Inspection on 07/07/08 for Milbury 46 Flambard Road

This inspection was carried out on 7th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury 46 Flambard Road 15/08/07

Milbury 46 Flambard Road 20/03/07

Milbury 46 Flambard Road 20/04/06

Milbury 46 Flambard Road 25/10/05

Milbury 46 Flambard Road 01/06/05

Milbury 46 Flambard Road 11/01/05

Milbury 46 Flambard Road 26/10/04

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 28/09/2008.

CARE HOME ADULTS 18-65 Milbury 46 Flambard Road 46 Flambard Road Harrow Middlesex HA1 2NA Lead Inspector Tony Lawrence Key Unannounced Inspection 7th July 2008 09:25 Milbury 46 Flambard Road DS0000017532.V365939.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 Milbury 46 Flambard Road DS0000017532.V365939.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. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Milbury 46 Flambard Road Address 46 Flambard Road Harrow Middlesex HA1 2NA 020 8907 5896 F/P 020 8907 5896 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) Milbury Community Services Ltd Caroline Elizabeth Hodgson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 15th August 2007 Date of last inspection Brief Description of the Service: 46 Flambard Road is registered to provide care and accommodation to a maximum of 8 people who have learning disabilities. The Registered Provider is Milbury Community Services. The home is located on a residential road fairly close to central Harrow and Kenton. It is close to a variety of shops, health and social care facilities and services, public transport and other community leisure facilities. The building is on two floors. All bedrooms are single and are located on both floors. The home has a lounge, dining room and conservatory. There is a laundry room and kitchen. There is a large garden to the rear of the property. The home has some parking spaces on the front driveway. Otherwise there are some metered street parking places available. The home has its own vehicle that can be used by people living in the home to access the community, providing there is a member of staff on duty who can drive. The provider told us the fees are approximately £1,100 per week. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. This unannounced key inspection took place on Monday 7th July 2008 from 09:25 – 16:15. We spent time talking with people who live in the home, staff on duty, the home’s manager and the provider’s Operations Manager. We also checked care records kept in the home and saw all communal areas and some residents’ bedrooms, with their permission. The provider sent us an Annual Quality Assurance Assessment (AQAA) and we have used information from this to write this report. We would like to thank the residents, manager and staff who spent time telling us about the services provided in the home. What the service does well: What has improved since the last inspection? What they could do better: The provider must make sure that the procedures for admitting residents in an emergency are followed. The Manager and staff must make sure that individual’s care needs identified in assessments and care plans are met appropriately. The provider must make sure that we are told about significant incidents involving people living in the home. Managers and staff must also make sure that they follow the local authority’s procedures for safeguarding adults. Please contact the provider for advice of actions taken in response to this Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 6 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. Milbury 46 Flambard Road DS0000017532.V365939.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 Milbury 46 Flambard Road DS0000017532.V365939.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. People using the service experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home understands the importance of having sufficient information when choosing a care home. It has developed clear information to help people understand what specialist services the home can provide. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a service user’s guide. EVIDENCE: ‘I’ve lived here a long time, I like it here’. (Comment from a resident). ‘I didn’t like the place I used to live in so I came here, it’s better here’. (Comment from a resident). ‘We have developed the Service User Guide and Statement of Purpose in pictorial format. New support plans are now in place’. (Extract from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we saw that the home has a Statement of Purpose that had been produced using pictures to make the information easier for some residents to understand. We also saw that each person living in the home had Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 9 an individual Service User Guide that also used pictures and plain English to make the information more accessible. The Service User Guide also included summaries of the provider’s complaints and safeguarding adults policies and procedures. While the home’s Statement of Purpose includes procedures to be followed when new residents are admitted in an emergency, we found evidence that these are not always followed in practice. A person admitted in an emergency shortly before we visited had not been supported to make an informed choice to move into the home. Managers and staff from the home had not had the chance to meet the person. The provider had not completed a care needs assessment, although some good information had been provided by the local authority Social Services Department responsible for funding the placement. To make sure that a person’s care needs can be met appropriately, Managers must make sure that the provider’s referral and admission procedures are followed when people are admitted to the home in an emergency. Milbury 46 Flambard Road DS0000017532.V365939.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care which affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. Care plans are person centred and are agreed with the individual. Plans are written in plain language, are easy to understand and look at all areas of the individual’s life. They include reference to equality and diversity and address any needs identified in a person centred way. EVIDENCE: ‘I talk to staff about what I want to do and they help me’. (Comment from a resident). ‘My key worker talked to me about my plan and we had a meeting’. (Comment from a resident). Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 11 ‘The plan is drawn up with the involvement of the service user, family/friends/advocate where possible and relevant agencies as appropriate’. (Extract from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we reviewed the care plans for three people living in the home, including one person who had been admitted in an emergency shortly before our visit. We saw that the two care plans for the people who had lived in the home for a number of years had been reviewed and updated in March or June 2008. We saw clear evidence that residents had been involved in reviewing their plans and 2 people also told us that this happened. We saw that the plans were divided into outcome areas, including health care, communication, cultural and spiritual expression, personal care needs and preferences and relationships. We saw that each outcome area was reviewed every month and the residents and their key worker signed to show that needs and goals had been discussed. The local authority responsible for funding the person placed in an emergency had provided a care plan that had been updated 2 days before they moved into the home and a care needs assessment that had been completed in February 2008. There was a need to make sure that needs identified in the care plans and needs assessment could be met in the home. For example, the care plan said that the person needed a wheelchair to go out of the home, but this had not been provided. Daily care records showed that the person had not been out for 10 days, apart from a short walk on the home’s front drive. The care needs assessment also referred to a ‘seizure monitor’ and this had not been provided. The Manager told us that she had asked the person’s social worker and had been told that this was not needed, although it was included in the assessment and care plan recently completed. When this person lived at home, they went to a day centre five times a week. Managers and staff from the home had not been able to make arrangements for the person to contact their family or attend day services. While we felt that the standard of care planning for people living in the home as permanent residents was very good, the standard of care planning for temporary residents or people admitted in an emergency must be improved to show that their care needs are met appropriately. During our visit we saw that staff frequently offered people choices about a number of aspects of their daily lives. We saw that staff gave residents time to make an informed choice and their choices were always respected by the staff team. We saw that risk assessments had been reviewed and updated in June or July 2008 for the two people living permanently in the home. The assessments covered fire safety, mobility, road safety, behavioural issues and medication. We felt the risk assessments were well-written and included clear guidance for staff on how identified risks should be minimised. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 12 We also saw that the home’s Deputy Manager had completed risk assessments for the person recently admitted in an emergency. These covered mobility, management of the person’s epilepsy, risk of falls and manual handling. We felt the assessments were well completed and provided clear guidance for staff. Milbury 46 Flambard Road DS0000017532.V365939.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 and 17. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. EVIDENCE: ‘I like the food, I can always eat what I want. Sometimes I go shopping with staff’. (Comment from a resident). ‘I go out by myself or staff come with me sometimes’. (Comment from a resident). ‘We have introduced library tickets for everyone, more activities and outings, introduced massage therapist and music therapist. Requirements from last Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 14 CSCI inspection met’. (Extract from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we looked at the daily care records for three people living in the home. These records showed that the two people who live in the home permanently were supported to take part regularly in activities they chose. One person travelled independently to the area of West London where they used to live. They would meet up with friends and return to the home later in the day. The records also showed that this person went to the cinema, parties, picnics and spent time with members of their family. The second permanent resident needed more support from staff to take part in activities outside the home. The daily care records showed that they had recently been shopping, out for a drink at a local café, to a party and a barbecue. Both people went out for some time during the day we visited the home. The daily care records for the person who was recently admitted in an emergency showed that they had taken part in no organised activities outside the home in the 10 days they had been living there. This person had been used to going to a day centre every day Monday – Friday and staff from Flambard Road must make sure that they support this person to take part in activities outside the home while they are living there. We saw that the contact details for residents’ relatives, friends and other significant people were well recorded as part of their care plan. The daily care notes showed us that staff supported individuals to keep in touch with these people. Residents also told us that they saw relatives and friends whenever they wanted. Residents’ bedrooms were very individual and provided spaces where they could spend time in private. We saw that people had a TV or music system in their rooms and one person told us he liked to watch his extensive collection of DVD’s during the evenings and at weekends. Residents told us that they enjoyed the food provided for them in the home. The weekly menus showed a variety of nutritious meals were provided, based on residents’ choices and known preferences. Milbury 46 Flambard Road DS0000017532.V365939.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 and 21. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action plan. EVIDENCE: ‘We support service users to attend appointments to relevant health care professionals and any recommendations are acted upon. We have a competency assessment and medication policy in our practice manual’. (Extract from the provider’s Annual Quality Assurance Assessment – AQAA). We saw that people’s care plans included a clear record of their personal care support needs and preferences. The guidance for staff emphasised the importance of developing and maintaining people’s independence. Care plans focussed on what people could do for themselves to make sure that they were able to live as independently as possible. