Inspection on 13/10/05 for Aytun Care Home

This inspection was carried out on 13th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aytun Care Home 31/08/07

Aytun Care Home 27/06/06

Aytun Care Home 22/02/06

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 Aytun Care Home 33 Strode Road Forest Gate London E7 0DU Lead Inspector Lea Alexander Unannounced Inspection 13th October 2005 12:00 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Aytun Care Home Address 33 Strode Road Forest Gate London E7 0DU 020 8555 6097 020 8555 6133 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) FBP Ventures Ltd Mrs Yetunde Majekodunmi Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration is for 3 adults with a mild/moderate learning disability, either sex, in the category of LD, 1 of whom may have both a learning and physical disability. First inspection under National Minimum Standards Date of last inspection Brief Description of the Service: Aytun Care home is a three bed roomed house in a residential area of Forest Gate. It completed the registration procedure in January of this year and currently has two service users. The home aims to support adults with learning difficulties. The home is situated close to the local shopping facilities at Forest Gate and nearby Stratford with its train and tube routes can be accessed by bus. This is the homes first inspection under National Minimum Standards. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of an afternoon and early evening. The Inspector sampled service users personal files, staff personnel files, the homes policies and procedures and other relevant documentation. The Inspector also met privately with one service user, a staff member and the homes Registered Manager. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that it comprehensively completes it own assessment tools. Service users should have the opportunity to test drive the home before moving in. All service users should have a contract with the home. The individual plans developed with service users should address all areas of need including how independent living skills will be developed and maintained. All Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 6 service users should be supported to participate in fulfilling educational, occupational, community and leisure activities. The home must fully complete its own risk assessment tools and identify and implement a risk assessment strategy. Sufficient numbers of staff to meet identified needs must be scheduled on duty. The home needs to revise its confidentiality policy. Significant shortfalls in the homes medication policy, administration, recording and storage were identified and must be addressed. Only the applicable complaints policy should be available in the home, and a complaints log must be developed. The homes policies and procedures must be reviewed to ensure only those applicable are kept, these must be indexed and fully accessible to staff and service users at all times. The home must provide adult protection training as a matter of priority. The home must attend to the numerous maintenance and environmental issues identified, including the appropriate storage of potentially hazardous cleaning substances. The home would benefit from a more “homely” atmosphere. All staff must be subject to pre employment checks including two written references and a Criminal Records Bureau (CRB) check. The home must develop a structured, recorded induction programme. All staff must receive regular, recorded supervision. The home must implement its quality assurance policy. The home must develop an incident recording procedure and make audited accounts available for inspection. Fridge and freezer temperatures must be recorded daily and foodstuffs must be appropriately labelled. 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. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. The home has produced a statement of purpose and service user guide to assist service users to make informed decisions about where they live. The home has evidenced that it obtains relevant material from other professionals as part of the referral process. The Inspector was satisfied that the home is able to meet the needs of the current service user group. The home has not been comprehensively completing it own assessment tool as part of the admission process. The home has yet to finalise individual contracts with service users. EVIDENCE: The home has produced a statement of purpose and service user guide that address many of the areas required by National Minimum Standards. Some minor revision is required for both of these documents and these are detailed in the requirements section of this report. The Inspector sampled the personal files for both service users currently residing at the home. From these it was evidenced that a copy of the health authority or social services Care Needs Assessment had been obtained for both service users. The home has developed its own assessment tool and whilst this was found on both service users personal files it had not been comprehensively completed on either. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 9 Based on records available and discussion with staff and one service user the Inspector was satisfied that the home was able to meet the assessed needs of service users. Of the two service users currently placed at the home one was admitted on an emergency basis. It was not however evidenced that the other service user had had the opportunity to “test drive” the home prior to admission. The registered manager advised the Inspector that contracts with service users had been drafted and had been sent to their respective care managers but had not yet been returned. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Service users have their needs assessed by the home and recorded in an individual plan. These plans and discussion with one service user evidenced that the home supports service users to make informed decisions about their lives. It was not evidenced that all areas of identified need had been assessed and included in the individual plan. The home is not regularly holding service users meetings that are minuted as a forum to include them in the day-to-day running of the home. The home must address identified shortfalls in their risk assessment practises and recording and in the homes confidentiality policy. EVIDENCE: The Inspector sampled the personal files for both service users and found completed individual service users plans on each. The plans were noted to include information on the services to be provided by the home and goals for service users. The Inspector noted that for one service user there was no individual plan to address their personal development through occupational or educational Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 11 involvement. There was also no information addressing contact with family or friends. Discussion with one service user and information recorded on the individual service user plan evidenced that the home supports service users to make their own decisions about their lives. The Inspector asked to see the minutes of service users meetings and was advised that none were available. The service user spoken to was unable to recall service users meetings being held. The Inspector viewed the homes “risk taking policy” and noted that this did not address issues of managing identified risk. Service users personal files included a generic “resident risk assessment” but this had not been fully completed and again did not address issues of risk management. For one service user individual risk assessments had been completed to address issues of physical aggression, verbal aggression and wandering. The Inspector noted that these assessments identified “controls” and recommends that the home reconsider its approach using identification and management strategies to avoid limiting the service users preferred activity or choice. The Inspector viewed the homes confidentiality policy. This requires revision to include guidance on circumstances when confidentiality may need to be breached, for example when adult protection issues are disclosed. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. It was not evidenced that individual plans and the homes current practises support service users to maintain and develop independent living skills. Service users are supported to maintain contact with their families in the way they prefer. Staffs interact with service users and consult them with regard to meal choices. Staffs have been proactive in identifying local resources of interest to one service user. This practise should be evidenced as being applied to the other service user. EVIDENCE: The Inspector sampled the personal files for the two service users living at the home. One of these contained an individual plan that identified a need for staff to support with cooking and identified some limited household chores. The other personal file contained an individual plan that identified one household chore. The Inspector is of the view that the home needs to develop its individual plans and practise to identify and develop independent living skills for service users. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 13 The Inspector noted that the two service users currently residing at the home have differing abilities. The service user spoken to identified how staffs are continually finding out about local activities and resources that may be of interest and encourage them to attend. The other service user attends a day service. Their individual plan identified that they also liked to watch TV and read magazines. The plan stated that the service user should be “encouraged to get out and about more”. It was not evidenced that staff had supported this service user to find or take part in other fulfilling activities. The home must evidence that all service users are offered an appropriate level of support in developing educational, occupational and leisure activities. The home must ensure that a choice of appropriate entertainment is available within the home. Discussion with one service user and inspection of personal files indicated that the home supports service users to maintain contact with family in the way they choose. During the course of the inspection the Inspector observed staff talking and interacting with service users. Discussion with one service user evidenced that service users have the choice when to be in company and when to be alone. The service user spoken to by the Inspector advised that staff are willing to cook whatever meals he requests, and that the food prepared is of a good standard. The Inspector noted that a weekly menu was also displayed in the kitchen area. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. The home should develop its individual plans to reflect how service users prefer to receive personal care and support. Service users are appropriately supported to attend annual healthcare checks and regular GP appointments. The homes medication policy, administration, storage and recording practises are not satisfactory and must be developed to ensure service users safety and wellbeing. EVIDENCE: Service users plans identified the specific assistance required by service users with their personal care. The member of staff spoken to indicated that they would ask service users how they preferred to be supported and then integrate this into their practise. The home should develop its practise in this area by incorporating more detailed information into individual plans that addresses service users preferences. The Inspector noted that service users personal files contained contact details for relevant health services and included details of appointments. It was evidenced that service users are being supported to attend annual health checks and regular GP appointments. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 15 The Inspector sampled the Medication Administration Record (MAR) for both service users and inspected the medication available within the home. The archived September 2005 MAR sheet for one service user was noted to have multiple blank entries with no code entered to identify the reason the medication had been missed. For the other service user a record of medication in the personal file recorded a different dosage to that recorded on the MAR. Each service user has a small glass fronted cabinet with lock in their room that contains their medication. As no service users are currently self-medicating, staffs hold keys to these cupboards. However, the Inspector noted that two of the three medication cabinets had faulty locks and could be opened by hand without using a key. These cabinets were also noted to be glass fronted. Whilst inspecting the contents of one service users medication cabinet the Inspector noted that a discontinued medication was still being stored there. Inspection of the first aid box in the kitchen identified that one-service users medications were being kept in this; staff were asked to remove these and store them appropriately. The Inspector sampled the homes medication policies and identified several revisions that are detailed in the requirements section of this report. