Inspection on 05/05/04 for Cowden Road, 52 - 54

Care Homes For Adults (18 ­ 65)Cowden Road, 52 - 5452 - 54 Cowden Road Orpington Kent BR6 0TRUnannounced Inspection5th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Cowden Road, 52 - 54 Address 52 - 54 Cowden Road, Orpington, Kent, BR6 0TR Email address Tel No: 01689 896591 Fax No: 01698 896591Name of registered provider(s)/company (if applicable) The Avenues Trust Limited Name of registered manager (if applicable) Mr Andrew Crees Type of registration Care Home No. Of places registered (if applicable) 5Category (ies) of registration, with (number of places) Learning disability (5) Registration number G010000075 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 30th July 2002 Yes NO 11/12/03 If Yes refer to Part CCowden Road, 52 - 54Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 35th May 2004 09:30 am Mrs Joan FordID Code096059Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionCowden Road, 52 - 54Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementCowden Road, 52 - 54Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Cowden Road, 52 - 54. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Cowden Road, 52 - 54Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 52/54 Cowden Road is a modern end of terrace house, and an inner terraced house, converted into one property, providing support in a residential setting for five adults of either sex with learning disabilities. The home is situated in a residential area within a cul-de-sac, close to Orpington Town Centre, with a good range of shops, leisure facilities and public transport links. Central heating is provided to all areas of the home and residents can control the temperatures in their own bedrooms. Some of the radiators are guarded as part of a rolling programme, to lessen the risk of an accident, giving priority to the areas deemed to be at a higher risk. Residents accommodation is on two floors accessed by steep stairs with a sturdy banister either side, which makes it unsuitable for people for people with significant mobility difficulties. The residents have access to an attractive and wellmaintained garden to the rear of the house, in which the staff and residents have planted a variety of vegetables, along with the flowers and shrubs. Each of the residents has their own bedroom. One bedroom, on the ground level, has access to an en-suite shower and toilet facility. All of the other bedrooms have their own vanity hand washbasin with hot and cold running water.Cowden Road, 52 - 54Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The home has a warm and homely atmosphere. The inspector met and spoke to three of the service users and two staff members on the day of the unannounced inspection. One service user answered the front door. The home was clean and tidy; one service user was at home on a social training day. Another service user was in the lounge listening to music, watching a video and reading their daily paper. Both service users looked comfortable and relaxed in their home environment. All of the service users who spoke to the inspector were satisfied regarding the care and accommodation provided at the home. Choice of Home (Standards 1-5) Three of these standards were met. The home requires a full and holistic pre-assessment to be carried out by the care manager of the placing authority and any other professionals involved with the care of the prospective service user. Families are fully involved in the admission process and throughout the service users continuing care if the service user wishes them to be. On admission to the home there is a trial period of six weeks or longer if required. All of the service users had a copy of the homes service user guide and provided with a written contract. Individual Needs and Choices (Standards 6-10) Five of these standards were met. All of the service users had an individual care plan based on their pre assessment and the initial assessment as part of the homes admission procedure. Each service user has a social training day and takes part in small household domestic tasks relevant to their personal needs. Service users are given the choice of all aspects of their daily living. All risk management strategies are agreed and entered in the residents care plan and reviewed on a regular basis. All staff members are made aware of the issues of confidentiality as part of the organisations policy and the Data Protection Act 1998. Lifestyle (Standards 11-17) Five of these standards were met. The homes support workers will encourage all of the service users to develop and maintain their independent living skills, domestic and social activities. Records show that service users are well supported by staff members to maintain their skills and the service users who spoke to the inspector verified this. The records of food provided show that service users have a choice of nutritious wholesome and varied meals.Cowden Road, 52 - 54Page 6 Personal and Healthcare Support (Standards 18-21) Three of these standards were met. Risk assessments are carried out where applicable and maintained on the individual service users file. Each of the service users has a personal care plan. All service users are registered with a local GP all specialist services are referred to by the GP or social services `Community Team for People with Learning Disability. Concerns, Complaints and Protection (Standards 22-23) Two of these standards were met. The home has a complaints policy that is also available in `Makaton and audiotape format. There is also an adult protection policy and `Code of Conduct that all staff is made aware. All complaints are dealt with within 28 days. Environment (Standards 24-30) Five of these standards were met. The premises are in keeping with the local community housing and have a style and ambience that reflects the homes purpose. The furnishings and fittings provided are of a good quality and domestic in style. New carpets had been fitted throughout the ground floor corridor area. The bedrooms are personalized and comfortably furnished to a good standard. There are private areas available to residents to see their visitors if they wish. The home has a programme of regular maintenance checks of both the premises and the equipment. This is carried out as part of the monthly audit to ensure continued safety within the home. Staffing (Standards 31-36) Five of these standards were met. Members of