Inspection on 07/09/06 for Azalea House 2

This inspection was carried out on 7th September 2006.

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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Azalea House 2 24/10/08

Azalea House 2 16/07/08

Azalea House 2 16/08/07

Azalea House 2 15/05/06

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Azalea House 2 69 Winifred Road Bedford Bedfordshire MK40 4EP Lead Inspector Pursotamraj Hirekar Unannounced Inspection 7th September 2006 3:55 Azalea House 2 DS0000066691.V311676.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 Azalea House 2 DS0000066691.V311676.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. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Azalea House 2 Address 69 Winifred Road Bedford Bedfordshire MK40 4EP 01234 342215 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) Minster Pathways Limited Jan West Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2006 Brief Description of the Service: Azalea Services are two privately owned care homes situated in a residential street on the west side of Bedford. The two adjacent houses operate in conjunction with each other. House 1 is registered for 4 service users who have a diagnosis of learning disabilities and mental health needs; house 2 is registered for 3 people in the same category. The purpose of the service is to offer appropriate support for service users, including developing or maintaining their independence skills. This house, adjacent to the main house next door accommodates 3 service users. The house is a large domestic property and offers 3 single bedrooms, a lounge; bathing facilities, staff sleeping room, a dining room and a kitchen. One of two current service users regularly goes to the main house next door. There is a garden at the back that connects the two houses. The new owner will carry out major re-development and refurbishment of the houses. The plan is that the office is to be moved into an extension in the back garden, the refurbishment of bathrooms and laundry facilities takes place and generally environmental standards are improved. The house is located approximately one mile from the town centre and within walking distance of local shops, pubs and transport links. The fee quoted by the manager was in the range of £700-£1300. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 07/09/06 over 4 hours by pursotamraj hirekar. The method of inspection included review of outstanding requirements, study of care plans, risk assessments, discussion with the service users’, staffs on duty, partial tour of the premises and observations. The manager coordinated the inspection. What the service does well: What has improved since the last inspection? What they could do better: The goal planning and monthly monitors needed review and update for all the service users’. Service users must have an up to date contract that addresses all points from standard 5 Staffs’ recruitment procedures need to be adhered to before employing any staff member. The identified training needs of staffs’ needed to be implemented as planned to avoid any risk of service users being managed inappropriately. The manager must be more assertive in working with colleagues and also needed support from the senior management to run the home well in the best interest of the service users’. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 6 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. Azalea House 2 DS0000066691.V311676.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 Azalea House 2 DS0000066691.V311676.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had a good admission procedure, including written information, to provide service users with the opportunity to make an informed choice about the home and make sure that their needs would be met. The service users’ contracts needed completion. EVIDENCE: The statement of purpose and service users’ guide was reviewed and updated to make it more specific to the home. Both the documents were user friendly for the comfort of service users’ and their representatives. The manager was asked to keep separate sets of document for each home, to maintain the autonomy, as both these homes were registered as autonomous institutions. A requirement was made in the previous inspection reports that service users must have an up to date contract that addresses all points from standard 5. The timescale to comply with this requirement was extended twice, on this inspection the manager had asked for another extension of time to comply with this requirement before 28/09/06. The service users needs and aspirations were assessed prior to their admission into the home and were incorporated into their respective care plans. Azalea House 2 DS0000066691.V311676.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had made adequate arrangements for assessments of individual needs and choices of service users. However, goal planning and monthly review needed regular update. EVIDENCE: Currently, in all there were 4 service users’ at both the homes. 