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Service users and staff may be confused by the two separate complaints policies currently available within the home. Should a service user make a complaint there is no log for the complaint or investigation to be recorded in. Significant shortfalls were also identified with regard to staff understanding of adult protection issues and it was not evidenced that the home has provided adult protection training. To ensure service users safety and wellbeing these shortfalls should be addressed urgently. EVIDENCE: The Inspector viewed the homes policies and procedure file and noted that this contained a different complaints policy than that published in the Service Users Guide. The Inspector asked to see the homes complaints log and was advised that one has not yet been developed. On arrival at the home the Inspector asked to view the homes policies and procedures and was advised by staff that these were not available as they were locked in the managers office. The member of staff on duty advised the Inspector that they were familiar with all the homes policies and procedures and did not need to access them on a regular basis. The Inspector asked the member of staff what the homes adult protection policy is, and the member of staff was not able advice the Inspector of this. Further discussion highlighted a significant shortfall in staff understanding of adult protection issues and their responsibilities. Perusal of personnel files later in the day indicated that no adult protection training had been provided by the home for staff. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 & 30. The home provides adequate communal and private spaces for service users. Each service user has their own bedroom that they can choose to personalise. The communal areas of the home lacked a “homely” feel. An extensive list of repairs and maintenance issues were identified which is of concern for a home that has been opened for such a short period of time. The home was found to be clean and hygienic, although potentially hazardous cleaning materials had not been appropriately stored to ensure service users safety. EVIDENCE: The Inspector toured the communal and staff areas and the three service users bedrooms. The accommodation comprises of an entrance hall, communal lounge and dining area, large kitchen with access via patio doors to a lawned garden. The communal lounge/dining area has a sofa and other comfortable seating and has a TV and stereo system. Also on the ground floor there is a large bathroom with bath, WC and washing machine and a service user bedroom that is currently unoccupied. On the first floor there is a staff office, storage cupboard, small shower room with WC and a further two service users bedrooms. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 18 The Inspector noted that potentially hazardous cleaning materials had been left unsecured in the ground floor bathroom. The Inspector noted that there was sufficient private and shared space for service users and that furnishings and equipment were of a domestic nature. The Inspector identified an extensive list of maintenance requirements that are detailed in the requirements section of this report. The Inspector was advised that the home does not have a maintenance log or improvement plan, but that there is a “handyman” who can be approached to carry out works. The Inspector formed the view that the premises could benefit from a more homely atmosphere and that the decorations could be developed to reflect the personalities of the service users living there. Each service user has their own bedroom that has been comfortably furnished and has a private wash hand basin. Service users have the opportunity to personalise their bedrooms if they wish. The service user spoken to by the Inspector advised that they were not able to lock their bedroom door. The Inspector found the premises to be clean, hygienic and free from offensive odours. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. Staffs appear able to develop and sustain appropriate relationships with service users. Staffs were described as very patient and helpful. It was not evidenced how one service user receives the 1:1 care identified in their individual plan at certain points in the day. It was not evidenced that the homes recruitment practices safeguard and protect service users. Significant shortfalls in obtaining written references and applying for Criminal Records Bureau (CRB) checks were identified. It was not evidenced that staff receive copies of their job descriptions, and no structured induction programme was available for the Inspector to view. No training and development programme and supervision records were available. EVIDENCE: During the course of the inspection the Inspector observed that staff were accessible to, approachable by and comfortable with service users. The service user spoken to described staff as “very patient and helpful”. Discussion with this service user evidenced that staff get to know and develop a relationship with the service users they support. The Inspector noted that one service users individual plan identified the need for 1:1 staffing throughout the day and evening. The staffing rota seen by the Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 20 Inspector did not provide adequate staffing levels to provide 1:1 staffing from 4.30 pm to 8.00 pm, when the other service user had returned from their day service, or at the weekend. The Inspector sampled two support workers personnel files. It was not evidenced that staff receive a copy of their job description. In the two files only one written reference was available. One personnel file contained an entry stating verbal references had been obtained. Neither personnel file contained a current Criminal Records Bureau (CRB) check or evidence of a “POVA first” (Protection of Vulnerable adults register check). A copy of a CRB obtained by a previous employer was found on one personnel file. The Inspector advised the Manager that the staff member with no written references and no CRB must not work unsupervised with service users with immediate effect, and that these checks must be conducted as a matter of urgency. The manager advised the Inspector that the home is in the process of developing a staff training and development programme. The Inspector asked to see the homes staff induction programme and was advised that the staff handbook formed the basis of this. No induction checklist that had been signed off by the staff member and manager was available. The Inspector requested staff supervision records and was advised by the manager that supervision occurs regularly but is not recorded. The member of staff spoken to confirmed that they received regular supervision and stated that they received copies of supervision minutes. The Inspector was therefore unclear of the homes current practise regarding the frequency and recording of supervision. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 42 & 43. The home has developed a quality assurance procedure that it must now implement. The home must ensure that policies and procedures are regularly reviewed, applicable to the home and readily accessible to staff and service users. The home safeguards service users with regular fire testing, but needs to incorporate a fire evacuation drill into its practise. The home regularly records water temperatures and has up to date gas and boiler safety certificates. The home has an accident book. Fridge and freezer temperatures are not being recorded on a daily basis and opened and prepared foods are not being correctly labelled. There is no incident book and no accounts were available. EVIDENCE: The Inspector viewed the homes quality assurance policy that identifies surveying stakeholders as key component in the development plan. The Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 22 manager advised that the home is still developing its survey tool and feedback surveys had not yet been distributed. The registered manager has procured a set of standardised policies and procedures relevant to the homes setting. These must be reviewed to ensure that all apply to the home or are appropriately reviewed. The policy file has in excess of 400 pages, and there is no index for which policies appear where. This does not make this a user-friendly tool for staff to refer to on a day-to-day basis. The home has records to evidence that it has complied with the London Fire and Emergency Planning Authority (LFEPA) recommendations with regard to promoting fire safety within the home. Records indicate that regular fire alarm testing occurs. There was no record of a fire evacuation drill or evacuation times. The home produced its Environmental Health report and a follow up visit record. This indicated that all recommendations had been implemented. The Inspector viewed the homes record of fridge and freezer temperatures and noted that there were gaps in this record for several consecutive dates. The temperatures that were recorded fell within acceptable limits. During the site inspection the Inspector observed that there was no thermometer in the fridge, and that both thermometers were in the freezer. Inspection of the contents of the fridge indicated that some processed food products had been started but not labelled with an opened date or use by date. An item of fruit had also been prepared and whilst wrapped in cling film had again not been labelled with a start or use by date. The inspector viewed the homes accident log, which at present has no occurrences recorded in it. The Inspector was advised that the home does not currently have an incident reporting log or procedure. The home has a gas safety certificate and boiler test certificate that are in order and are dated December 2004. The home keeps a record of water temperatures within the home and these were found to be within acceptable limits. The Inspector asked to see the homes accounts and was advised that these are currently with their accountant. The registered manager did produce a record of invoices issued by the home. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 2 2 Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 X X 3 LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 2 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Aytun Care Home Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score X X 2 2 X 2 2 DS0000062024.V257638.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 4,5,6 & Sch 1 Requirement The homes statement of purpose requires revision to include: (i) Specific information on the range of needs the home is able to meet. More detailed information on the homes admission procedure including emergency admissions. A complaints procedure with current contact details for CSCI and timescales within which complaints will be investigated. Timescale for action 13/02/06 (ii) (iii) The homes statement of purpose states that “care plans will be reviewed by the manager on a monthly basis”. This does not accurately reflect the homes practise and should be revised accordingly. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 25 The homes service users guide should be revised to include: (i) (ii) A summary of service users feedback. A summary of the complaints procedure that meets the requirements of National Minimum Standards. 13/02/06 2 YA2 14(1)(a) New service users must only be admitted on the basis on a full assessment undertaken by the home by people competent to do so. The Registered Manager must ensure that prospective service users are given the opportunity to “test drive” the home. 3 YA4 12(2) & 14(c) 13/02/06 4 YA5 14(1)(d) The Registered Manager must 13/02/06 develop and agree with each service user a written and costed contract of the terms and conditions between the home and the service user. Individual service users plans must address all aspects of personal and social support. The registered manager must ensure that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 13/02/06 5 YA6 15(1) 7 YA8 12(3) 13/02/06 8 YA9 13(4) (b) & The home must complete its risk 13/02/06 (c) assessment tool, identify management strategies and DS0000062024.V257638.R01.S.doc Version 5.0 Page 26 Aytun Care Home regularly review these as part of the individual plan. 9 YA10 12(4)(a) The homes confidentiality policy must be revised to include the circumstances when staff may be required to breach confidentiality, for example when adult protection issues are disclosed. Service users must be enabled to maintain and develop their independent living skills. The home must ensure that all service users are supported to find and participate in valued and fulfilling activities. 