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 16 During this visit we checked the healthcare records of two people living in the home. The care plans for each person included some well written goals about their health care needs. This showed us that staff are aware of each person’s needs and the arrangements for meeting these in the home. Both care plan files included a good record of appointments and contact with health care professionals, including their GP’s, dentists, opticians, chiropodist and community nursing services. One person’s care plan included a good record of reviews by the psychiatrist in January, April and June 2008. During this visit we saw staff using strategies recommended by the psychiatrist to manage one resident’s anxiety. The provider must make sure that residents admitted in an emergency are registered with a local GP if required, to make sure that primary healthcare support is available. We saw that the home used the Boots Monitored Dosage System (MDS) to manage each resident’s prescribed medication. We saw that all medication was securely stored in a lockable metal cabinet. We checked the Medication Administration Record (MAR) sheets for each resident. The MAR sheets were well completed by staff and we saw no errors or omissions. Staff should make sure that they record the opening date on bottles of eye drops and creams to make sure that these are used within their expiry dates. During our visit we saw that the two residents’ care plan files we checked included an outcome area on ageing, illness and death. We felt that these sensitive areas had been well assessed and recorded and regularly reviewed, with the residents and their representatives. Milbury 46 Flambard Road DS0000017532.V365939.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 and 23 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the NMS and regulations. The procedure has been produced in a format that is accessible to residents. There is some guidance for staff on safeguarding people who use the service but this is not specific to the home. Staff may not be familiar with the guidance or be able to access them easily. EVIDENCE: ‘I’d tell the manager or staff if something was wrong’. (Comment from a resident). During this visit we saw that the home had developed a clear complaints policy and procedures for responding to complaints from residents and other people. The procedures had been produced using pictures and Plain English to make the information easier for some residents to understand. Although we saw no recorded complaints in the home’s complaints record, the manager told us that a formal complaint from a former resident’s relatives was being dealt with by the provider’s legal advisors. Talking to staff, we were not confident that all those working in the home were familiar with the home’s procedures or the issues that should be recorded and investigated. The Manager and staff team must discuss the home’s procedures for recording and managing complaints to make sure that residents’ concerns are responded to consistently. We saw that the home has a copy of the Department of Health’s guidance on safeguarding adults, ‘No Secrets’, but the Manager must obtain a copy of the Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 18 local authority’s policies and procedures. This would make sure that staff are familiar with the need to report safeguarding incidents to us and the local authority. For example, the home’s incident and accident records included incidents where staff had observed unexplained bruises on residents’ bodies and incidents where one resident had been physically aggressive towards other people living in the home. We felt that the provider should have told us and the local authority about these incidents. This would have enabled independent investigations to be carried out and multi-agency plans agreed to make sure people were safe. During this visit we also checked the personal finance records of three people living in the home. We saw that the records were well maintained and up to date. A record was kept of any expenditure of residents’ own money and receipts were in place for every transaction. Milbury 46 Flambard Road DS0000017532.V365939.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, 25, 27, 28 and 30. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is a very pleasant, safe place to live the bedrooms and communal rooms meet these Standards or are larger. Residents are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. EVIDENCE: ‘I like my bedroom very much. I watch television in here’. (Comment from a resident). The home is located on a residential road, close to central Harrow and Kenton. It is indistinguishable from neighbouring properties and is suitable for use as a registered care home. It is close to a variety of shops, health and social care facilities and services, public transport and other community leisure facilities. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 20 The building is on two floors. All bedrooms are single and are located on both floors. The home has a lounge, dining room and conservatory. There is a laundry room and kitchen. There is a large garden to the rear of the property. The home has some parking spaces on the front driveway. Otherwise there are some metered street parking places available. During this visit we saw all communal parts of the home and three residents’ bedrooms, with their permission. The communal areas offered a choice of spaces for resident to spend time, either alone or with other people. All communal areas were comfortable, well decorated and welcoming. The residents’ bedrooms we saw were well decorated and furnished and very individual. Residents told us that staff had helped them to choose how they wanted their room decorated. All three rooms has items of the residents’ own furniture, pictures and other personal possessions. During our visit we saw that all parts of the home were clean and hygienic. Milbury 46 Flambard Road DS0000017532.V365939.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 and 36. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents told us they have confidence in the staff who care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently. The provider’s recruitment procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. EVIDENCE: ‘I like the staff. I like my key worker and the manager’. (Comment from a resident). ‘I didn’t like the staff where I used to live. I like the staff here’. from a resident). (Comment ‘I have regular supervision with my manager and I can usually do the training that I need’. (Comment from a member of staff). ‘I’ve worked here a long time because I love my job’. (Comment from a member of staff). Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 22 During this visit we spent time talking to staff on duty, the home’s Manager and the provider’s Operations Manager. We checked the weekly staff rota and saw that there was a minimum of three staff on each shift in the morning and the afternoon. At night, there was one member of staff awake in the home and a second person asleep in the home who could be called if needed. We felt that this level of staffing during the day and at night was sufficient to meet the identified care needs of the people living in the home when we visited. During our visit we saw that staff worked well together to respond to residents’ requests for information and support and some people were supported to go out locally during the day. We also checked two staff personnel files during this visit. Each file included a copy of the person’s Criminal Records Bureau (CRB) check, training and supervision records. The home’s Manager and Operations Manager told us that application forms and employment references were kept at the provider’s Head Office but the Manager saw these as part of the recruitment process. Both staff files included records of training attended by the member of staff and a copy of their Learning Disability Award Framework (LDAF) induction training. Both files also included up to date supervision records and copies of annual appraisals. Milbury 46 Flambard Road DS0000017532.V365939.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, 40, 41 and 42. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. The Annual Quality Assurance Assessment (AQAA) contained clear, relevant information that was supported by a wide range of evidence. The AQAA let us know about changes they had made and where they still need to make improvements. It showed clearly how they are going to do this. The data section of the AQAA was accurately and fully completed. EVIDENCE: During this visit we spent time talking with the home’s Manager and the provider’s Operations Manager. The Manager told us that she had more than 20 years’ experience of working with older people and people with a learning disability. She was completing her National Vocational Qualification (NVQ) Level 4 training and we had registered her as a fit person to manage a care Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 24 home. The Manager returned the Annual Quality Assurance Assessment (AQAA) that we sent to her. The AQAA contained clear, relevant information that was supported by a wide range of evidence; it let us know about changes they had made and where the home still needed to make improvements. The data section of the AQAA was accurately and fully completed. The Operations Manager was at the home for the provider’s annual service review. She told us that questionnaires were sent to residents, their relatives / representatives and other people connected with the home before the review to get their comments on the services provided. Relatives, advocates, social and health care professionals were also invited to the home to take part in the review. The Operations Manager also spent time with each resident during the day to record their opinions about the home and the care and support provided. The Operations Manager told us that the results of the review would be collated and used to produce a satisfaction score and action plan. The plan would be produced in an accessible format for residents and would be discussed at team meetings. The provider will also send us a copy of the review and action plan. We also saw that staff support residents to complete a monthly survey about what they had liked or disliked in the home that month. We saw copies of the surveys on two residents’ files and staff told us that these are also used as part of care planning and the annual review of the home. We checked a variety of records during this visit, including care plans and risk assessments, medication, health and safety and finance records. Standards of record keeping in the home were good. We checked health and safety records kept in the home and saw that the fire risk assessment and emergency fire plan had been reviewed and updated in January 2008. We saw good records of weekly fire alarm tests, monthly fire drills and weekly tests of the emergency lighting system. Records showed that the fire safety equipment in the home was last serviced in April 2008. The home’s Deputy Manager completed monthly health and safety inspections and we saw that good records were kept of these. The Manager must make sure that a personal emergency evacuation plan is completed immediately for residents admitted in an emergency. Milbury 46 Flambard Road DS0000017532.V365939.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 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 3 3 3 X 3 X 3 2 X Milbury 46 Flambard Road DS0000017532.V365939.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 YA2 Regulation 14 (1) (c) Requirement To make sure that a person’s care needs can be met appropriately, Managers must make sure that the provider’s referral and admission procedures are followed when people are admitted to the home in an emergency. The standard of care planning for temporary residents or people admitted in an emergency must be improved to show that their care needs are met appropriately. The provider must make sure that residents admitted in an emergency are registered with a local GP if required, to make sure that primary healthcare support is available. The Manager and staff team must discuss the home’s procedures for recording and managing complaints to make sure that residents’ concerns are responded to consistently. To evidence that the home’s safeguarding adults procedures are followed, the provider must make sure that we are told DS0000017532.V365939.R01.S.doc Timescale for action 31/10/08 2. YA6 15 (1) 31/10/08 3. YA19 13 (1) (a) 31/10/08 4. YA22 22 31/10/08 5. YA23 37 31/10/08 Milbury 46 Flambard Road Version 5.2 Page 27 6. YA23 13 (6) 7. YA42 13 (6) about any significant incidents affecting residents. To protect people living in the home, the provider must notify the local authority of any incidents that may involve safeguarding adults concerns. To make sure that all residents are safe in the event of a fire, the Manager must make sure that a personal emergency evacuation plan is completed immediately for residents admitted in an emergency. 31/10/08 31/10/08 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 YA20 Good Practice Recommendations Staff should make sure that they record the opening date on bottles of eye drops and creams to make sure that these are used before expiry dates. Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Milbury 46 Flambard Road DS0000017532.V365939.R01.S.doc Version 5.2 Page 29 - 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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