Inspection on 14/05/07 for Craignish Avenue (4)

This inspection was carried out on 14th May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Craignish Avenue (4) 31/01/06

Craignish Avenue (4) 23/09/05

Craignish Avenue (4) 16/12/04

Craignish Avenue (4) 19/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Craignish Avenue (4) 4 Craignish Avenue Norbury London SW16 4RN Lead Inspector Lee Willis Key Unannounced Inspection 14th May 2007 09:00 Craignish Avenue (4) DS0000039500.V339956.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 Craignish Avenue (4) DS0000039500.V339956.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. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Craignish Avenue (4) Address 4 Craignish Avenue Norbury London SW16 4RN 020 8679 8951 020 8679 1096 claire.adam@croydon.gov.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) London Borough of Croydon Ms Claire Louise Adam Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2) of places Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 08/06/2006, two named Service users (female) over the age of 65 , with a learning disability, can be accommodated within the home. 31st January 2006 Date of last inspection Brief Description of the Service: Craignish Avenue is run by Croydon Borough Council to provide short-stay respite care for younger adults with moderate learning disabilities. There are approximately forty individuals who currently use the Centre on a regular basis, although the duration and frequency of their stays varies considerably. The registered manager, Claire Adam, has worked at the centre for well over ten years and has been in operational day-to-day control for the last two and a half years. The centre operates from a semi-detached terrace house in the heart of Norbury, and is well placed for accessing a wide variety of local shops, cafes, banks, and pubs. The property is also within ten minutes walk of several main line bus routes and a local train station, which have excellent links to south and central London. The centre comprises of five single occupancy bedrooms located on both the first and second floors. All the communal space is concentrated on the ground floor and consists of a main lounge, an open plan dinning area, kitchen, office, and laundry room. The garden at the rear of the property, which has a large lawn and a fully operational greenhouse, is well maintained. Prospective service users and their representatives are supplied with all the information they need to know about the services and facilities provided by the centre, which is also available in ‘easy’ to read formats. The centres current scale of charges ranges from £9.04 to £ 64.96. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process the Commission for Social Care Inspection (CSCI) has judged the centre to have a substantial number of strengths with a sustained track record of delivering a high quality service that ensures good outcomes for service users. Furthermore, where areas of improvement have emerged in the past the centre has always managed these weaknesses well. This unannounced site visit was carried out on a Monday morning between 9am and 12noon. During the course of this three hour inspection all four of the people who had stayed at the centre over the weekend were met, along with the registered manager, a support worker, and a domestic. The remainder of the site visit was spent examining the centres records and touring the premises. As part of the inspection process the centre was also sent a preinspection questionnaire (PIQ) and a number of comment cards for people who use the service and their representatives to complete. The Commission received ten ‘have your say’ comment cards from service users and their representatives. What the service does well: All the written and verbal feedback received from service users and their representatives about Craignish Avenue was extremely complimentary about the quality of the service provided. One service user wrote, “ Staff are all friendly and I have a good time and do lots of things”, while a service users relative said Craignish Avenue was “an exceptional service”. The centre is particularly good at ensuring information about the service and facilities provided are available in formats suitable to the needs of the people who use the centre, and their families. For example, the centres service users guide, care plans, complaints procedures, and satisfaction questionnaires are all written in plain language and illustrated with ‘easy’ to interpret pictures, photographs, and symbols. This ensures information about how the centre is run is more meaningful, interesting, and above all, accessible. The majority of people met who regularly use the centre told us they liked staying at Craignish because it was a good place to meet up with their friends and go on day trips with them. The centre is very good at seeking the views of service users and using this information to plan activities both in the home and in the wider community. Activities are service user focused and can be quickly changed to meet individuals wishes. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 6 The staff team is very experienced and highly motivated. The majority of support workers have already achieved a National Vocational Qualification Level 4 in care. Furthermore, the staff team has remained unchanged for many years thus ensuring they all have a thorough understanding of the particular needs of the service users, and can deliver highly effective person centred care. The centre is also proactive rather than reactive in its approach to staff training and ensures all its staff members undertake additional qualifications beyond the basic required. For example a number of staff have received deaf awareness and British Sign Language (BSL) training in recent years to ensure they are able to communicate more freely with all the service users that stay at the centre using their preferred methods of communication. What has improved since the last inspection? What they could do better: All the positive comments made above notwithstanding there are a few areas of practice the centre could improve upon: People who use the service are given a choice about what they eat and individual’s cultural and specific dietary needs are always catered for. However, the centres manager conceded that more thought could be given to providing service users with better information about healthier eating options. It is recommended that the providers consider sending staff on a healthy eating course to help them to give service users more informed advice about healthy eating. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 7 More suitable floor covering needs to be laid in one bedroom to eradicate the offensive odour that is currently present in this room. All the damaged tiles in the kitchen must also be replaced. