Inspection on 05/04/07 for Avalon House

This inspection was carried out on 5th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avalon House 24/11/08

Avalon House 28/12/07

Avalon House 27/02/06

Avalon House 17/08/05

Avalon House 09/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Avalon House 114-116 Manor Avenue Brockley London SE4 1TE Lead Inspector Ornella Cavuoto Unannounced Inspection 5th April 2007 11:00 DS0000025605.V335148.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 DS0000025605.V335148.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. DS0000025605.V335148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avalon House Address 114-116 Manor Avenue Brockley London SE4 1TE 0208 6942717 0208 691 5107 ruth@auroraoptions.org.uk 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) Aurora Charity Angela Browne Care Home 12 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places DS0000025605.V335148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 12 persons with a learning disability, one of whom may be a wheelchair user 27th February 2006 Date of last inspection Brief Description of the Service: Avalon House provides a care home to a maximum of twelve women and men with severe learning disabilities, who might also have other support needs. The overall aim is to provide a service driven by the needs, abilities and aspirations of the service users and placing their rights at the forefront. The home declares its core values to be: individual approaches, equal opportunities, inclusion and shared values. Avalon House aims to achieve this by ensuring that the service would be based on a thorough assessment of needs and delivered in collaboration with external agencies. Staff would seek to advance the rights to privacy, dignity, independence, security, civil rights, choice and fulfilment in all aspects of their work and of the environment. The provider, an organisation originally named The Aurora Charity has recently changed its name to ‘Aurora Options’. It also runs other homes. A chief executive and a service manager, to whom all the staff are ultimately accountable, direct the service. The day-to-day running of the home is delegated to a care manager, who leads a team of staff. Accommodation is provided in two converted, adjacent, Victorian houses and is set on four floors. There is a small garden and a multi sensory room. There are 12 single bedrooms. None have en-suite facilities. Provision has been made for one of the bedrooms to accommodate a person using a wheelchair. There is a minibus to facilitate group outings. The area is served by public transport and has a selection of shops and a supermarket. At the time the inspection was held there were three vacancies. One of the residents who lived at the home had passed away over the past year. In respect to making information about the service available to potential service users the home has a brochure, which it sends out to referrers. The service user guide is presently under review. CSCI inspection reports are made available by directing individuals to the CSCI web site or a copy will be sent to individuals on request. The home has a block contract with Lewisham Social Services. However, monthly fees for the home average at £836.50. This information was provided to CSCI May 2007. DS0000025605.V335148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was not present. They have not been working at the home since January 2007 with the service manager covering the post since this time. They were present for the inspection. The inspection also involved speaking to two of the people who live at the home and three staff members. Other methods used during the inspection included inspection of records, a tour of the premises and case tracking. What the service does well: People living at the home that were spoken to said they were happy living at the home and satisfied with the support received. People ‘s needs are fully assessed and the home makes sure it is able to meet the needs of prospective residents before they are offered a place at the home. Care plans are detailed with individuals’ needs and goals included. People are supported by staff to make decisions about their own lives and to lead independent and fulfilling lives as possible that involves responsible risk taking and to be engaged in a range of valued activities including attending educational classes. Individuals are very much involved in the local community using local facilities such as pubs, restaurants, and shops amongst others. Individuals are able to maintain family links and have been supported by staff to develop personal relationships. Individuals are involved in choosing meals cooked and help to prepare these. Physical and emotional health care needs of those living at the home are well met. Individuals are well protected by the home’s medication policy and procedures. The home has effective complaints and adult protection procedures in place to protect those living at the home and staff are kept well informed of adult protection procedures and to be aware of adult abuse. The home is generally well maintained, homely, comfortable and clean throughout. Staff are supported to gain appropriate qualifications and generally have access to regular training in both mandatory topics and in topics specific to the needs of those living at the home to ensure their individual and collective needs can be met. Overall, the home is well run and managed. Individuals’ views are regularly sought by the home as part of monitoring the service provided. DS0000025605.V335148.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025605.V335148.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 DS0000025605.V335148.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was committed to a full assessment of individuals’ needs and aspirations before offering a place to live at the home. EVIDENCE: There have been no new admissions to the home for some time. Yet, the policy of the organisation in relation to any future admissions was that individuals who may want to move in would need to receive a full assessment by the appropriate professionals. Only then would the home confirm the offer of a place, if identified needs and aspirations could be met. DS0000025605.V335148.