.S.doc Version 5.2 Page 9 fees. However, the contracts do not include a complete breakdown of hours of support to be provided and do not sufficiently explain why some service users’ fees are up to £400 per week higher than other service users. The home must ensure that this information and explanation is included in service users’ contracts. (Refer to requirement YA5.) DS0000007004.V326162.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessed and changing needs are not fully reflected in all care plans, and risk assessments are not adequate and need to be updated. Service users are helped to make decisions about their own lives. EVIDENCE: The home has a good system for care planning which is linked to individual residents needs assessments. Care plans are being initially set up with each service user identifying objectives and review dates. The provider has introduced a new system for care planning which staff are getting to grips with. However, this system does not provide for showing whether objectives or goals have been met. This makes it difficult to review progress when carrying out reviews. Notes are kept in daily records regarding when activities happen. However, it is extremely difficult to use these notes as a reference when carrying out reviews. DS0000007004.V326162.R01.S.doc Version 5.2 Page 11 Not all care plans show that service users have been involved as they have not signed the care plans and there is no clear indication as to whether they were at the planning meeting. There are weekly plans in place showing activities for individual service users but these are not dated and there is not enough information about routine activities such as outings, going to church or going to local amenities. The personal care plans are included in the care planning system but there is no evidence of six-monthly reviews happening for all service users. There is a key worker system in place and each key worker is responsible for planning activities for their residents. When activities don’t happen for whatever reason these are not closely monitored by a senior person or the manager. Overall, care plans are adequate but there is a lot of work needed to make improvements to ensure consistent planning and implementation for each service user. Personal care plans need improvement to ensure that they are more specific regarding how to support individuals during personal care in bathrooms, and also in other activities such as cooking, shopping and mobility. (Refer to requirements YA6.) Service users communicate well with staff who include them in day to day decision making. A number of advocacy services are used for decision making when needed. The home is looking for more involvement from advocacy services for one resident whose advocacy needs are greater. The home provides information in the home’s service users’ guide about how to get advocacy support. The home manages finances and benefits including bank accounts for five residents who are their own appointees and signatories. Two residents have Court Protection Orders and their finances are managed by social services or solicitors. All of the remaining 14 residents either manage their own benefits and finances or have their family do so on their behalf. Small amounts of money, £50, are held by the home at the request of these residents and good records and receipts are kept. Service users’ files show that risk assessments are being carried out for each service user on admission, and that these are detailed and provide for safeguarding services users from harm. However, these are not being reviewed on a six-monthly basis and in some cases risk assessments do not show when they were last reviewed. The home must ensure risk assessments are reviewed at least every six months and are dated. (Refer to requirement YA9.) DS0000007004.V326162.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities for personal development, and are able to take part in age/peer and culturally appropriate activities. They are part of their local community, and are supported to have relationships. Service users rights are respected, and good meals are provided. EVIDENCE: Two service users have started an employment course at Southwark Cathedral run by Circles Network. Both received good support from staff and got help in some cases from a volunteer in reading, writing and computer skills. Care plans include supporting service users to continue their education and where appropriate to find jobs. There was a requirement at the previous inspection for the home to ensure that better arrangements are made for service users to access transport flexibly when they need it. This is now met. Staff support service users to DS0000007004.V326162.R01.S.doc Version 5.2 Page 13 participate in their local community. There are now three wheelchair accessible vehicles to support service users to go out which is important given the location of the house. Information about activities is available in care plans and on an activities’ notice board. The manager has been introducing some new activities such as a silk printing course and visits to Kent and North London with a community group. Two residents have started going to an exercise group and exercise activities are provided in the home. Family are encouraged to visit service users and there are no restrictions on visiting times. In emergencies overnight stays can be facilities for close family members. Some service users have maintained close personal relationships with partners and have been supported by the home to do this. Staff were observed to be very respectful of service users and spoke to them in a manner which put them at their ease All service users have a key to their bedrooms and a special key system for activating the front door of the building is in place. Service users are given their own mail to open and staff only open their mail when requested by the service user. Two service users said that staff are very friendly and “do what we want”. Each resident has a nutritional assessment which is used to devise the menu for the home. Personal food preferences are included in this information. There is a chef employed by the home who cooks all of the meals and receives information from care plans about individual service user dietary requirements. All residents are offered two choices of meals each day and three service users said that the food was good and they were able to eat what they wanted. The home has conducted surveys with service users about the food provided and the outcome of one survey resulted in a new chef being appointed. DS0000007004.V326162.