staff are required to undertake an induction-training programme and are made aware of the homes aims and objectives and the code of conduct that they are required to sign. All staff members are encouraged to develop and maintain relationships with the service users group they support. The home operates a key worker system and provides a one-to-one key worker with the current service users. The home has a dedicated training budget. Conduct and Management of the Home (Standards 37-43) Six of these standards were met. The manager demonstrates that he maintains and updates his knowledge, skills and competence by undertaking regular and periodic training. The home carries out a monthly audit and an annual assessment of the homes development and future requirements. Policy manuals provided are monitored and updated on a regular basis with input from staff members and service users involvement through the organisations policy and review group wherever possible. The Registered Manager ensures so far as is reasonably practical the health and safety of service users and staff members.Cowden Road, 52 - 54Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations? The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 23 YA1818 &29 The Registered Person must ensure that suitable adaptations are made and equipment provided to meet the changing need of service users. The Registered Person must ensure a record of all information and documents in respect of persons carrying on managing or working at a care home is maintained at the care home as specified in Schedule 2 and 4. The home has demonstrated that it is working towards compliance. 2 13 30 & 38 Met 1 April 2004217YA3434March 2004The Commission for Social Care Inspection to ensure compliance in regard to the above requirements is taking action. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Cowden Road, 52 - 54MET (YES/NO)Page 8 YESCowden Road, 52 - 54Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 7,9,19 YA3434 Schedule 1 The Registered Manager must ensure a record of all persons employed is kept in the care home. July04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10. Cowden Road, 52 - 54 Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. Of care staff employed (excluding managers) Total No. Of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NO YES NO YES NO YES YES YES YES NO YES NO YES 3 0 0 YES YES YES YES 4.05 X 5/5/04 10.00 6.00Cowden Road, 52 - 54Page 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Cowden Road, 52 - 54Page 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 556.00 750.00 Range of fees charged From To £ £ (Per week) YES Any charges for extras If yes, please state what the extras are Hairdressing, newspapers, toiletries. 4 Key findings/Evidence Standard met? The homes statement of purpose provides all of the information as required within Schedule 1 and includes a copy of the homes last inspection report and complaints procedure. This is also available in a CD Rom format accessible to all service users. Each service user is provided with the homes service user guide and the individualised folders are kept in their room. The guide contains staff details and a photograph of the service users key worker and the current service users. Photographs and pictures are also included of the homes facilities provided and the local amenities and places of interest within the community. Information is provided in Makaton/picture format if required.Cowden Road, 52 - 54Page 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Service users are referred via social services care management. A pre assessment is required by the home to be carried out by care management and any other professionals involved with the prospective service users health/care. The homes procedure for prospective service users and a pre-admission and admission form are available to staff members who are aware of this and is to be used as part of the service users care planning. Families are fully involved in the admission process and throughout the service users continuing care if the service user wishes them to be. A copy of the review reports are made available to relatives if they are unable to attend the service users review. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home had access to specialist services through social services community health team for people with a learning disability. Service users who might have a dual diagnosis advise and treatment is sought through the intervention of the teams psychiatrist or psychologist in conjunction with the service users GP. Regular six monthly reviews are held with the service users and their GP or more frequent if required. Other specialist services are obtained such as advise and support for one service user through the `Parkinsons Societies nursing services. The manager had undertaken training within this specialism regarding the quality of care and this is to be extended to other staff members within the home. The home demonstrates they communicate effectively with the service users. Two staff members had undertaken Makaton training symbols and signs were available to the service users. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Prospective service users are invited to visit the home as often as they wish. They are invited to meet with the current service users and staff group. Stay for meals or join in any of the activities/social gatherings within the home. The service user is introduced to their room and will have an input to personalise their bedroom. On admission to the home there is a trial period of six weeks or longer if required. This is geared to the service users individual needs and ability.Cowden Road, 52 - 54Page 14 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All of the service users are provided with a written contract that is signed by the resident and a copy maintained on their individual file. This includes information on the accommodation to be provided and a statement of the homes terms and conditions. A copy of the homes complaints procedure is included along with the furniture to be provided and the fee charged. Contracts can be provided in a format/language to meet the individual residents needs where required.Cowden Road, 52 - 54Page 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? The home had developed and implemented the `Person centred Plan system as part of the service users care planning. These include background information of the service user, communication, education, health and personal care, daily living, spiritual and cultural needs. All of service users had an individual plan based on the pre-assessment and initial assessment. The plans detail action staff members are required to take regarding the service users personal care needs and their preference on how this is delivered. Service users individual folders are distinctive and had been chosen by the service users that are easy to identify. Service users demonstrated that they are aware of the role of the care manager and the home support worker. Service users are fully involved with their care planning that may include any other professional body involved in their care, wellbeing, and/or their changing needs. Case reviews are held 6 monthly and key worker meetings 2 monthly or more frequent if required. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service users said they had a choice in all aspects of their daily living. The current service users felt they are able to voice their likes and dislikes. The inspector noted the support workers discussing options with the service users and offering them a choice. Service users are encouraged to manage their own monies with staff support if required. Service users choose to hold their personal allowance in a lockable tin in their room, they are also encouraged to use public transport where they are able and to their own ability.Cowden Road, 52 - 54Page 16 Standard 8 (8.1 ­ 8.5) The registered manager ensures 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. 4 Key findings/Evidence Standard met? Each service user has a social training day and takes part in small household domestic tasks relevant to their personal needs as demonstrated at the time of the inspection. Records of activities are maintained and reviewed at key workers meeting and service users reviews. Statistics of service users activities is maintained and collated annually and a pie chart is made available to monitor the variety and consistency of activities taken. Service users are also involved in the selection of new staff members and staff will support them to set out questions. Service users also receive feedback regarding the outcomes of their involvement. Standard 9 (9.1 ­ 9.4) Staff enables service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? A risk assessment is carried out on all aspects of the service users care and social requirements records are maintained in the individuals care plan. Risk assessments seen refer to travel training, holidays or day trips for each individual. Other risk assessments carried out regarding the service users safety include, bathing, hot water temperatures and the general health and safety aspects of household tasks along with the action to be taken and how to minimise the risk if it is found to be worthwhile. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? All staff members are made aware of the issues of confidentiality as part of the organisations policy and the Data Protection Act 1998. All staff members are required to sign as part of their induction programme. Service users are informed of their right to access their records and are reminded in the house meetings and records are kept.Cowden Road, 52 - 54Page 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enables service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Specialist services are available through the service users GP, care management/specialist team within social services. The homes support workers will encourage all of the service users to develop and maintain their independent living skills, domestic and social support. The support workers it was said will also provide opportunities for residents to fulfil there spiritual needs. Two service users attend their place of worship twice a week.Standard 12 (12.1 ­ 12.6) Staff helps service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Service users are encouraged to maintain their links and contacts within the local community. One service user helps out at a local day centre. Another service user works part-time in a `café linked into a day centre and had undertaken `food hygiene training. Records show that service users are well supported by staff members to maintain their skills and this was demonstrated at the time of the inspection.Cowden Road, 52 - 54Page 18 Standard 13 (13.1 ­ 13.5) Staff supports service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Service users are encouraged and supported by staff members to maintain their links within the community and to make full use of the amenities. All of the service users are members of the local libraries. Service users are within easy reach of Orpington Town Centre with all of its shops and leisure facilities and make good use of them with support from staff. Service users are registered to vote and staff will assist if required.Standard 14 (14.1 ­ 14.6) Staff ensures that service users have access to, and choose from a range of, appropriate leisure activities. 4 Key findings/Evidence Standard met? It was noted that the service users had a variety of individual activities. From the inspectors discussions with the service users and the records maintained show that service users are encouraged to use the local amenities and resources for their entertainment either as a group or on an individual basis. Holidays are planned on an individual basis and staff members support the service users to organise and arrange their holiday. Holidays arranged for this year include the Norfolk Broads, Eastbourne, Yorkshire, Germany and France. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Staff members encourage service users to maintain their links and contacts within the local community. Two service users visit their family on a regular basis and are encouraged to maintain regular contact through birthdays and Christmas. Visitors are welcome at all times and service users said they may see their visitors in private or in the communal areas if they wish and can offer refreshment to their visitors.Cowden Road, 52 - 54Page 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Staff members demonstrated their awareness of the values of privacy and dignity at the time of the inspection. Staff members were seen to ask the service users permission to enter their room. All service users had a key to their own room and to the front door of the home. Appropriate locks had been fitted to all bedroom doors that can be accessed from the outside in the case of an emergency. The preferred terms of address is entered on the services users care plan. It was noted that service users had access to all communal areas of the home. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users have weekly meetings to plan the menu and organise the food shopping for the week. The records of food provided show that service users have a choice of nutritious, wholesome and varied meals. All service users have the opportunity to individually take part in cooking the main meal with assistance from staff members as required.Cowden Road, 52 - 54Page 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provides sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Service users seen at the time of the unannounced inspection were neatly dressed in their own choice of clothes. A staff member of the same gender will provide personal hygiene care to service users in private. Mealtimes are flexible, particularly breakfast, and would depend on the individual service users daily commitment. The home had carried out risk assessments, where applicable, and maintained on the individual service users file. A risk assessment for a particular service user regarding getting in and out of the shower and how the service user prefers to be assisted was well documented and maintained on their care plan.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. Of incidents where service users have been taken to Accident & Emergency during last 12 months No. Of service users with pressure sores at the time of inspection (From information taken from care notes) 103 Key findings/Evidence Standard met? Details of the service users care needs and how care is to be delivered is entered on their personal care plan that also contains their health care needs. Records of visits to the GP and other health care professionals are maintained. The records also include appointments to NHS and other primary care services. If the resident is unwell the visiting medical officer will visit them in their own home. All service users are registered with a local GP all specialist services are referred to by the GP or social services `Community Team for People with Learning Disability. One accident had been recorded since the last inspection. The home has a copy of the accident record book that is compliant with the `Data Protection Act. Cowden Road, 52 - 54 Page 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Four service users are currently on medication. All staff members receive training on the safe handling and administration of medications held within the care home and staff signatures is maintained on file. Two-service users self-medicate and written confirmation had been provided by their GP. Risk assessment and self-assessment charts regarding selfmedication is maintained on the service users files. All medication seen was securely stored and records of administration clear and up-to-date. The home has a GP assessment and written confirmation on all household remedies taken by individuals in the home. Photographs are maintained on each of the service users medication record. The home had a written contract with the local pharmacist that states they will provide advice support and training to staff members in the home.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The home had a policy on how care staff deal with ageing, illness and what to do in the event of the death of a service user. The service user wishes concerning terminal care would be taken into account and service users who wish may be cared for in their own room if this is what they wish, unless there is a medical reason not to. The majority of staff has attended basic training on bereavement counselling and the home has a policy and procedural guidelines accessible to all staff members.Cowden Road, 52 - 54Page 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. Of complaints made to the home during last 12 months No. Of these complaints fully substantiated No. Of these complaints partly substantiated No. Of these complaints not substantiated No. Of these complaints not yet resolved No. Of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 4 Key findings/Evidence Standard met? The home has a complaints policy that is also available in `Makaton CD Rom and audiotape format and notices displayed and accessible to the service users and their visitors. The homes service users guide containing the complaints policy and procedure is available to all service users, their visitors and staff members. Records of complaints would be maintained with the action taken and the outcome recorded.Cowden Road, 52 - 54Page 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX2 Key findings/Evidence Standard met? The home has a No More Abuse policy available to the service users with an audiotape. The homes policy on `Adult Protection is held within the organisational policy manual. The adult protection policy and `Code of Conduct is available to staff member that they are made aware. All complaints are dealt with within 28 days. The home has a whistle blowing policy available to all residents and staff members. The manager has attended an abuse awareness training day. The Registered Manager is to obtain a copy of the Department of Health `No Secrets. This will be monitored at the next inspection.Cowden Road, 52 - 54Page 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? The home was bright with a welcoming atmosphere at the time of the unannounced inspection. The home provides sufficient and suitable lighting that is domestic in style. All windows above ground level are restricted to reduce the risk of an accident. All fire doors are fitted with a magnetic holder that will release when the alarm is activated. The home offers transport to access the local amenities. The premises are in keeping with the local community housing and has a style and ambience that reflects the homes purpose. The furnishings and fittings provided are of a good quality and domestic in style.Cowden Road, 52 - 54Page 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. Of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. Of wheelchair users accommodated for in rooms at least 12 sq.m Total no. Of wheelchair users accommodated for in rooms less than 12 sq.m Total no. Of shared rooms at least 16 sq.m Total no. Of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. Of single bedrooms Number of single bedrooms with en suite Total no. Of double bedrooms Number of double rooms with en suite YES NO NO 5 1 0 0 5 01 0 0 03 Key findings/Evidence Standard met? The home provides the same usable floor space as they provided as at 31 March 2002.Cowden Road, 52 - 54Page 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms are personalised and comfortably furnished to a good standard. Service users private rooms have central and bedside lighting. The majority of service users have a music centre and television for their own use. There is a communal comfortable lounge and dining room that both had patio doors leading onto the rear garden. The kitchen and utility room are accessible to all service users.