2 service users’ 1 from each home was case tracked on this inspection. The home had made adequate arrangements for assessments of individual needs and choices of service users. Service user –1 the 6 monthly risk assessments were reviewed on the 11/05/06 and care plans were reviewed on the 06/09/06. Assessed needs and choices were then incorporated into the care planning process which included assessment of practical independence of service users’, risk assessments, dietary plan, weekly menu offered, food intake monitoring form, weight chart, medication chart, medication change history chart, blood tests, health screening and immunisation records, daily diary, medical appointments, and contacts with advocacy alliance. However, the goal planning and monthly monitors needed review and update from 05/05/06 onwards, the manager had Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 10 agreed on this inspection, to complete before 20/09/06 for all the service users’. Service user –2 risk assessments were reviewed on 01/02/06, 23/08/06 and 24/08/06 and the care plan was prepared on the 07/09/06. The manager was unable to provide a copy of the care plan reviewed on this inspection. Challenging behaviour fortnightly monitor chart was last dated 20/04/06. However, behaviour management plan was update on the 22/08/0. Dietary plan, weekly menu offered, food intake monitoring was dated 29/05/06. The manager saw key worker monthly reports and there were no record of manager’s comments, signature and date on the same. Medication chart, medication change history, blood test, GP, dietician and chiropodist appointments were recorded and maintained. Azalea House 2 DS0000066691.V311676.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home offered choice to service users in choosing their lifestyle, their activities and to form relationships as they wanted. EVIDENCE: The home had made appropriate arrangements and developed service user specific individual activity plans that meet their lifestyle needs. On the 14/08/06 weekly activity plan was reviewed. A weekly activity programme was agreed and displayed on the notice board for each individual. This way, users were encouraged to develop their own initiative and the activities included attending college, baking cakes at home, swimming, going out with staff for pub lunches, going to the library or, as they chose, just resting at home with music or TV. This programme covered different times during the day and included evenings. Service users were observed interacting with each other and with staff, and their relationships seemed friendly and supportive. The home had a dietary plan and menu was prepared on a weekly basis service Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 12 users had the choice of menu and the food intake was monitored on a weekly basis. The service users’ moved freely between houses and enjoyed that freedom. The service users’ had a designated space for smoking in the rear part of the home and the staffs supported the service users’ to follow. The service users’ had no problem in following the smoking policy of the home. Fresh fruit was on a table during the site visit. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The staff encouraged independence, but also supported service users to meet all their healthcare needs. EVIDENCE: On this inspection 2 service users’ were case tracked 1 from each home. As part of the needs assessment and care plan process the home had organised and maintained various records pertaining service users’ health and well being that included; Involvement of external health professionals and included basic healthcare needs, such as frequency of dental, opticians, chiropody appointments, medication chart, blood tests, health screening, immunisation and weight chart. Medication was stored, recorded and administered appropriately. The staff had good knowledge of medication. Service users were also well informed about their medication. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 14 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 and 23 Quality in this outcome area is good. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had an effective complaints policy and procedure that enabled service users to express their opinions and potential dissatisfaction. EVIDENCE: The home had developed policies and procedures that included adult abuse and protection, aggression towards staff, bullying in the workplace, racial harassment, whistle blowing and staff grievances. There was no evidence of any complaint since the previous inspection. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 15 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 and 30 Quality in this outcome area is good. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had made changes to the environment that had positive impact on the service users’ and the staffs’. EVIDENCE: 1 bath in home 71 was replaced and 1 bath was refitted in home 69. The door lock needed repair, a mirror needs to be fixed in home, toilet roll holder and a handrail needed fixing. Home 69 and 71 kitchens’ have new cooker, new fridge freezer, all the cupboards changed, new flooring, waiting for new boiler in 71 to be fitted, and new dishwasher fitted in 71 and waiting for 69. Washer dryers were replaced in home 71 and 69. The had maintained hot water outlets daily checks of various points that include bathroom, toilet, kitchen sink, kitchen hand wash and office. The home had also completed various cleaning tasks of both the homes, which was recorded systematically to include frequency, time, date and signature of the person doing the job. Fire extinguisher checks were dated January and May 2005 and date of next checks recorded January and May 2006. There was no further evidence available on this inspection. The home was clean and tidy without any offensive odours. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 16 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, 34 and 35 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The fully staffed team achieved recently after latest recruitment ensured that consistent and appropriate care was provided for service users. However, the identified training needs of staffs’ needed to be implemented as scheduled and recruitment procedures need to be adhered to before employing any staff member to avoid any risk of service users being managed inappropriately. EVIDENCE: The home had undertaken staffs’ needs assessments and developed staffs’ training plan. The details of training received by each individual staff member and the commission on 18/09/06 received the plan for future training programme. The various trainings received and planned included induction and foundation, NVQ2, NVQ3, NVQ4, first aid, fire safety, infection control, moving and handling, health and safety awareness, boots medication, POVA, conflict management, mental health, diversity, safer foods better business, food hygiene and anger management. On this inspection 3 staffs records were seen. Staff –1 was working since 11/02/04 had CRB checks and references, the contract of employment need to be signed. Staff –2 had CRB checks, references and contract of employment was signed. Staff – 3 working since 17/04/06 had POVA check done on 10/04/06, no CRB check, no contract and had references. The monthly staffs supervision was regular and supervision record was signed. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 17 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, 42 and 43 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. There has been considerable improvement in the management of the home since the previous inspection. However, manager needed to be more assertive in working with colleagues and also needed support from the senior management to run the home well in the best interest of the service users’. EVIDENCE: As was the requirement in the previous inspection report, all staffs now have clear job descriptions but not even a staff member have signed the same, the manager had suggested to complete before 15/09/06. The home had developed and canvassed the quality assurance forms with various professionals, service users’ representatives and families. The professionals included psychologist, social workers and occupational therapist. On this inspection there was no evidence of clear procedure on how to deal with any issues or concerns that were raised in the quality assurance feedback. The manager had agreed to develop the procedure and sent it across to the commission, which was received by the commission on 18/09/06. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 18 The home had some 44 various policies and procedures, which were generic in nature. However, the home had reviewed some of those policies and updated to meet the specific needs of the 2 homes. The policies and procedure reviewed were guidelines to deal with late returns-night log register, adult abuse and protection, aggression towards staffs, bullying in work place, communicable diseases and infection control, medication, fire safety, health and safety at work, management of service users’ money, racial harassment, admission policy, smoking, alcohol, staff supervision, whistle blowing, reporting of sick leave, annual leave, staff grievance and discipline. There has been a considerable improvement with regard to the management of the home, which has been detailed under various outcome groups, especially the environment. However, on this inspection, records pertaining to service users assessments and contracts were not available and the manger said that they were missing and expressed helplessness after checking with staffs. The manager needed to be more assertive in working with colleagues and also need support from the senior management to run the home well in the best interest of the service users’. The staffs training and supervision is detailed under staffing outcome group. Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 19 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 2 3 X 3 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000066691.V311676.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Azalea House 2 Score 3 3 3 X 2 X 3 X X 2 2 Version 5.2 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 YA6 2. YA5 5 Standard Regulation 15 (2) b Requirement The goal planning and monthly monitors needed review and update for all the service users’. Service users must have an up to date contract that addresses all points from standard 5 (This requirement was set on the previous inspection with deadline 15/05/06 and a new time scale was set on this inspection.) Staffs’ recruitment procedures need to be adhered to before employing any staff member. Timescale for action 20/09/06 28/09/06 3 YA34 4 YA32 19 (4) b 30/10/06 18 (1) c The identified training needs of 30/11/06 staffs’ needed to be implemented as planned to avoid any risk of service users being managed inappropriately. The manager must be more assertive in working with colleagues and also needed support from the senior management to run the home well in the best interest of the service users’. 30/10/06 5 YA42 13 Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 21 6 YA43 24 The home must have clear lines of accountability within the home to ensure effective management process was in place. 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Azalea House 2 DS0000066691.V311676.R01.S.doc Version 5.2 Page 23 - 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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