13/02/06 10 YA11 12(1)(a) 13/02/06 11 YA12 12(1)(b) 13/02/06 12 YA14 16(2)(m) & The home must ensure that all (n) service users have access to appropriate leisure activities. A range of entertainment must be available within the home. 13/02/06 13 YA20 13(2) Medication Administration Record (MAR) sheets must be fully completed and an appropriate code recorded for any missed doses. All records of medication must tally. Medication must be stored in a suitable cupboard with an appropriate lock. Discontinued medications must be appropriately disposed of. Service users prescribed medications must not be stored in the homes first aid box. The home must develop its 30/11/05 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 27 medication policy to guidance on controlled drugs. The homes policy on selfmedication requires revision to include a risk assessment framework for self-medicating service users. 14 YA22 22 & Sch 1 The home must ensure that only 30/11/05 the current/applicable complaints policy is available to staff and service users. The home must develop a complaint log that records the details of the complaint, investigation and outcome as required by regulation. 15 YA23 13(6) The registered person must ensure that service users are safeguarded from abuse in accordance with a written policy. This policy must be available to staff at all times. Staff must receive initial and regular refresher adult protection training. 16 YA24 13(2) & 23(4) The lawn mower currently being stored in the kitchen area must be removed and stored more appropriately. The ripped carpet in the communal lounge must be replaced. The communal lounge should be made more homely and reflective of the personalities of the service users who live there. Fire doors must not be wedged open. 13/02/06 13/02/06 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 28 The ground floor bathroom requires the following repairs: (i) (ii) (iii) The bath must be securely fixed. The ceiling must be properly painted. The bath side and end panels should be properly secured and the corner/edging strips securely fitted. The broken toilet seat must be mended or replaced. The floor covering around the WC must be properly fitted. The grab rail by the toilet must be properly secured. Missing tiles must be replaced. The bathroom door must be able to be effectively locked from the inside. (iv) (v) (vi) (vii) (viii) In the vacant bedroom the following maintenance issues must be addressed: (i) (ii) (iii) (iv) The dripping tap must be repaired. The missing wardrobe handles must be replaced. The curtains must be properly hung. The doorframe must be repaired to a good standard. In the hallway the banister and handrail must be properly secured. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 29 In the first floor bathroom the following maintenance issues must be addressed: (i) (ii) (iii) (iv) The broken folding entrance door must be replaced. The broken toilet seat must be repaired or replaced. The broken toilet roll holder must be repaired or replaced. The shower door must be properly secured. Potentially hazardous cleaning materials must be stored securely. 17 YA26 12(4)(a) & 23(2)(a) The registered person must ensure that service users rooms are lockable and that staffs use an override device only as indicated in a service users risk assessment. The registered person must ensure that toilets and bathrooms are lockable and that staffs use an override device only as indicated by service users risk assessment. The registered manager must evidence that staff have clearly defined job descriptions. The registered manager must ensure that sufficient numbers of support staff are on duty to provide 1:1 support as detailed in service users individual plans. The registered person must operate a thorough recruitment procedure based on equal DS0000062024.V257638.R01.S.doc 13/02/06 18 YA27 23(2) & 12(4) 13/02/06 19 YA31 12(5)(a) & (b) 18(1)(a) 13/02/06 20 YA33 13/02/06 21 YA34 19 & Sch 2 13/02/06 Aytun Care Home Version 5.0 Page 30 opportunities and ensuring the protection of service users. This must include: (i) Two written references must be obtained prior to appointment. CRB checks are not transferable and the home must conduct its own CRB check on potential staff. The home must ensure that staff without two references or a current CRB check do not work unsupervised and that these checks are urgently carried out. 13/02/06 (ii) (iii) 22 YA35 18(1)(c) The registered person must develop a staff training and development programme. All new members of staff must complete a structured induction programme that is recorded and signed off by the manager and staff member. 23 YA36 18(2) Staff must receive regular recorded supervision meetings at least six times per year. The home must implement its quality assurance policy and procedure. The homes written policies and procedures must comply with current legislation. Staff and service users must have ready access to an indexed 13/02/06 24 YA39 24 13/02/06 25 YA40 12(4)(a) & (b) 13/02/06 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 31 copy of the homes policies and procedures. 26 YA42 23 & 13 The home must conduct regular fire evacuation drills and record evacuation times. Fridge and freezer temperatures must be recorded on a daily basis. A thermometer must be kept in the fridge at all times. Processed and prepared foods stored in the fridge must be labelled with a start and use by date in accordance with the product instructions and food hygiene and safety practises. The home must develop an incident reporting procedure and log. 27 YA43 25(2) (a) The registered person must ensure that a business and financial plan is available for inspection. 13/02/06 13/02/06 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 YA18 Good Practice Recommendations The home should develop it individual planning to include information within this detailing how service users prefer to be supported. Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 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 Aytun Care Home DS0000062024.V257638.R01.S.doc Version 5.0 Page 33 - 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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