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? The home offers at least the same number of en-suite toilets, bathrooms, showers, toilets and wash-hand basins as they provided at 31 March 2002. It was noted that the shower unit sited on the first floor is not suitable for the current service users specialist needs and is rendered obsolete. However, this could be adapted into a shower unit to meet the needs of the current service users and has been assessed by an occupational therapist for this purpose. The inspector requires this to be reviewed with an action plan to identify when the work is to be carried out. See Requirement 1 under outstanding requirements. The manger informed the inspector funding had been approved for the adaptation and they are waiting for the commencement date to carry out the work. This will be monitored at the next inspection. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home had a good size garden area that is accessible to the service users. The garden provides seating areas and is well used in the warmer weather. There is a pathway and sturdy rail fitted at the front of the home to assist service users with access. The kitchen and laundry facilities are homely and domestic in scale. There are private areas available to residents to see their visitors if they wish. The home is currently a non-smoking home. The home provides an office and sleep-in area for staff members to store their personal belongings.Cowden Road, 52 - 54Page 27 Standard 29 (29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 2 Key findings/Evidence Standard met? Specialist equipment is provided to meet the service users changing needs. There is an emergency call system in all areas that used by service users that is tested on a regular basis and records maintained. The home had a programme of regular maintenance checks of both the premises and the equipment this is carried out as part of the monthly audit to ensure continued safety within the home. One service user had difficulty getting into and out of the bath and the shower unit at the opposite end of the first floor corridor has a large step leading into the shower, space for manoeuvrability is limited and poses a potential harmful risk. See Requirement 1 under outstanding requirements.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean tidy and free of offensive odour at the time of the inspection. The home has policies and procedures for infection control. Staff members and residents are provided with disposable gloves and water-soluble bags for the laundering of soiled articles. Handwashing facilities are prominently sited in the laundry. The home does have a policy and procedures for the segregation and washing of laundry contaminated with body fluids. The homes infection control policy is available to all staff members.Cowden Road, 52 - 54Page 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Competent and qualified staff supports Service users. An effective staff team supports Service users. Service users are supported and protected by the homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? All staff members are provided with a job description. Members of staff are required to undertake an induction-training programme and are aware of the homes aims and objectives and code of conduct that they are required to sign. All staff members had access to the homes policies and procedures. The home does not currently use voluntary staff. All staff members are provided with the `General Social Care Council and copies were available in the home.Standard 32 (32.1 ­ 32.6) Staff has the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home had a key worker system and provides a one to one key worker with the current service users. Staff members have monthly staff meetings and records are maintained. It was demonstrated that staff members have built up links with the community specialist teams as required. All staff members are encouraged to undertake the NVQ and ongoing training relevant to the service user group. Service users said they feel able to talk to staff members if they had any concerns and know they would be listened to. One member of staff is currently undertaking the NVQ level three. There is a training profile for each member of staff with ongoing staff training. The home is working towards 50 of care staff holding the NVQ level two by 2005. The homes induction staff training is working towards the TOPPS training specification.Cowden Road, 52 - 54Page 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. Service users High needs No. Service users Medium needs No. Service users Low needs Total no. Of hours needed No. Of staff with NVQ level 2 or above No. Of Trainees registered on Sector Skills Council training programme 1 1 3 203 2 No. Of full time equivalent Staff with nursing qualification (where applicable) No. Staff hours allocated No. Staff hours allocated No. Staff hours allocated Total Hours Provided X X X 203 Nursing X X X1X3 Key findings/Evidence Standard met? The home has maintained the staffing levels agreed by the previous registering authority. All staff members are encouraged to develop and maintain relationships with the service user group they support. The home benefit from a stable staff group that offer uninterrupted work with individuals One staff member had undertaken the homes induction programme within the first six weeks of their appointment and is due to follow-up with the foundation course within the first six months.