Inspection on 09/08/06 for First Choice Care Ltd 18 St Andrews Ave

This inspection was carried out on 9th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

First Choice Care Ltd 18 St... 17/01/06

First Choice Care Ltd 18 St... 09/09/05

First Choice Care Ltd 18 St... 09/03/05

First Choice Care Ltd 18 St... 01/09/04

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

CARE HOME ADULTS 18-65 First Choice Care Ltd 18 St Andrews Ave 18 St Andrews Avenue Sudbury Middlesex HA0 2QD Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 9th August 2006 10:00 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.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 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.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. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service First Choice Care Ltd 18 St Andrews Ave Address 18 St Andrews Avenue Sudbury Middlesex HA0 2QD 020 8904 5250 020 8904 5250 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) Mr Divya Gandhi Mr Vinod Kabriya Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Mosaic House is run by a private company called First Choice Care Limited. The home is a semi-detached house, which has been extended on the side and back. It is situated in a residential area of Sudbury and is easily accessible by public transport. There is a garden to the back of the house, which is accessible to service users from the lounge and the kitchen. There is parking on the road in front of the home. Mosaic House is registered for five adults with mental health needs. The statement of purpose states that it caters for Asian, African and Caribbean service users. All service users have single bedrooms. The accommodation is on two floors with two bedrooms, lounge/dining area, an office, a toilet/shower and kitchen on the ground floor. There are three bedrooms, one bathroom with bath and toilet, and the sleep in room on the first floor. Service users normally have been inpatients or users of other services before being admitted to the home. The aim of the home is to provide rehabilitation and support to service users and to develop their independent living skills with regard to being discharged back to live independently in the community. Fees charged by the home range from £850 to £1150 according to the needs of the residents. At the time of the inspection there were four service users in the home. One was on leave. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key unannounced inspection. It started at about 09:30 and finished at about 14:30. During the course of the inspection, the inspector was able to speak to two service users, one member of staff and the manager. He was also able to tour the premises and to look at a sample of records in the home. The inspector would like to thank the service users, the manager and his staff for their kind welcome to the home and for their support during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 6 While all prospective service users have a pre-admission assessment of their needs by the home’s staff, there is no documentation about the findings of the assessment. It is necessary that the findings of the assessments of the needs of service users by staff from the home are appropriately recorded. The home has admitted a resident inappropriately. The resident was under a detention section of the Mental Health Act 1983 and should not have been admitted to the care home. As a result the registered persons must ensure that they are familiar with the sections of the Mental Health Act as well as their obligations under the Care Standards Act 2000. The manager must have a qualification in care as soon as possible. It must also have 50 of care staff trained to NVQ level 2 in care as soon as possible. The home should also look at how to provide the training that has been identified in its training plan such as manual handling and infection control. Although there seems to be a commitment by staff in the home to provide a quality service, it was not clear how the quality management system would be used to evaluate the quality of the service. Satisfaction questionnaires must be sent on a yearly basis to gauge stakeholders’ views of the service. The policies and procedures in the home must be reviewed. Some have not been reviewed since 2002. Service users are generally safe but a few issues were noted which if not addressed, may affect their safety. There was no emergency fire plan and there seems to be a complication with regard to accessing the assembly point of the home if staff exit the home through the back door. A gas safety certificate was not available for inspection. 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. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to choose whether they want to live in the home. The home carries out a pre-admission assessment of prospective service users, but the findings are not always clearly documented. As a result it is not clear whether all the needs of the prospective service users have been considered by the home. A lack of knowledge of the relevant care home and mental health legislation may lead to service users being inappropriately admitted. This could be detrimental to the individual service user and to other service users. EVIDENCE: The home has had a recent admission. The inspector was informed that the service user was offered information about the home and that the latter also visited the home to meet existing service users and members of staff, and to ask questions about the service, prior to deciding if he/she wanted to move into the home. The needs assessment and the risk assessment of the funding authority were available on file. It was noted that staff from the home visited the service user in his/her previous place of stay to carry out their own assessment. There was however no records of the outcomes of the home’s assessment. There was evidence that the proprietor wrote to the funding authority to confirm that the needs of the service user could be met in the home. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 9 The service user above was under a detention section of the Mental Health Act and was still under this restriction when admitted to the home. By definition of a care home, service users who are subject to a detention section cannot be admitted to a care home. 18 St Andrews Avenue must be registered as an Independent Hospital to be able to accept people being detained under the Mental Health Act (Care Standards Act 2000, section 2 and 3). The above showed a lack of awareness on the part of the registered persons of the Mental Health Act and the relevant detention sections that are made under this Act. As a result of the above the service user was admitted to the home inappropriately. Records showed that staff in the home were not experienced enough and trained to meet the needs of the service user and that at times they found it hard to cope. There is also evidence that other service users accommodated in the home were put at risk. As a result the registered persons must ensure that comprehensive assessments of the needs of service users are carried out and recorded and that they acquire a working knowledge of the Mental Health Act 1983 and of the Care Standards Act 2000. In case of uncertainty while admitting prospective service users the Commission can be contacted for advice. Most service users in the home had a written contract or terms and conditions of the placement signed by a representative of the home and by the service user. Those who did not have one made a decision that they did not want to have one. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are comprehensive and address the needs and safety of the service users while focusing on the need for service users to acquire new skills, to be more involved in the local community and to become more independent. EVIDENCE: Each service user had a well-written and clear care plan. The care plan addressed all the needs of service users and contained the action that needed to be taken to meet the needs of the service user. These were reviewed six monthly and there was evidence that the service users were involved in drawing up and in reviewing the care plans. The care plans also addressed the outcomes of the Care Programme Approach (CPA) to ensure that the service users are able to meet the actions that have been agreed in the CPA meeting. Each service user has a key worker. The manager also stated that although there is a key worker all care workers are aware of the plan of care for each service user and support them in achieving the aims and objectives of the care plans. For example the inspector was informed that staff support service users with regard to making decisions about jobs and about courses to follow. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 11 Service users in the home look after their own finances except for two service users who are supported because of their inability to do so independently. In these cases appropriate records are kept to ensure that a full audit trail can be operated. Although service users are free to go out of the home, they are encouraged to inform staff about their movement to ensure that staff are aware of their whereabouts. Care plans contained a range of risk assessments which have been agreed with the service users. It was noted that these serve the purpose of managing particular risks that users of the service may face while they go about their daily life or when they engage in activities to acquire new skills, to promote their independence and to increase their involvement in the local community. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to take part in activities suited to their needs and wishes, while focusing on their personal development and the development of living skills. Service users’ nutritional needs are maintained by the provision of appropriate meals. EVIDENCE: None of the service users in the home had a job although the inspector was informed that service users have made attempts to get jobs and that they have been supported in this process by staff. This involved helping service users with completing application forms and supporting them in following the progress of the applications. It was noted that one service user was at college and that other service users had the opportunity to attend courses as arranged through the day centres. Some of the service users also attend a drop-in centre where they also receive support. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 13 As mentioned previously most service users manage their own finances. The manager stated that service users are only offered support when they agree to such support. If they refuse this support then the service users deal with their issues independently. Most of these decisions about how service users are supported are also discussed in CPA meetings so the home is not alone in reaching decision about specific aspects of the care of the service users. Service users in the home are able to engage in the local community. Most of them are able to use public transport when they attend day centres or when they go to visit friends and relatives. They are also able to visit local shops and use local amenities. On the day of the inspection, the inspector noted that service users went for walks outside the home in the local community. One of them stated that he goes to the local shops. At the time of the inspection one service user was on holidays abroad with his relatives. Another service user had also been on holidays with staff. He proudly showed the inspector a photograph taken during his holidays. The manager stated that the service users also go for outings such as to parks. He added that trips are planned to Brighton and that holidays are being arranged for service users to go to Butlin’s. The inspector noted from records that service users contributed to the accommodation and boarding of staff who accompanied them on holidays. While regulations and minimum standards do not give clarifications on these matters, a transparent process has to be adopted with regard to how service users come to agree to contribute to staff’s expenses. Therefore information that residents have to contribute to staff costs when they go on holidays should be contained in the service users guide and residents/representatives must be able to give informed consent about these matters. The funding authority/social worker should also be advised as a matter of good practice. Relatives and friends are able to visit service users in the home as long as they comply with the rules of the home. There were records to confirm that service users are able to go out with their friends and relatives and to visit them. Service users are supported in making decisions about their daily life and they are encouraged to take responsibility for their own development. On the day of the inspection some service users chose to wake up at a time that they wanted to, although staff may encourage them to get up earlier if the service users have to go to day centres or if they have appointments. Service users were also observed making tea and helping themselves to drinks and food or requesting for drinks. The rules about smoking, drinking and drugs are clearly stated in contracts although a clear policy on these matters was not available. Since the last inspection smoking has been confined to outdoor smoking and smoking is only allowed inside the home when it rains. The manager stated that the home was looking at ensuring that all smoking is carried out outside and that a more First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 14 permanent arrangement for smokers was being sought. There are plans to build a conservatory for that purpose. Provision of meals was a flexible arrangement in the home. Staff prepared a variety of meals according to the choices of service users. There were records of meals cooked for each service user. These showed that service users had meals according to their choices. There were also fruits and fresh vegetables in the home. The kitchen was clean and tidy and all the necessary records were being kept. Opened items of food and containers in the fridge were labelled and dated. This was good practice. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that service users’ personal and healthcare needs are met. Medicines administration in the home is of a good standard to ensure the safety of service users. Care records address the ageing of service users and their aspirations and wishes for the future. EVIDENCE: It was noted that service users received personal care in a private and sensitive manner and according to their needs. Personal care is provided in the bedrooms of service users or in the bathrooms. The provision of personal care is based on the individual abilities of service users and is detailed in the care records. It was observed that a service user was offered the opportunity to choose his own clothes while others were encouraged to attend to their personal hygiene and dressing. Service users’ healthcare needs are addressed in care records. They are seen by healthcare professionals according to their needs. There were records to show that staff in the home monitored the appointment of service users to ensure that they do not miss these and to ensure that they are able to support the service users where necessary. Some of the service users attend appointments with members of staff while others are able to do so First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 16 independently. Service users mental health is monitored and feedback is provided to the multi-disciplinary team in CPA meetings. Members of staff are also able to access the relevant healthcare professionals should the mental health of service users deteriorate. Medicines management in the home was good. There were records of medicines received in the home and administered. Medicines were provided in ‘dossette’ boxes which were filled by the chemist. Service users receive prescriptions for 28 days. The inspector noted that although the amount of medicines were recorded when received, the amounts were not totalled to provide a balance. It was therefore difficult to audit and ascertain in a short space of time the balance of each medicine. Good practice was however noted with medicines to be administered as required, when there was a balance on the medicine chart. The manager stated that all staff receive training to administer medicines except for some medicines which are administered by injection. These tasks are carried out by the Community Psychiatric Nurses in the clinic. It was noted that there was a section in the care records which addressed the aspirations and wishes of service users with regard to the future and what they expected to happen to them. Furthermore there was another section addressing the wishes of the service users and arrangements, if there were any, about the end of life care of residents and about death. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes complaints and allegations of abuse seriously. EVIDENCE: There have not been any entries in the complaints book since the last inspection. Service users receive the complaint procedure in the service users’ guide and a copy is also available in the foyer of the home. Service users stated that if they had any issues they would contact the manager or a member of staff. Views of residents are also received in residents meetings. Minutes of these were available for inspection. The manager stated that staff have had training on abuse and on Protection of Vulnerable Adult. This was confirmed by training records. A whistle blowing policy was available in the home. In the past the home has dealt with a suspicion of abuse in an appropriate manner. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was in the main suited to meet the needs of the service users, but there was ample room for improvement. EVIDENCE: The grounds at the front of the home were tidy. The grounds at the back of the home were also maintained although there could have been more flowers and colours at the back to make the area more pleasant. The exterior of the building was also in good condition. The doors to the extension/garage on the side of the home (which serves as an office) have been replaced with UPVC doors and front, making the front of the home more pleasant. There has not been any redecoration work done to the lounge/dining areas since the inspection in September 2005. The inspector noted that these areas of the home continue to look dark and uninviting. This was also noted by another inspector who carried out the last inspection. It was noted that the walls of the staircase have been repainted. It was also observed that the paint on the handrail was also coming off in some places. The carpet on the staircases look worn and plans should be made with First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 19 replacing these. The inspector is of the view that the home would benefit from an overhaul of the decorative state of the lounge/dining areas and the foyer of the home. A redecoration plan was provided to the Commission with timescale. The inspector was informed that two bedrooms of service users have been repainted since the last inspection. One of the bedrooms was inspected and it was in a good state of redecoration and was appropriately personalised. The home was on the whole clean and free from odours. The home has not yet introduced paper hand towels in the bathrooms/toilets to dry hands. The manager stated that he was making arrangements for this to happen. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has on most occasions, staff in adequate numbers to meet the needs of residents. The home does not have 50 of its staff trained to NVQ level 2 in care. The home uses handbooks for training in some statutory areas. The quality of this training may be good for induction but may not be appropriate for formal training of staff in these areas. EVIDENCE: The home normally has one member of staff on duty in the morning and two members of staff in the afternoon. Staff have job descriptions and regular supervision to discuss their job and issues with regard to working in the home. Conversation with one member of staff showed that the latter was clear of what was expected from him. Most of the staff in the home have worked abroad in nursing/care positions. They were therefore relatively skilled to look after the residents in the home. The personnel file of one new member of staff was inspected and it was noted that all the appropriate records as required by legislation were in place, including an enhanced CRB check. One member of staff out of the five members of staff has an NVQ qualification in care. Another member of staff is doing a degree in a healthcare associated First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 21 subject. As a result the home does not yet have 50 of the carers trained to NVQ level 2 in care. The home has arranged training for staff. Individual training records were in place in the file of individual members of staff. The home have a number of training packs such as in fire training and food hygiene. While these may be appropriate as part of a comprehensive induction package, the registered person must consider the provision of more formalised training in food hygiene for members of staff, particularly if they are responsible for food preparation as well as training in fire training and health and safety. Although there is not a lot of manual handling of service users in the home, it is recommended that this training be provided. The training plan of the home also mentioned that it would provide training in food hygiene, infection control, fire training and manual handling. All members of staff have had training in 1st Aid. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in an open and transparent manner for the benefit of the service users. The process to evaluate the quality of the service is not clear as the quality management system to use for this purpose is not detailed. Health and safety aspects of the service were not always comprehensively managed. EVIDENCE: The manager has recently been registered. He has worked in the area of mental health for a number of years and is familiar with the needs of residents with mental health. He has ensured, within his remit, that previous requirements and recommendations were met. Care plans of residents were of a good standard and the provision of recreational activities for residents was also being promoted. There was evidence that staff meetings and residents meetings were being held. The manager has a qualification in management but does not yet have an NVQ level 4 qualification in care. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 23 The inspector was informed that the home is accredited to IIP. While IIP gives an indication of the quality of the workforce and the commitment of the organisation to the development and training of the workforce there was no clear system to evaluate the quality of the service that the home provides. The home has a quality assurance procedure. It mentions that the home has a quality management system, but the actual system is not detailed. It is therefore not clear how this management system will work with regard to evaluating the quality of the service that it provides. A satisfaction survey was carried out in April 2005. Another one has yet to be completed for this year. The inspector was shown a monthly monitoring plan which was being completed by the manager. It seems that this was some form of monthly monitoring as per Regulation 26 of the Care Homes Regulations 2001. Regulation 26 visits however have to be carried out by the provider and not by the manager. The home has a number of policies and procedures. A few of them were noted to have been updated and were left for staff to read and signed. However a few of them were last reviewed in 2002. As a result some of them were due for review. As mentioned previously the home did not have a smoking policy, and for the use of alcohol and drugs. Although there is some information in the contract, the current practice with regard to smoking was not detailed in a policy and the designated smoking areas were not identified. The home had records of regular checks on the fire detection system and emergency lights. Fire drills were also recorded. It was noted that should staff go out through the back doors in a scenario where the fire alarms have been activated, that they would not be able to get to the assembly point. This is because there is no passage on the sides of the home for staff to come to the front of the home where the assembly point is. It is therefore required that the registered person review the fire emergency plan with regard to how staff should get to the assembly point. A fire risk assessment was available in the home and records about health and safety checks were also available for inspection. The home however did not have a gas safety certificate available for inspection. A up to date PAT testing certificate was later forwarded to the inspector. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 1 3 X 4 3 5 3 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 X 34 3 35 2 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 3 2 x 2 2 x 2 x First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 10(1,2) Requirement The registered persons must have a working knowledge of the Mental Health Act 1983 and the Care Standards Act 2000 and must be aware of the limitations with regard to the service that the home offers. The person carrying out a preadmission assessment must make a record of his findings with regard to the assessment of the needs of the prospective resident. The registered person must ensure that 50 of the care staff are trained to NVQ level 2 in care as soon as possible. The registered person must consider the provision of more formalised training in food hygiene, health and safety and fire training. The registered manager must have an NVQ level 4 qualification in care as soon as possible The quality management system to use to evaluate the quality of the service must be clarified. The registered person must ensure a review of policies and DS0000017493.V307681.R01.S.doc Timescale for action 15/10/06 2 YA2 14(1)(a) 15/10/06 3 YA32 18(1)(c) 30/06/07 4 YA35 18(1)(c) 15/10/06 5 6 7 YA37 YA39 YA40 9(2)(b)(i) 24(1) 10(1) 30/06/07 15/10/06 15/10/06 First Choice Care Ltd 18 St Andrews Ave Version 5.2 Page 26 procedures in the home. 8 9 YA40 YA42 10(1) 13(4) The home must have a policy on smoking, and the use of alcohol and drugs The registered person must ensure that the home has a Fire Emergency Plan and that the issue about how staff should reach the assembly point in cases when it is necessary to do so, is clarified. The home must have a gas safety certificate available for inspection 15/10/06 15/10/06 10 YA42 13(4) 15/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA20 YA30 Good Practice Recommendations The registered person should keep a balance of the amount of each medicine when a new supply is received in the home. It remains strongly recommended that the home provide disposable hand towels/or dryers for service users and staff in communal toilets instead of cloth towels, which can be a source of cross-contamination. The registered person should provide manual handling training and infection training for staff as identified in its training plan. The monthly monitoring plan should be completed by the registered individual as part of visits as per regulation 26. 3 4 YA35 YA39 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI First Choice Care Ltd 18 St Andrews Ave DS0000017493.V307681.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. Re-publishing this information is in breach of the terms of use of that website. 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