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Craignish Avenue (4) DS0000039500.V339956.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 Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they stay over at the centre. EVIDENCE: A copy of the centres recently revised service users guide, which now contains a lot more photographs and pictures than before, was looked at. The manager told us that a new ‘easy read’ format had been introduced to make the guide more accessible to service users. One service user spoken with told us they had seen the new guide and had liked the look of it. Selected three individuals to case track at random. Case tracking confirmed good practice. The manager had recently undertaken a thorough assessment of the individual’s care needs during a visit to the unit. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 10 The manager confirmed that is was customary for all prospective service users to be asked about their religious beliefs and clearly understood the importance of ascertaining this type of information, despite the short stay nature of Craignish Avenue. The two permanent members of staff spoken to were very clear about the importance of offering prospective service users and their representatives the opportunity to visit the centre before deciding whether or stay there. The manager told us that the centres most recent referral had made arrangements to come for tea next week in order to meet some of the staff and other service users. Written admission documentation was adequate and included a copy of the care management assessment. Basic information was available to staff to ensure they could meet the social, emotional and care needs of new service users. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect what is important to the individual, there capabilities and what support they need to achieve their personal aspirations. Excellent systems have been introduced to ensure people who use the service are consulted on, and are encouraged to participate in the day-to-day running of the centre. Consequently, service users have greater freedom to make informed decisions about all aspects of their lives during their time there. The centres arrangements for assessing and managing identified risks are sufficiently robust to ensure service users are able to take ‘responsible’ risks and develop their independent living skills. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 12 EVIDENCE: The manager told us that the forty or so service users who currently stay at the centre on a regular basis all had far more person centred Care plans in place, which had been drawn up with each of them. The individual care plans for the two people selected for case tracking were both examined and contained written statements from the service users about what they wanted to achieve during there short stays at the centre, as well as detailed guidance for staff regarding the actual support they each required to ensure everyone’s unique personal, social and health care needs were met. In addition to identifying individual’s needs care plans also contained a lot of detailed information about what a person enjoyed doing. The manager was able to describe how they use and help develop care plans, and accurately described the plans for the two service users whose care was being case tracked. This knowledge means that service users can be confident that they will get support from people who understand their care needs. All four service users met during an informal group meeting in the lounge said they always attended service user meetings held every Sunday at the centre. The minutes of the last meeting revealed that service users are actively encouraged to share their views about any activities they have engaged in during their stay. One service user told us they had really enjoyed visiting HMS Belfast at the weekend, which had been minuted at last Sundays meeting. It was also positively noted that since the centres last inspection new satisfaction surveys which service users are encouraged to complete after each stay and a suggestions box have both been introduced. The suggestions box is prominently sighted in the lounge and has comment cards attached for people to complete if they wish. One service user seemed particularly impressed with the new suggestions box and told us they had completed three comment cards during the course of their weekend stay. The minutes of the centres most recent staff meetings, which are held on a fortnightly basis, revealed that staff always discuss feedback from service users and acted upon. The centre has clearly demonstrated its commitment to ensuring service users are consulted about and actively encouraged to participate in its day-to-day running. Assessments taken from the two care plans being case tracked contained detailed guidance that enabled staff to provide these individuals with appropriate support and therefore minimise risks associated with specific behaviours that challenged the service. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of activities within the centre and community mean the service users have various opportunities to participate in stimulating and motivating activities during their time there. Dietary needs and preferences are well catered providing daily variation, choice, and interest for the people who use the service. EVIDENCE: A yearly activity schedule has been drawn up which the manager told us is based on what the service users said they liked doing. The schedule showed that plans to visit HMS Belfast in the heart of London had been made sometime ago. Two service users met said this is what they had done at the weekend as arranged. The schedule revealed that service users are given the Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 14 opportunity to take part in a variety of activities both within the home and community. The manager told us the schedule was flexible and is used as a rough guide to help service users decide what activities they want to participate in when they arrive. All the service users met said they contributed to the activity programme and were satisfied that this programme offered more or less what they wanted. As previously mentioned in this report service users views about activities they engage in are ascertained via weekly meetings and various satisfaction surveys. All four service users who had stayed over at the centre at the weekend were occupying themselves watching TV in the lounge, whilst awaiting transport to take them to various day centres. A number of service users spoken to said they liked watching TV with the others in the lounge, although they could now watch television in the privacy of their bedrooms if they wished. The manager confirmed that service users are always offered keys to their bedroom and the front door, and can decide whether or not they want to take on the responsibility. Staff maintain an up to date record of