Inspection on 27/06/06 for Aytun Care Home

This inspection was carried out on 27th June 2006.

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 10 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 22/02/06

Aytun Care Home 13/10/05

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 Key Unannounced Inspection 27th June 2006 11:00 Aytun Care Home DS0000062024.V300187.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 Aytun Care Home DS0000062024.V300187.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. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 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.V300187.R01.S.doc Version 5.2 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. 22nd February 2006 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 that registered to operate as a care home in January 2005. The home accommodates three adult service users with learning difficulties. The home is situated close to the local shopping facilities at Forest Gate and nearby Stratford. There is good access to public transport with train, tube and bus routes nearby. This was the homes third inspection under National Minimum Standards. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector over the course of two half days. The Inspector met with the Registered Manager and spoke privately with a support worker and two service users. The Inspector sampled service users personal files and staff personal records. Other documentation relating to the running of the home was also seen and the premises toured. The main focus of this inspection was to look at key standards for residential care homes and to establish the progress made with requirements made at a previous inspection in February 2006. What the service does well: Service users spoken to by the Inspector said that they “like living” at the home. One of the service users said that staff were “very good”, and that they “really liked (their) big room and comfortable bed”. This inspection evidenced that the home had exceeded National Minimum Standards in one area – over 80 of care staff has attained NVQ level 2. The home has a contract, and developed individual plans for each service user. Service users receive support to manage their finances and appropriate records of expenditure are maintained. Service users are also supported to engage in a range of educational and occupational activities including day services and college. Some service users have been supported to access specialist services such as occupational therapy. Service users have also been supported to engage in community activities such as visiting the cinema and having meals out. There is also a range of activities available inside the home. Service users are encouraged to maintain appropriate family relationships and one to one support is available where identified in the individual plan. The home aims to address service users cultural needs through the meals provided and entertainment bought into the home. The home has flexible mealtimes and service users choose the items appearing on the weekly menu. Service users each have an individual plan, and where appropriate this includes detailed information on the support to be provided with personal care. Personal care is provided in a respectful and dignified manner in a private area. Specialist equipment identified in assessments is available on site. The home maintains a record of all healthcare appointments and there outcomes. The home has developed a range of policy and procedure including; medication, adult protection and recruitment. The home has responded appropriately to an adult protection concern and staff on duty demonstrated a good understanding of adult protection issues and their responsibilities. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 6 Service users have their own bedrooms and benefit from range of communal spaces. The home is clean, hygienic and free from odours. The home employs competent, qualified staff and its recruitment practises safeguard service users. The Registered Manager has obtained NVQ level 4, and many of the records required by regulation were maintained in good order. What has improved since the last inspection? What they could do better: Some requirements have been restated over a number of inspections, including the need to obtain appropriate assessment information from referring authorities. The home also needs to carry out and appropriately record their assessment. The home must ensure that it addresses all areas of need identified in the individual plan, and appropriately and regularly review service users moving and handling needs. Any need such as physiotherapy exercises or communication difficulties should also be included in the individual plan. The home should revise its controlled drugs policy to address storage. The homes medication administration and recording practises should be developed to ensure that: All medication is listed on the Medication Administration Record (MAR). All discontinued medication should be disposed of. All medication must be administered in accordance with prescription. Dossett boxes must be correctly loaded and include a record of the medicine contained within the dossett. Correction fluid should not be used on the MAR sheet. All lists of medication must correspond. Medication refresher training should be a priority for all staff. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 7 The home must also ensure that all adult protection concerns and strategy meetings are reported to the Commission promptly. Maintenance issues should be attended to and a programme of refurbishment planned. Potentially hazardous cleaning materials must be appropriately stored, and all health and safety records kept up to date. Fire doors should be fitted with returns and not left wedged open. Staff must receive regular supervision, and a minimum of six sessions per year. A copy of the homes policies and procedures must be available to staff at all times. All records maintained by the home should be signed and dated and the home should fully implement its quality assurance process and publish the outcome. 