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care support for service users is not always provided in the way that they prefer or in accordance with assessed needs. Respectful and sensitive support is provided for service users regarding and health care and emotional needs. Service users are not fully supported to retain administration of their medication. EVIDENCE: There was a requirement at the previous inspection for the home to ensure that an occupational therapist was involved in carrying out assessments about service users’ access within the home. This was done and a physiotherapist has been employed by the home two days a week. There was a concern raised by one service user regarding damage to a wall in her room caused by wheelchairs. This was investigated and appropriate action was taken. Examination of five service users’ files showed that there is generally a need to include more detail in the service users’ personal care support plans. These care plans should be more prescriptive for staff in how to provide the support in order to maintain service users’ individual level of independence. Some DS0000007004.V326162.R01.S.doc Version 5.2 Page 15 assessments showed that service users needed high levels of staff support during personal care, but personal care plans did not describe how this would be provided. This could potentially result in either too much or too little support, resulting in either higher risk or service users independence being affected. Two service users said that staff are very helpful in helping them in the bathrooms but that they would “like to be able to do some more for themselves”. They also said that they were not sure what was in their care plans about how they were to be supported. (Refer to requirement YA18.) All residents are registered with a GP service locally at Paxton Green Health Centre and have a GP health care assessment on their file. Professional support is provided by district nurses, a continence advisor and a diabetes nurse. All service users receive professional dental care and all are registered with the London Eye Clinic. Other professionals are accessed through the community health team at Townley Road. The home provides well for the health care support needs of service users. The home has an adequate medication policy and the majority of residents are on prescribed medication. The Boots’ blister pack system is used for all service users. One resident is self-medicating, and there is a locked cabinet in her room for the storage of medication. The home does not currently have independent pharmacy audits although there is a high level of medication administered. The home has entered into discussions with Boots Pharmacy who are investigating what can be done to address this situation. Some service users are on controlled drugs and good records of administration are being kept in a separate book. Only shift leaders administer medication, although all the staff have had training in the administration of medication. Currently the home does not assess service users’ ability or wishes regarding self medication on admission and this must be addressed by the home to ensure that they are routinely assessed. (Refer to requirement YA2 in this report.) DS0000007004.V326162.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do feel that they are listened to when they have any concerns. The homes written policy on Adult Protection does not adequately provide for the protection of service users. EVIDENCE: The home has a policy in place for the management of complaints which was last reviewed in 2004. The next review is scheduled for 2007. The policy shows that complaints will be responded to within 21 days and there is a good system in place for showing complaints received, the date they were responded and when they were resolved. There is a regional complaints coordinator that gets information from the home about complaints in order to monitor the system. Information is provided to the regional director. The regional manager sends a quarterly summary to the regional director to help the organisation to monitor levels and trends of complaints. There have been two complaints since the previous inspection; one concerning the use of a lap strap by a service user for their wheelchair and another from a service user concerning the attitude of a member of staff. Both were responded to quickly and action was taken by management to investigate and act on the findings. It was not felt that either of these complaints were upheld, though action was taken to improve the service provided. The home has an adult protection policy that was last reviewed on the 17 August 2001, and re-issued in April 2004. There have been no allegations or referrals under this policy since the previous inspection. The manager and DS0000007004.V326162.R01.S.doc Version 5.2 Page 17 staff showed good awareness of the requirements of this policy. However, the policy does not include information regarding POVA, although staff are made aware during their induction. This policy needs to be reviewed to fully inform all those concerned about the implications of POVA. (Refer to requirement YA23.) DS0000007004.V326162.