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support plans drawn up with people who live at the home are person-centred, are easy to understand and demonstrate that individuals are encouraged to make their own decisions and choices. However, not all care plans had been updated to reflect changes in need and support, annual placement reviews had been held and risk assessments had not been regularly reviewed. EVIDENCE: The personal files of four people living at the home were inspected. These all contained a detailed care plan that covered all aspects of personal and social support and healthcare needs. Individual specialist requirements were also addressed and guidelines and interventions were in place for staff about how to meet the needs of individual service users. In addition, to these more formal care plans, there was evidence of person -centred support plans that were in an accessible format and contained comprehensive information about needs, preferences and lifestyles that had been drawn up with residents. This meets the previous requirement made in respect to care plans. Despite it being DS0000025605.V335148.R01.S.doc Version 5.2 Page 10 identified that only one person’s care plan and person –centred support plan had been reviewed and updated it was acknowledged by the service manager that due to the registered manager not having worked at the home since January 2007 that this area had been neglected. However, the home was in the process of addressing this matter and some reviews had been completed although the care plans had not yet been updated and for others reviews were in the process of being arranged. There was evidence to support this so a requirement is not to be specified although it is advised that care plans are updated as soon as possible after a review is held. There was evidence from previous reviews held that those living at the home, relatives and other professionals such as key workers from day centres are invited to attend and be involved in decision making. However, it was noted that social workers from the placing authority had not been involved. The service manager reported that they have been invited but do not attend. Neither was there evidence that annual reviews conducted by the placing authority to assess continued suitability of the placement for those individuals living at the home had been completed. The home needs to contact the placing authority about this particularly as it was identified that there had been a deterioration in the well being of one of the residents that would need to be discussed as part of a review as to the suitability of the home to be able to continue meeting that individual’s needs (For further details see Standard 24) (See Requirements and Recommendations). As mentioned above there was evidence within the reviews held with service users and also in the drawing up of their own support plans that they had been actively involved and supported to make decisions about their own lives. Weekly meetings had also been held where service users had made decisions about social activities they wanted to be involved in, holidays and other aspects of the running of the home. Discussions with service users and staff confirmed that service users were supported to take risks to enable them to lead independent and fulfilling lives as possible. Staff provide advice and information as necessary. The personal files looked at all contained comprehensive risk assessments in which service users had clearly been involved. Yet, it was noted that the majority of risk assessments had not been reviewed within the past year and this needs to be addressed (See Requirements). DS0000025605.V335148.R01.S.doc Version 5.2 Page 11 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 &17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living at the home are able to enjoy a full and stimulating lifestyle and are supported to be involved in all areas of daily living including planning meals and meal preparation. Their individual rights are also promoted which includes maintaining and developing personal relationships. EVIDENCE: There was evidence available within individuals’ personal files and weekly activities schedules in place that demonstrated that the those living at the home had been involved in a range of activities that include doing various classes at the day centres they attend such as pottery, cookery, drama, sports amongst others as well as attending community education classes in subjects that include computers, looking at friends and relationships and literacy. They have also had opportunities to get involved in leisure activities and to socialise with others such as going bowling and attending the Gateway club. People spoken to confirmed this. DS0000025605.V335148.R01.S.doc Version 5.2 Page 12 It was clearly evident from the personal files belonging to those living at the home including their personal support plans and also from speaking to individuals that they were very much part of the local community using the local shops, pubs, restaurants, cinemas and leisure centres as well as other local facilities. People living at the home confirmed they have had contact with family. One resident said they regularly spend weekends at home with their relatives. There was also evidence within personal support plans and personal files that they had been supported to develop personal relationships. Observations during the inspection and again speaking to people who live in the home confirmed that the home was run to promote their independence and individual choices. Previous inspections have identified some tensions in the area of smoking and drinking between promoting individual rights and safe guarding staff and other residents and it was recommended that the home involve external people with experience of promoting the rights of individuals in reviewing this area. This had not been addressed and is not to be restated in this report. At this inspection restrictions were identified that had been placed on residents who smoke, for example they were not allowed to smoke in the home and for one resident staff kept hold of their cigarettes but issued them on request, which was observed. However, these individuals were spoken to and were both happy with these arrangements and understood why they were in