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? The homes have a recruitment procedure based on equal opportunities. Copies of the information and documenters in respect of persons carrying on managing or working at the care home must be kept within the home. Schedule 2-4 Regulations 7,9,19. See requirement 1.Cowden Road, 52 - 54Page 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home had a dedicated training budget. All staff members undertake the homes induction training programme. Individual training records are maintained for each staff member and personal development plans had been implemented with training goals set. This also forms part of the annual staff appraisal and possible leads to NVQ training. The profiles seen are well documented. Specialist training such as Parkinsons care, medication and dementia training are identified within the monthly staff supervision.Standard 36 (36.1 - 36.8) Staff receives the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Records of monthly staff supervision and annual appraisal are maintained and staff members are required to sign. The supervision records also monitor work being carried out with individual service users. The records seen were well recorded up-to-date and informative. Records are maintained on staff training and development. This also identified specialist training to meet the residents needs. All staff has access to the homes written grievance and disciplinary procedures. Measures are in place for staff members who may need to deal with physical aggression. This would also be identified and risk assessed on the service users individual care plan.Cowden Road, 52 - 54Page 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES4 Key findings/Evidence Standard met? The Registered Manager had undertaken the `Registered Managers Award and the `Certificate in Management Studies training. The manager had a written job description that indicates their line of responsibility and accountability. The manager demonstrates that they research, maintain and update their knowledge, skills and competence by undertaking regular and periodic training.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? It was demonstrated at the inspection that the manager includes service users in the decision-making and other aspects of their daily living. The inspector observed clear lines of communication between the manager staff and service users and the friendly respectful manner in which staff and management addressed the residents. House meetings are held monthly and records kept. Informal discussions are encouraged around the dining table and on a one-to-one basis.Cowden Road, 52 - 54Page 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The home carries out a monthly audit and an annual assessment of the homes development and future requirements. The service users and staff members are requested to feedback all aspects of the homes environment and care services. The organisation has a questionnaire that is supplied to the service users relatives and other professionals to gauge the services provided. Service users, it was observed, is very interactive and is consulted about events happening in the home.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? All staff members have access to the homes policies and procedures. Policy manuals provided are monitored and updated on a regular basis with input from staff members and service users involvement through the organisations policy and review group wherever possible. Appropriate formats of the complaints and abuse policies seen are accessible to and in a format that would be clearly understood.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Service users have access to their records or any other information written about them. The service users have written confirmation to inform them of their right to see their records that they are requested to sign. They are also reminded it was noted at the house meeting and records maintained. All records held in the home are secure and maintained in accordance with the Data Protection Act 1998.Cowden Road, 52 - 54Page 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? All staff members are required to undertake moving and handling course that is updated annually. Fire safety is undertaken as part of the induction-training programme. Fire drills are carried out monthly and alarm tests weekly and records maintained. All staff is required to undertake a health & safety course. Five staff members have undertaken first aid training. All staff had undertaken food hygiene training. All accidents and incidents are recorded. All cleaning materials are securely stored with some information on COSH available. Hot water temperatures are maintained and thermostatic valves are fitted to baths to maintain the hot water at the required temperature of 43oc. However, it was noted that the hand-wash basins varied in water temperature and some service users hand-wash basins were above the recommended temperature. Thermostats had been fitted to the hot water outlets that are supplied to the service users to lesson the risk of an accident. The home has had non-returnable waste valves fitted to the washing machine and other appliances recommended by the `Thames Water Authority. There was evidence that the manager had carried out a water consumption risk analysis in the prevention of bacteria/legionella. The Registered Manager ensures so far as is reasonably practical the health and safety of service users and staff members. Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met? The Annual House Account was available for inspection. There is nothing to suggest the home has a shortage of staffing provision or equipment. Training, supervision and the managers appraisal, and quality monitoring are carried out on an annual basis via the service manager. Residents are consulted and have input in choosing items for the home. The public liability insurance certificate was displayed and in date for £5 million.Cowden Road, 52 - 54Page 34 PART C(Where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureCowden Road, 52 - 54Page 35 Public reports It should be noted that all CSCI inspection reports are public documents.Cowden Road, 52 - 54Page 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5th May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Cowden Road, 52 - 54 Page 37 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Cowden Road, 52 - 54Page 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Cowden Road, 52 - 54Page 39 - 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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