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs some physical changes made to ensure that it is homely and comfortable. It is a safe clean and hygienic place to live. EVIDENCE: There was a requirement made at the last inspection that the home must ensure that a plan of action, including consultation with service users, is drawn up to ensure that the home accommodates a maximum of 20 people, with no more than 10 people sharing a staff group, a dining area and other common facilities. The registered provider had initiated discussion with service users in 2005, and explained that Athol House is part of an organisational development plan, which would result in a service user consultation process in 2006, regarding re-provision. The service users are being regularly updated at monthly service user forum meetings, about progress in this area. The registered provider has experienced difficulty in finding alternative accommodation in the area, and is continuing to search for possible alternatives. Given the importance of this issue for service users, it is a DS0000007004.V326162.R01.S.doc Version 5.2 Page 19 continuing requirement that the provider maintain consultation with service users, about options available for re-provision, or refurbishment of the existing premises, with the involvement of appropriate family members and advocacy. This is an ongoing requirement, which is being met by the provider, and a timescale of the first of April remains by which time the provider should give service users a written update of developments to date. (Refer to requirement YA24 and YA39.) There were also comments on the last inspection report regarding wheelchair accessibility as follows: “The new manager has made plans to make the building more accessible, ordering a new ramp to the rear entrance so that service users go into the office more easily and independently”. This has now been done and the ramp is in place providing better access for service users. The manager is in discussion with the provider and with the landlord, Dulwich College, regarding future development of the home, including some changes to the internal structure. One of the main issues is that the dining room area accommodates a maximum of 16 residents which does not cater for all of the service users and the staff needed to support them, at any one time. Until agreement is reached with the landlord, proposed developments to improve the environment cannot go ahead. There was a recommendation a the previous inspection that the walls and especially the corners of walls are protected from impact by wheelchairs. This has been assessed by the occupational therapist and a decision was reached that any protection plates would look unsightly and instead the home ensures that areas damaged are quickly repaired and decorated. This seemed a sensible approach and the recommendation is withdrawn. All bedrooms within the home are single occupancy with only one bedroom provided with en suite facilities. Twenty-one residents share two bathrooms and two shower rooms on each floor. The home is fully wheelchair accessible and is reasonably well maintained. The home is clean, hygienic and well maintained. Due to the continence support needs of some residents there is a separate sluice room for dealing with continence laundry. This is reasonably well maintained and free from odour. The home has a range of policies and procedures in place for the prevention of infection and safe handling of clinical waste. DS0000007004.V326162.R01.S.doc Version 5.2 Page 20 DS0000007004.V326162.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32. 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff, who are properly trained to carry out their duties. Service users are protected by the homes recruitment policy and practices. EVIDENCE: The home employs a total of 20 care staff to provide support for up to 21 service users. There are also separate house-keeping staff such as two cleaners, two laundry staff, one maintenance worker, to provide maintenance services for the home. Cooking is contracted to an outside chef who provides the service on site in the home. There were 3.5 staff vacancies, which shows a reasonable level of staff in post. Of the 21 service users 13 are male while eight are female. These are supported by 17 female and three male support staff. As part of the homes service users satisfaction survey, male and female service users have been asked about their views and preferences. When the results of this survey are published, it is recommended that the provider make plans to address any DS0000007004.V326162.R01.S.doc Version 5.2 Page 22 expressed need for change in how same sex personal care is provided, and also consider this issue in the recruitment process. (Refer to recommendation YA32.) Sixteen care staff have completed NVQ level 2 or 3, with two more soon to complete qualification. This is a high level of NVQ qualified staff. Five staff files were inspected and were seen to have a training plan in place for each member of staff, including pressure care, epilepsy, dealing with bereavement and loss, visual and sighted awareness and a range of statutory required training. Staff are experienced and a number of service users said that they are good listeners and “help us whenever we need it”. The home has a recruitment policy and receives support from the organisation’s human resources department in recruitment and selection of staff. There are always two managers and one service user involved in conducting interviews and a list of set questions are used to ensure fairness at interview. There are good records kept showing that CRB checks, IDs, references, health care checks are being carried out prior to employment. There is a three month probation period for all new staff involving at least three supervisions, a methodical induction programme and shadowing other more experienced staff. The registered provider has a training department which helps the home set up and carry out a training programme for staff. Each staff member has a training plan in place which was seen on their files and these plans include between six and ten days training annually. Training plans seen were of a good standard and three staff confirmed that they attend this training. DS0000007004.V326162.