place. Also, it was included in the home’s contract issued to residents that smoking was not allowed in the home and had been addressed in their individual risk assessments. Furthermore, since the last inspection an adult protection investigation was initiated after it was alleged that individual staff were inappropriately withholding the resident’s cigarettes. This was dealt with promptly and appropriately by the provider with the staff in question being suspended until the matter was fully investigated demonstrating any abuse of this arrangement was not to be tolerated. The investigation that also involved other allegations being made against these staff members had yet to be concluded at the time the inspection was carried out (For further details see Standard 23). People who live at the home are encouraged where appropriate to prepare their own breakfasts and lunch if they are around although it was reported generally residents are out at lunchtimes attending day centres or doing other activities. In respect to evening meals, there is a cook who prepares the evening meal during the week. At the weekends staff do this. There was evidence that residents had been involved in menu planning which is done on a weekly basis. A rota was also in place where they take turns to help the cook to prepare the meal. Cooking sessions involving residents are also held at weekends with staff. Records showed that all those living at the home receive well-balanced nutritious and varied meals. Individuals can choose from a range of frozen meals if they do not like the meal that has been prepared. Snacks DS0000025605.V335148.R01.S.doc Version 5.2 Page 13 and drinks are available. A suppertime was observed and the meal provided was healthy and nutritious with ample portions given. DS0000025605.V335148.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home receive effective personal and healthcare support and there is an efficient medication policy and procedure in place. EVIDENCE: People living at the home are encouraged where possible to take responsibility for their own personal care and staff prompt and provide support where required. All were observed as being well dressed and groomed. The home operates a key worker system to ensure consistency of support. Individuals spoken to, were aware of who their key worker was and were satisfied with the support they received. There was evidence within care plans and also for each person there was an up to date record of appointments that had been attended with a range of different health care professionals including GPs, chiropodists, dentists, opticians, psychologists, and audiologists amongst others. Staff had also written up a brief note on the outcome on each appointment attended. Not all individuals whose personal files were looked at had had their weight recorded monthly. It was reported not all residents need to have their weight monitored DS0000025605.V335148.R01.S.doc Version 5.2 Page 15 regularly. For those where it was required this had been specified within care plans. Therefore, it is advised that for those residents where monthly weight monitoring is not considered necessary the forms are removed from their personal files although this should be recorded at least six monthly for all people living in the home (See Recommendations). The home uses a blister pack system for storing and administering medication. None of the people presently living at the home take responsibility for their own medication. There was a list of signatories who were all trained to administer medication, which is undertaken via Lewisham Partnership. A sample of four medication records belonging to residents was checked. These were largely accurate although it was identified that where medication had been refused or was prescribed to be taken ‘as and when required’ and had not be administered there had been an inappropriate and incorrect use of the codes that should be used to identify this. It is advised all staff be given information about the correct use of codes in these circumstances and these are used consistently (See Recommendations) DS0000025605.V335148.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&23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users spoken to felt confident to take their concerns and complaints to staff and the home has taken measures to ensure service users are protected from abuse as much as possible. EVIDENCE: The home has a complaints procedure, “We want to hear about what you think” that is in an accessible format to service users. Service users spoken to stated they did not have any complaints about the home but would speak to staff or specifically their key worker and were confident that any concerns would be acted upon. There was a complaints log in place but no complaints had been made since the last inspection. The home had a robust adult protection procedure that defined the different types of abuse and responsibilities of support staff and managers in reporting abuse. There was also a comprehensive whistle blowing policy. All staff had undertaken adult protection training that is refreshed on an annual basis. There had been one adult protection investigation since the last inspection. This followed allegations made by staff working at the home against the registered manager and one of the Senior Support Workers of inappropriate practices against two of the service users living at the home. These included for one of the service users as mentioned in respect to Standard 16 with holding their cigarettes and also with holding social opportunities and day time activities to punish, what was considered to be inappropriate behaviour. For another service user inappropriate mealtime procedures were put in place. The DS0000025605.V335148.R01.S.doc Version 5.2 Page 17 provider immediately took action on be alerted to these allegations with both staff members being suspended and adult protection procedures being followed appropriately including a referral to the Protection of Vulnerable Adults (POVA) list. At the time the inspection was held the matter had not been concluded and the investigation was still ongoing. In respect to service users finances, it was reported that staff take responsibility for managing the finances of the service users for which there are robust systems and procedures in place to ensure these are kept in order. A sample of service users’ finances were checked and were all found to be in order. DS0000025605.V335148.