all the food consumed by service users at meal times. The record showed that although service users frequently choose to eat the same meals as their peers there were nevertheless a number of occasions when people had chosen to eat something else. For example, one service user from an Asian background who expressed a preference for far eastern cuisine would regularly choose to have noodle and soy sauce based dishes. Care plans contain detailed information about service users food and drink preferences, as well as their dislikes. The food consumed record also revealed that meals are varied, if not always nutritional well balanced. Two service users spoken with at length about the meals said they were generally very good and that they tended to get what they wanted. The inspector accepts the managers point that it is not always easy to promote healthy eating because of the short stay nature of the centre, which means service user food preferences usually takes precedent over nutritional considerations. Nonetheless, it is recommended that more information and advice about healthy eating options is sought from a dietician and the manager considers sending more of her staff on a healthy eating course. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficiently robust arrangements are in place to ensure the people who regularly stay at the centre receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are always recognised and met. The centres policies and procedures for handling medication are sufficiently robust to minimise the risk of service users being harmed. EVIDENCE: Both the permanent staff on duty during this visit were observed being patient and kind when interacting with the service users. The manager told us that if they felt service users needed to see a doctor or any other health care professionals staff would always notify the relevant parties without delay. Staff maintain detailed records of all the accidents and significant incidents involving service users, which revealed that only one service user had been Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 16 admitted to casualty in the past fourteen months. The Commission was notified about the incident as soon as it occurred and the manager confirmed that the action taken by staff on duty at the time was appropriate. None of the other accidents or incidents involving service users in the same period have resulted in anyone sustaining any ‘serious’ injuries. The centres medication policies are being put into practice and staff spoken to were aware of their content. Records of the receipt of medication, which arrives almost on a daily basis and service users come and go, are extremely well maintained. No gaps or recording errors were noted on medication administration sheets sampled at random. The one member of staff spoken with about the centres medication handling arrangements was acutely aware of the need to vigilant when checking in a new arrivals medication to confirm it matched the centres own records about the individual’s current medication regime. The staff member told us that any discrepancies would be immediately followed up with the relevant health care professionals. During the course of this visit this same member of staff was observed double-checking with a new arrivals GP about recent changes made to the individuals medication. The manager told us that all the centres staff have up dated their medication training in the past year as required at the last inspection. Documentary evidence was made available on request in respect of the two permanent staff who were on duty at the time of this unannounced visit. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The centres complaints and adult protection protocols and sufficiently robust and understood by staff to ensure service users feel safe and listened to. EVIDENCE: A pictorial version of the centres complaints procedure, which is also written in plain language, is conspicuously displayed on a notice board in the entrance hall. The manager told us that no complaints about the centre had been received in the past year, although a number of informal concerns and suggestions had been made in this time. In the past year one service user has been subject to a safeguarding adults referral. The local authority decided not to investigate the matter under its safe guarding adult’s procedures, although the individual’s health is being more closely monitored as a result of the appropriate action taken by the centre. The manager clearly has a good understanding of the local authorities safe guarding adult’s protocols. As previously mentioned in this report, care plans being case tracked contained specific guidance to help staff deal with behaviours that challenged. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 18 Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The centre is domestic in appearance and the condition of the décor; fixtures and fittings are in the main adequate, ensuring service users live in a relatively comfortable environment, which is also safe. EVIDENCE: The centre was immaculately clean throughout. One service user spoken with at length about the bedrooms said they usually liked the room they were allocated, which always contained sufficient storage space for them to put away their belongings. The manager conceded that the furniture and fittings in most of the bedrooms remains rather basic, but is nonetheless adequate to meet the needs of the service users. None of the unit’s bedrooms have been redecorated since 2004, although all the bedrooms viewed looked relatively comfortable. The odour emanating from one of the Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 20 top floor bedrooms is quite offensive and the manager has already obtained a quote for more ‘suitable’ floor covering to be laid in this room. The inspector is also aware that the manager has introduced an intensive cleaning regime to try and resolve this on going hygiene matter. The temperature of the hot water emanating from the centres first floor bath was found to be a safe 42 degrees Celsius, when tested at 10.35am. The manager assured the inspector that the first floor shower facility has been fitted with a suitable thermostatic mixer valve that prevents the temperature of hot water exceeding 43 degrees Celsius. During a tour of the communal areas it was positively noted that all the recommendations made by a qualified occupational therapist who carried out a thorough assessment of the building in 2005 have now been fully actioned. This included the fitting of additional, longer, and ‘newel’ rails, along the length of the centres staircases, and grabs rails in all the bathrooms. All the centres bathing facilities have also been supplied with non-slip mats. A number of the wall tiles in the kitchen are cracked and must be replaced to ensure the centre meets environmental health standards. The centres washing machine is capable of cleaning laundry at appropriate temperatures in accordance with infection control standards. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of very experienced and competent staff are employed on a daily basis to support the needs, activities, and aspirations of the people using the centre. The centres recruitment procedures are sufficiently robust to minimise the risk of service users harmed by people ho are ‘unfit’ to work with vulnerable adults. EVIDENCE: All the staff on duty at the time of this visit were observed interacting with the service users in a very professional manner throughout. The manager told us that two out of four of the centres staff team had achieved a National Vocational Qualification – (Level 2 or above) in care, and that the other two were currently working towards this qualification. It was positively noted that the vast majority of staff had exceeded this standard by Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 22 achieving an NVQ Level 4 in care, which only registered managers are expected to obtain. On arrival a support worker and the registered manager were both on duty. The manager told us that at least two members of staff must always be on duty in the centre during the day when it is occupied. The manager has a flexible approach to planning the duty rosters and will sometimes employ additional staff to ensure all the service users needs are met and that community-based activities go ahead as planned. The centre uses one agency member of staff who as worked there for sometime and is therefore familiar with the service users and the centres daily routines. The centre continues to experience an exceptionally low rate of staff turnover and therefore has not needed to recruit any new staff for nearly two years. The manager told us that in line with recommended good practice all the staffs Criminal Records Bureau (CRB) checks are renewed every three years. Documentary evidence was produced to request to show that the one support worker who was on duty had their CRB check renewed last year. The manager told us that she prioritises training and encourages staff members to undertake external qualifications beyond the basic requirements to improve outcomes for the people who use the service. For example, in addition to staff receiving basic training in fire safety, moving and handling, first aid, food hygiene and health and safety, a number of staff have also undertaken specialist courses, including deaf awareness, British Sign Language (BSL), autistic spectrum disorders, learning disability and dementia, mental health, equality and diversity, financial and stress management, and supervision. The one staff member spoken with was very clear about their role as support worker, knew exactly what was expected of them, and showed a good understanding of the actions they needed to take to meet and promote equality and diversity. Craignish Avenue (4) DS0000039500.V339956.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management arrangements are meeting the needs of the service, and the quality of the service provided remains high. The centres quality assurance systems are sufficiently robust to ensure service users and their representative’s views about the standard of care provided will underpin the centres development. Health and safety arrangements are sufficiently robust to safeguard the health and welfare of service users, their guests, and staff. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has been in operational day-to-day control of the centre for two and a half years. It was clear from comments made by the manager and the other member of staff met that the centre remains committed to promoting equality and diversity of the service users. The manager has achieved her Registered Managers Award and in the past year has undertaken additional training in managing homes budgets. The manager told us her line manager visits the centre at least once a month to carry out prearranged inspections and have supervisions. The centre has introduced a number of different systems for assuring quality, which are based on seeking the views of service users and their representatives. Since the last inspection a new suggestions box has been introduced for service users to share their views about the centre. This box is used in addition to the centers official concerns book. The centre also uses satisfaction questionnaires to ascertain service users views about their time spent at Craignish Avenue. Records revealed that one service user in particular is very keen to have their say about the centre at the end of their stay. As previously mentioned in this report, staff meet at least once a fortnight and any feedback received from service users in that time will always form part of the agenda for the meeting. Finally, the results of the centres various quality assurance systems are now compiled together at the end of the year and published in an easy to read format for any interested parties to view. The centres fire records are well maintained and revealed staff continue to test the fire alarm system every week and undertake fire drills on a quarterly basis. During a tour of the premises it was noted that none of the centres fire resistant doors were being inappropriately wedged open to prevent there automatic closure in the event of a fire. The two fire resistant doors tested at random both closed flush into their frames when released manually. The London Fire and Emergency Planning Authority last visited in August 2006 and made no recommendations for the centre to action. The centres fire risk assessment of the building and emergency evacuation procedures were last reviewed in August 2006 and up dated according to reflect any changes. Up to date Certificates of worthiness were in place to confirm that suitably qualified engineers had tested the centres fire alarm system, fire extinguishers, emergency lighting, and portable electrical appliances in the past twelve months. Craignish Avenue (4) DS0000039500.V339956.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 26 No 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. Standard YA26 Regulation 16(2)(c) (k) Requirement Timescale for action 01/09/07 2. YA28 More suitable flooring covering must be laid in the top floor bedroom to eradicate the offensive odour emanating from this room. 23(2)(b) (d) All the damaged tiles in the kitchen must be replaced to ensure the walls are readily cleanable as a means of controlling infection. 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations More information and advice about healthy eating options should be sought from a dietician and staff attend suitable training in food nutrition. Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Craignish Avenue (4) DS0000039500.V339956.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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