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a manager who receives good support from the registered provider. Service users views are included in the homes system for quality assurance and planning. The Health and safety of service users and staff are promoted by the home and registered provider. EVIDENCE: The registered manager is qualified to NVQ level 4 in care management and also has a post graduate diploma in management. She also previously worked as a manager of a resource service for a ten year period. She is registered with CSCI and the registration certificate displayed is accurate. The manager is fully involved with staff recruitment, supervision and training. The registered provider has developed an organisational self-assessment quality assurance system. This is completed annually by the registered DS0000007004.V326162.R01.S.doc Version 5.2 Page 24 manager and a full audit is carried out by an external quality assurance team every three years. The regional director carries out comprehensive monthly management visits and these show that action is being taken to address any short comings. This system gives good support and direction for the manager who confirmed that she received good support from management. Service users have a monthly residents’ forum which the home’s manager attends, for sharing information and minutes of these meetings are kept and displayed for service users. Separate service user’s satisfaction surveys are being conducted. There is a development plan in place for the organisation and a specific one for this home. This plan covers the period 2006 to 2008 and the recent service user survey report, which is about to be published, shows clearly a range of areas for development as a result of service users identifying areas for improvement. Health and safety within the home is well managed and all documentation was found to be in order and up-to-date. The home has an adequate health and safety policy, which includes risk assessment, fire safety, food hygiene, moving and handling, and all of these are included in the staff induction and training programme. Fire equipment checks are being done on a weekly basis and the home has certificates for electrical and gas appliances which are up to date. Kitchen and bathroom areas are maintained to a high level of cleanliness and safety. DS0000007004.V326162.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X X 3 X DS0000007004.V326162.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement The Registered Provider and Manager must ensure that all service users including those privately funded have a full assessment of need in place prior to admission. They must also ensure any current service users who do not have a full assessment are provided with one. The Registered Provider and Manager must ensure that must ensure that service users’ contracts / statements of terms and conditions include a description of the support hours to be provided and the reasons for increased levels of fees as described in this report. The Registered Person must ensure that agreements in key work sessions are used to update Service User Plans, and that these include goals to meet the communication needs of service users, including their confidence and ability to use the skills they already have. This was a requirement from the previous inspection, DS0000007004.V326162.R01.S.doc Timescale for action 30/04/07 2 YA5 5 30/04/07 3 YA6 15 30/04/07 Version 5.2 Page 27 4 YA6 YA18 15 5 YA9 13.4 6 YA23 19 7 YA24 YA39 12(1)(a) 23 timescale 28/02/06; partially met. Timescale revised. The Registered Provider and Manager must ensure that all service users’ personal care plans are reviewed and include more detailed information regarding how to support individual service users in all personal care activities. The Registered Provider and Manager must ensure that the home’s risk assessments are reviewed at least every six months and are dated. The Registered Provider and Manager must ensure that the home’s adult protection policy is reviewed to include details of the implications and requirements of POVA. The Registered Person must ensure that a clear plan of action including service user consultation is drawn up, so that the home accommodates a maximum of twenty people with no more than ten people sharing a staff group, a dining area and other common facilities by 01/04/07 (Still within timescale – partially met and ongoing) 31/07/07 31/07/07 30/04/07 01/04/07 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 YA32 Good Practice Recommendations It is recommended that the Registered Provider consider means of addressing any service users expressed need for same sex personal care resulting from the current service user satisfaction survey, and if appropriate consider the employment of more male staff. DS0000007004.V326162.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent 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 DS0000007004.V326162.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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