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, 26,27,28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment of the home is generally comfortable and well maintained but it does not meet the specific needs of all the people who live there presently. EVIDENCE: The home is homely, comfortable and well –maintained. It meets the specific needs of the majority of people living at the home although it was identified that one resident’s needs had increased in that they had been experiencing an increased number of falls. There was evidence within the resident’s personal file that this was under investigation with their medication being reviewed and medical tests were to be undertaken. The issue had also been addressed within a risk assessment. However, the resident’s room was on the second floor. There were also quite steep stairs down to the dining room situated on the ground floor. Although there was a chair lift this was not in working order and it was reported that this could not be repaired, as the chair was no longer in production. This should be removed and a replacement purchased. Staff also DS0000025605.V335148.R01.S.doc Version 5.2 Page 19 reported concerns about the resident being at risk of falling down the stairs. Yet, the home only has one ground floor room that was occupied and it was reported that there was no possibility of the person presently occupying the room changing rooms. Given these concerns as mentioned in respect to Standard 6 this matter would need to be looked at as part of a placement review carried out with the placing authority and the resident concerned as to whether the home can continue to effectively accommodate their needs. The service manager did report that alternative premises are being looked at that would be more appropriate in meeting the needs of the people living in the home as they become older and their needs increase but there was no timescale in place for when this would happen (See Requirements). Individuals’ bedrooms were inspected and all found to be personalised and reflected their personalities and cultural needs. The carpet in one room was quite dirty and stained and needed to be cleaned (See Requirements). There were sufficient bathrooms and toilets to meet individuals’ needs. It was identified that one toilet on the second floor was out of order. The service manager reported that a request for this to be repaired had already been submitted and this should be done in due course. The home has communal spaces that generally are accessible, safe and spacious. There are two lounges on the first floor, one of which has a television and the other that can be used for individuals living at the home to do activities or sit quietly. On the ground floor there is a large dining area and kitchen. There is also an attractive garden, which is paved and has a seating area for people. The garden is accessible from the dining room and on the first floor there are also stairs leading down to the garden. On the day the inspection was held the home was clean, hygienic and free from offensive odours. DS0000025605.V335148.R01.S.doc Version 5.2 Page 20 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 &35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practice is robust and all staff receive relevant training to ensure the needs of the people living within the home are effectively met. EVIDENCE: At present there are six permanent support workers working within the home. It was also reported that the home has recently recruited four support workers for whom the required checks and references were waiting to be obtained prior to them commencing work. Also, interviews for a deputy manager were held the day of the inspection. Regular agency and bank staff have been used to cover vacant posts. Of the six permanent support workers it was reported five have completed a NVQ Level 2 and one is yet to start this training. Both bank staff members have achieved a NVQ with one having done a NVQ Level 2 and the other Level 3. In addition, all agency staff are qualified at NVQ Level 3. This meets the required target as specified within NMS (National Minimum Standards) that 50 of staff need to have achieved NVQ. Staff records belonging to two support workers and a bank worker that had been recruited since the last inspection was held were checked. For the two support workers there was evidence included in the files of all the documents required by regulation including a recent Enhanced Criminal Record Bureau DS0000025605.V335148.R01.S.doc Version 5.2 Page 21 check (ECRB), two references and appropriate identification. For the bank worker although there was an up to date ERCB and appropriate identification in place, there was no evidence that references had been obtained. The service manager reported that the worker had worked for a year at one of the other Aurora Options homes as a live in community service volunteer and had been assimilated into the post of bank worker. However, as specified by the Care Standards Act 2002 two references should still be obtained. Copies of these were sent to CSCI shortly following the inspection. Overall, it was evident that the vetting and recruitment procedures used by the provider are robust and operate in line with equal opportunities. A previous requirement that gaps in employment should be explored and accounted for had been met. Records of application forms and interview forms for prospective employees were seen with any gaps in employment having been identified and addressed with applicants. It was evident from records seen that support staff have completed all required mandatory training. These are automatically updated as required. In addition, staff had completed a range of training courses ensuring the individual and collective needs of service users are met. There was evidence all staff had completed an induction and also within their probationary period staff are required to complete the Learning Disability Foundation Award Units 1-4. DS0000025605.V335148.R01.S.doc Version 5.2 Page 22 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 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a