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.V300187.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 & 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home must ensure that the individual needs of service users are comprehensively assessed as part of the referral process. EVIDENCE: There have been no new admissions to the home since the last inspection. The Inspector sampled the personal files for two service users currently living at the home. For one of the service users the home had obtained a brief summary of need from the referring Care Manager and the home had briefly completed with one-sentence answers its own Activities of Daily living assessment. The home had also briefly completed a waterlow risk assessment and a nutrition assessment for this service user. For the second service user sampled there was no evidence of any information being obtained from the referring authority and no evidence of the home having assessed the service user. The home has developed a “pen picture” for each of the service users sampled that gave more information on their day-today preferences in terms of activities and contact with family as well as some background information. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 10 The Inspector was shown copies of the individual contracts the home has with each service user, and both parties had signed these. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported to participate in the day-to-day running of the home and to manage their finances. However, individual care plans and where appropriate, moving and handling assessments must be reviewed and updated. EVIDENCE: The Inspector sampled the individual plans for two service users. One of these was dated February 2006, and had been developed shortly after the service user moved into the home. This included detailed information regarding personal care, including the support needed with cleaning teeth, bathing and continence management. This service user has a history of challenging behaviour, and copies of guidelines devised at a previous placement to manage this were available. However it was not evidenced that the home had reviewed or updated these. The second service users individual plan was dated September 2005, and it was not evidenced that this had been reviewed. Whilst sampling the personal file the Inspector noted that this service user has does not have verbal Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 12 communication, but this was not detailed in their care plan along with strategies for communication. Additionally there was information suggesting that physiotherapy exercises should be carried out three times a week, and again this was not detailed in the homes individual plan. One of the service users sampled is subject to appointee ship and the home receives a regular monthly sum from the appointee for pocket money expenses. The home records monies received and all expenses on a sheet maintained in the service users personal file. A similar financial expenditure sheet was found on the other service users personal file. Service users correspondence and notifications from the Department of Work and Pensions were appropriately held in the service users personal files. The Inspector viewed the minutes of service users meetings. These had occurred on a monthly basis since the last inspection in February 2006. The minutes evidence that these meetings are used as a forum to involve service users in the day to day running of the home including choosing meals for the menu and daily activities service users would like to be involved in. Service users personal files sampled by the Inspector both contained completed risk assessment tools that include mobility, kitchen safety, bathing, challenging behaviour and outdoor safety. One service user requires a specialist hoist and assistance with all transfers and bathing. Guidelines from the previous placement to assist with transfers were found on file, but it was not evidenced that these had been reviewed or updated since the service user moved to the current placement. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to engage in appropriate occupational, community and leisure activities and to maintain relationships with their families. EVIDENCE: Sampling of service users personal files, discussion with the service users and the Registered Manager evidenced that service users are supported and encouraged to identify and pursue educational and occupational activities. One service user has an occupational therapist that visits them in the home and supports them to engage in their interest in gardening, they also attend a college course for dressmaking. Another service user is supported to attend the local library, whilst a third service user attends a regular day service. Service users are supported to engage with community activities by having meals out, attending cinema and bowling, visits to the hairdressers and walks in local parks. A service user who uses a wheelchair has flexible one to one support to enable them to engage in activities outside of the home. The Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 14 homes aims to address the diverse cultural needs of service users by providing culturally appropriate meals and entertainment within the home. An example of this would be inclusion of Yams on the homes menu and the provision of African movies for a service user of Somali origin. Service users are also supported to attend church or mosque if they choose to. The home provides a stereo with CD player, satellite TV and a range of games and reading materials for service users to engage with inside the home. Each of the service users personal files sampled by the Inspector included information on how service users are supported to maintain contact with their families. As well as having visitors in the home, one service user visits their mother each weekend. Throughout the course of the inspection staff were observed to be interacting with service users. Service users were observed to choose when to join in an activity, and when to be in company or alone. The Inspector viewed the homes record of meals provided. This evidenced that a variety of well-balanced dishes are prepared. Mealtimes are flexible according to service users individual routines, and service users stated that they choose which meals to put on the menu and like the food that is prepared. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive appropriate support with their personal care and to attend regular health check ups. However, the home must improve its medication administration and recording practises. EVIDENCE: The Inspector sampled individual plans for two service users. These were found to contain detailed information where support with personal care is required. During the course of the inspection, the Inspector noted that personal care; such as assistance with continence management was provided in private. Specialist equipment such as hoists and a bathing chair were available on site and are used for one service user. Service users are supported to choose their own clothes and hairstyle and their appearance reflects their personality. The service users personal files sampled by the Inspector contained a record sheet with details of all medical appointments attended and the outcome. Correspondence relating to medical appointments had also been retained. As previously stated in an earlier section of this report, one service users physiotherapy exercises had not been included in their individual plan, and it Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 16 was not evidenced from the daily log sheet that these were being done 3 times per week as required. The Inspector sampled the homes medication policy. This includes guidance to staff on the receipt, storage and administration of medicines within the home. The home currently has no self-medicating service users, although there is scope for this in the homes policy. The Inspector sampled the homes controlled drugs policy and noted that this does not address storage of controlled medicines. Individual service users medications are stored in a locked cabinet in their bedroom. The Inspector sampled the Medication Administration Record (MAR) for two service users against the medication actually available. For one service user an “as required (PRN)” laxative was not listed on their MAR, but was available in their medicine cabinet. Sampling of this service users MAR sheet evidenced that prescription eye drops had not been administered in accordance with instructions for the late dose on the 2nd and 5th June 2006. For a second service user the contents of a dossett box did not correspond with the number of tablets indicated by the list of medications on the MAR. As there was no indication on the dossett box of which medications it should contain the Inspector was unable to establish which medications had been incorrectly loaded. Whilst sampling these service users medications the Inspector noted that the MAR was annotated to state that one medication was being stored in the fridge. The Registered Manager was unable to locate this medication and thought it had been completed, although the MAR had not been updated to reflect this. This service user also has a prescribed medication to be taken each Monday, Wednesday and Friday. The Inspector noted that the MAR had been completed to indicate that this had actually been administered on a Monday and Tuesday. This service users MAR sheet had also been amended using correction fluid. The Inspector noted that lists of medication recorded in service users medication risk assessment did not correspond with those recorded on the MAR sheet. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users views are listened to and they are protected from abuse. EVIDENCE: The Inspector viewed the homes complaints policy. This outlines the procedure for making a complaint and a timescale of 28 days for investigating and responding to complaints. The policy also includes contact details for the Commission for Social Care Inspection. The Inspector viewed the homes complaints log, and noted that no complaints had been received to date. The Inspector also viewed the homes adult protection policy. This includes guidance for staff on possible indicators of abuse and outlines staff responsibilities to report adult protection concerns. The policy makes appropriate reference to the need to inform the local adult protection officer and the Commission for Social Care Inspection of any adult protection allegations. The home has a separate whistle blowing policy. The Inspector was advised by the Registered Manager of one incident of adult protection concern since the last inspection. This relates to allegations made by a service user against a support worker from the placing authority who was been escorting them on community activities. This has been appropriately reported to the local adult protection officer and a strategy meeting is pending. However, the Inspector noted that the home had not notified the Commission for Social Care Inspection of this incident. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 18 The Inspector met privately with one support worker. They demonstrated a good understanding of adult protection issues and were able to identify different types of abuse. The staff member was also aware of the homes policy and understood their responsibilities, including reporting any concerns. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 19 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, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from generally well-maintained and comfortable environment. EVIDENCE: The Inspector toured the communal and staff areas and the three service users bedrooms. The current registration and insurance certificates were prominently displayed in the entrance hallway. To the rear of the property there is a communal lounge. The lounge has been decorated with photographs of service users. There is a large kitchen to the rear of the property with access via patio doors to a patio and lawned area. The communal lounge/dining area has a sofa and other comfortable seating and has a satellite TV and stereo system. In the lounge area the curtains were not properly hung, carpets were worn and the walls were grubby and would benefit from repainting. The boiler is situated in the lounge area and overhangs a sofa sited underneath it, causing a potential health and safety hazard. The sofa has started to show signs of wear to the arms. In the kitchen several of the cabinets had loose doors and a number of handles were missing. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 20 Also on the ground floor there is a large bathroom with bath, WC and washing machine. The Inspector noted that the flooring in the bathroom was not properly fitted around the WC. One service users bedroom is also located on this level. On the first floor there is a staff office, storage cupboard, and a small shower room with WC and a lockable door. A further two service users bedrooms are also located on this level. The homes premises provide sufficient private and shared space for service users and furnishings and equipment are of a domestic nature. Each service user has a 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 smaller service users bedroom on the first floor was noted to have worn carpeting that would benefit from replacement. The Inspector found the premises to be clean, hygienic and free from offensive odours. However, potentially hazardous cleaning materials were being stored under the sink and not in a locked cupboard. Aytun Care Home DS0000062024.V300187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes recruitment practises protect service users and a high proportion of staff is NVQ qualified. However, the home must ensure that staffs receive regular supervision. EVIDENCE: During the course of the inspection staff members were observed by the Inspector to be accessible to, approachable by and comfortable with service users. The Inspector was advised that five staff have competed NVQ level 2 and that another staff member is due to start NVQ level 2 shortly. The staff member interviewed by the Inspector demonstrated a good understanding of how to promote service users dignity and respect whilst providing personal care. They told the Inspector how they seek the service users consent prior to starting assistance, establish how the service user would prefer to receive that assistance and make sure that any doors or curtains are closed. The staff member stated that where service users are able to assist themselves, they would leave them to privately complete these tasks and return later. The Inspector viewed the homes staffing rota. This was found to accurately reflect the situation in the home at the time of the inspection. In addition to the Registered Manager, the home has a Deputy Manager and five support Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 22 workers, including one waking night staff. The home has a recruitment policy and procedure that has been revised since the last inspection. This states that two satisfactory written references and a Criminal Records Bureau (CRB) check must be obtained for each new employee. The home has developed an induction programme for new staff members. A copy was seen by the Inspector who noted that it includes information on emergency procedures and provides general introductory information on the home. The Inspector sampled two staff personnel files. One staff member had commenced employment in February of this year, and the other in May. A completed application form and two satisfactory references were available on both files, as were photocopies of proofs of identity and educational and training certificates. A completed induction checklist, contract of employment and job description were also found for each sampled staff member. The staff member who started in February was evidenced as having a “POVA first” check and a CRB enhanced check undertaken by the home. The other staff member has a “POVA first” check obtained by the home and has applied for an enhanced CRB though the home. The Inspector sampled supervision records for the member of staff who commenced employment in February 2006 and evidenced supervision as occurring on one occasion. The Inspector also sampled supervision records for a long-standing care worker and evidenced that they had received supervision on five occasions in 2005 but only once in 2006. The Registered Manager advised the Inspector that the home has developed a core training programme, and all staff must complete this. Identified training includes first aid, moving and handling, health and safety and food hygiene. The Inspector noted that this does not include medication training and recommends that this is included as core training and is undertaken by staff as a priority. The Registered Manager maintains a centralised record of all training undertaken by staff. To date this year, the home has organised Infection Control and HIV awareness training for all staff. Aytun Care Home DS0000062024.V300187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 & 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a generally well run home. However, identified health and safety issues must be attended to and the quality assurance process fully implemented. EVIDENCE: The Registered Manager has successfully completed their NVQ level 4 studies and has a background as a qualified nurse. On the first day of the inspection the Registered Manager was away from the home, and the officer in charge advised the Inspector that policies and procedures were not available in the Managers absence. The records sampled by the Inspector during the course of the inspection were found to be generally up to date and accurate, although the Inspector noted that some records, for example individual plans and risk assessments had not been signed and in some cases dated. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 24 The home has developed a quality assurance process that includes surveying service users, staff members, visiting professionals and service users relatives. At the time of this inspection three staff surveys and one service user survey had been completed. The home should fully implement its quality assurance process and collate and publish the outcomes. The Inspector sampled a number of records relating to health and safety issues. The home maintains an accident and incident book, although no entries have been made to date. The homes fire records evidence that weekly fire alarm tests are carried out and that all alarms are in working order. In addition 4 fire evacuation drills have been held this year and recorded with evacuation times. A daily log of fridge and freezer temperatures is maintained and this record indicates that temperatures are maintained within acceptable parameters. The Inspector asked to view the homes record of water temperatures but staffs were unable to locate this. An inspection of the homes fridge and freezers evidenced that prepared foods in both had not been date labelled. In addition, started processed foods in the fridge such as pasta sauce had also not been date labelled. The Inspector also noted that fire doors in the communal lounge had been wedged open thereby creating a health and safety hazard. Since the last inspection the home has developed a business plan. This was sampled by the Inspector and was found to include financial projections for the business. Aytun Care Home DS0000062024.V300187.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 1 3 X 4 X 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 2 3 3 2 3 Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 & Sch 3 Requirement New service users must only be admitted on the basis on a full assessment undertaken by the home by people competent to do so. This is a restated requirement. Previous targets of the 31/02/06 and 01/07/06 were not met. The home must ensure that it obtains a copy of the health or social services care management assessment as part of the referral process. Individual service users plans must address all aspects of personal and social support. Timescale for action 30/09/06 2. YA6 15 30/09/06 3. YA9 13 This is a restated requirement. Previous targets of the 13/02/06 and 01/07/06 were not met. The home must ensure that a 30/09/06 manual handling risk assessment is completed and regularly reviewed for each service user who requires assistance with transfers. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 27 4. YA19 12 5. YA20 13 & 17 This is a restated requirement. The previous target of the 01/07/06 was not met. The Registered Person must ensure that assessed healthcare needs such as physiotherapy exercises are addressed in the care plan and carried out as required. The home must revise its controlled drugs policy to address the storage of such substances. Medication must be administered in accordance with its prescription. Dossett boxes must be correctly loaded and include a record of the medicine contained within the dossett. Discontinued medications must be appropriately disposed of. Correction fluid should not be used on the MAR sheet. All lists of medication must correspond. Medication refresher training should be prioritised for all staff. All adult protection concerns must be notified to the Commission for Social Care Inspection in line with the homes adult protection policy and procedure. The home should keep the Commission for Social Care Inspection advised of any planned strategy meetings and their outcome. The ground floor bathroom requires the following repairs: DS0000062024.V300187.R01.S.doc 30/09/06 30/09/06 6. YA23 13 & 21 30/09/06 7. YA24 13, 23 & 39. 30/09/06 Aytun Care Home Version 5.2 Page 28 The floor covering around the WC must be properly fitted. This is a restated requirement. The previous target of the 01/07/06 was not met. In the communal lounge area the following maintenance tasks must addressed: (i) (ii) (iii) (iv) (v) The curtains must be properly hung. The worn carpet should be replaced. The walls should be repainted. The sofa should be replaced. The furniture should be repositioned to address the potential health and safety hazard of the overhanging boiler. In the kitchen the following maintenance issues must be addressed: (i) (ii) Missing door handles must be replaced. Cabinet doors must be securely fitted. 8. 9. YA36 YA39 13. YA42 Worn carpet in the smaller of the second floor bedrooms must be replaced. 12 & 18 Staff must receive regular, 30/09/06 recorded supervision meetings at least six times per year. 24 The home must fully implement 30/09/06 its quality assurance policy and procedure and collate and publish its outcomes. 12, 37, 23 Processed and prepared foods 30/09/06 & 16 stored in the fridge must be labelled with a start and use by DS0000062024.V300187.R01.S.doc Version 5.2 Page 29 Aytun Care Home date in accordance with the product instructions and food hygiene and safety practises. This is a restated requirement. Previous targets of the 13/02/06 and 01/07/06 were not met. Prepared foods stored in the freezer must be labelled in accordance with good food hygiene practises. Potentially hazardous cleaning materials must be stored in a locked cupboard. The home must ensure that water temperatures reamin within acceptable parameters and maintain a record of actual water temperatures within the home. Fire doors must not be wedged open. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA35 YA40 YA41 Good Practice Recommendations The home should review its core training programme and consider adding medication training to this list. A copy of the homes policies and procedures should be available to staff and service users at all times. The home should ensure that the records it produces are signed and dated. Aytun Care Home DS0000062024.V300187.R01.S.doc Version 5.2 Page 30 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.V300187.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!