consistent record in monitoring its own practice and meeting health and safety requirements although it was found that incident reports have not always been sent to CSCI as required. Also, although overall the home is well run the present management arrangements need to be reviewed. EVIDENCE: As mentioned in respect to Standard 23 the registered manager has not been working at the home since January 2007 following their suspension after allegations from staff of inappropriate practice towards two of the people living at the home. This matter is still under investigation and the service manager has been covering the management of the home in the interim period that this is fully resolved. Although, the service manager has relevant management experience they are undertaking this role in addition to their own workload and it was acknowledged that the time they have available to directly manage the DS0000025605.V335148.R01.S.doc Version 5.2 Page 23 service was limited. Overall, it was evident that the home was well run. However, given that it is not clear when the situation with the present registered manager will be sorted out it is advised that these management arrangements are reviewed. The service manager did report how on the day the inspection was held following interviews being held the post of deputy manager had been offered to one of the applicants and potentially they could take responsibility for the management of the home although this is not an option for the short to medium term (See Recommendations). Service user surveys were seen that had been completed with service users in September /October 2006. It was reported that these are completed with the input of an advocate to ensure the process is unbiased and supports people to express their views. Surveys for completion with relatives and stakeholders had not been completed last year although have always been done previously. An annual development plan was in place that was partly based on the results of the surveys and clearly set out aims and outcomes for service users. In addition, as mentioned previously within the report weekly service user meetings are held in which service users’ views are obtained and they are involved in aspects of the running of the home. In relation to monthly provider visits there was evidence that these had been completed and copies of reports had been sent to CSCI. The home had comprehensive health and safety policies in place. There was an up to date maintenance certificate in place for gas safety and there was evidence that fire equipment had been checked and maintained. Fire alarm call points had been tested as required and regular fire drills had been undertaken. All staff complete fire safety training annually and other mandatory training such as moving and handling and food hygiene. General health and safety and infection control audits had been carried out regularly. An up to date fire risk assessment was sent to CSCI shortly following the inspection. However, in checking recording of incidents there was one incident where due to miscommunication between night staff a resident had been left to sit in their chair all night. Although, the incident was reported by the staff involved and appropriate action was taken by the home with one staff member being issued with a verbal warning and their probation extended whilst the other was issued with a final written warning, CSCI should have been notified of this under regulation 37 of the Care Standards Act 2002 (See Requirements). DS0000025605.V335148.R01.S.doc Version 5.2 Page 24 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 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 3 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 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X DS0000025605.V335148.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 (2) Requirement The registered provider must ensure that annual placement reviews for all those living at the home take place with the placing authority to ensure the home can continue to meet their individual needs effectively. The registered provider must ensure that risk assessments drawn up for individuals living at the home are reviewed at least six monthly to ensure any changes in need are included. The registered provider must ensure that the old chair lift is removed and a new one purchased to ensure that those individuals with mobility problems have access to equipment that is in safe and working order. The registered provider must ensure that the carpet in one of the resident’ s bedroom is cleaned as part of ensuring the physical environment of the home is maintained to an acceptable standard for all residents. The registered provider must DS0000025605.V335148.R01.S.doc Timescale for action 31/12/07 2. YA9 15(2)(b) 31/08/07 3. YA24 23(2)(c) 28/02/08 4. YA26 23(2)(d) 31/08/07 5. YA42 37 31/08/07 Page 26 Version 5.2 ensure that written notification is provided to CSCI of any incidents that fall within regulation 37 of the Care Standards Act 2002 so these can be monitored by CSCI and ensure that appropriate action has been taken by the home to address the incidents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered provider should try to ensure that care plans are updated as soon as possible after reviews take place so information regarding changes in needs is accessible. The registered provider should consider removing the monthly weight monitoring forms for those residents where this is not considered necessary and instead for these individuals try to ensure that their weight is monitored at least six monthly so any changes can be detected. The registered provider should try to ensure information regarding the correct use of codes for when medication is not administered is provided to staff to ensure consistency and accurate recording. The registered provider should try to ensure the present management arrangements of the home are kept under review so that the efficient running of the home is maintained. 2. YA19 3. YA20 4. YA37 DS0000025605.V335148.R01.S.doc Version 5.2 Page 27 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 DS0000025605.V335148.R01.S.doc Version 5.2 Page 28 - 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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