Inspection on 24/11/05 for St Blaise Avenue (2)

This inspection was carried out on 24th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Blaise Avenue (2) 15/04/08

St Blaise Avenue (2) 06/06/06

St Blaise Avenue (2) 20/02/06

St Blaise Avenue (2) 13/01/05

St Blaise Avenue (2) 04/10/04

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 09/07/2008.

CARE HOME ADULTS 18-65 St Blaise Avenue (2) 2 St Blaise Avenue Bromley Kent BR1 3DA Lead Inspector Ann Wiseman Unannounced Inspection 24th November 2005 12.30p St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 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 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 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. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Blaise Avenue (2) Address 2 St Blaise Avenue Bromley Kent BR1 3DA 020 8460 1851 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) Maxine.shawromley.gov.uk London Borough Bromley ** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration is subject to the home complying with the Fire Precautions (Workplace) Regulations 1997 and the requirements as stated in the report submitted by the London Fire and Emergency Planning Unit dated the 21/07/03. The home is registered as a Care Home (CRH), with a service category of (PC) Care Home only, with a Service User Category of (LD) Learning Disability five (5), of both sexes, of which (LD(E)) Learning Disability over the age of 65, one (1). 13th January 2005 2. Date of last inspection Brief Description of the Service: St Blaise is a two story semi-detached House in a residential road within walking distance of Bromley’s main shopping centre and is convenient for all local amenities and public transport. The home is part of the London Borough of Bromley’s care provision in the Learning Disability sector. The home provides support for five service users all whom have a learning disability; currently there are three male and two female service users. The home has its own manager and cares staff and will use Care Bank and Agency staff if the need arises. The Service Users in this home are supported in all their activities of day-today living to maximise their skills and to enable them to develop to their full potential. Friends and families are encouraged to participate in the in the Service Users lives and leisure activities. The house has a garden to the front with parking for two cars and a good sized back garden. Policies, procedures and recruitment are organised through the central office of London Borough Of Bromley. Senior staff management and staff support are provided through Bromley Borough. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced visit and consisted of two visits one of six hours and one of an hour to discuss issues that arose from speaking to one of the Service Users family members. The inspector spoke to the manager, three of the Service Users, two permanent staff members and a relative of one of the Service Users. All the staff members were cooperative and accommodating during the visit. The manager has recently be appointed and as yet has been not been registered but has initiated the process. Although the new manager has been in the house as an agency manager since the previous manager left, she was only appointed permanently a week ago. She received a handover from the outgoing manager who is still in the service, managing a different home, and is available for support and information. However the Commission has not been formally notified of either the previous manager leaving or the appointment of the new one. The house has a homely and relaxed atmosphere; it is warm and free from offensive odour. The decoration and furnishing in the communal areas are in need of redecoration but the home is mainly bright and comfortable The Service Users rooms observed are well furnished and reflected their interests and character. When the Inspector arrived there were three Service Users at home with one support staff and the manager on duty. Later during the inspection there was a handover and two more staff replaced the early shift and all the rest of the Service Users returned home from their day centre, so the Inspector was able to meet everyone and have a good overview of the home and its atmosphere. There has been a change in the client group since the last inspection with one of the men moving out and being replaced by a woman, therefore the house procedure for introducing a new client into the house could be assessed. What the service does well: The staff were friendly towards the Service Users and talked to them in an open and friendly manner, the Service Users responded well to the staff. In conversation with the Inspector one of the Service Users told her the names of the staff that he liked and said they were “good” and that he liked the home. There is a full and comprehensive recording of the Registered Care Review Meeting that every Service User has annually, in it is recorded the Service Users likes, dislikes and aspirations, guidelines and support needs. It is put together and written well. The Service Users Guide includes the contract, local agreement, service level agreement, and information on how to make a complaint. It is well written and St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 6 has a section that is produced in a format that should be easier for the Service Users to understand. What has improved since the last inspection? What they could do better: 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. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 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 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 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): As there had been a new admission since the last inspection the inspector was able to test all standards in this section and found the information provided was good and of a high standard, however there was no evidence of assessment or reassurance that the house would meet their needs in the service user files. EVIDENCE: The Inspector looked at the Service Users Guide it includes the contract, local agreement, service level agreement and information on how to make a complaint. It is well written and has a section that is produced in a format that should be easier for the Service Users to understand. However it is recommended that each Service User have their own copy kept in their individual file. Please see Recommendation 1 There was no evidence in the Service Users files of a full assessment having been carried out by the care managers or other person competent to do so, prior to their moving into the house. Please see Requirement 1 Nor was there evidence that the registered manager has written to assure the prospective Service User or their representatives that the home would be able to meet their needs. Please see Requirement 2 The new Service User was invited to visit the house for tea visits and then had an overnight stay before they and their representative decided if they liked the house and wanted to move in. The placement was reviewed after six weeks. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards 6 to 10 were assessed at this visit. Care plans were in place and the Inspector observed interaction between staff and the Service Users and found that staff members were respectful toward the Service User and gave them opportunities to make choices and take decisions for themselves. EVIDENCE: Each Service User has a care plan on file that comprehensively covers all aspects of the Service Users needs, although there is no indication when they were written, last updated or when they will be reviewed. It is recommend that these dates be added to the care plan. Please see Recommendation 2 There is a full and comprehensive recording of the Registered Care Review Meeting that every Service User has annually, in it is recorded the Service Users likes, dislikes and aspirations, guidelines and support needs. It is put together and written well. One of the Service Users does not like anyone to enter his room without invitation either while he is at home or not. This request is clearly indicated in his file and there are instructions for staff to knock and to wait for his response before entering the room. If he does not respond or give permission for them to enter they are not to enter. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 10 The Inspector observed staff knocking on bedroom doors and was informed that unless a Service User was present or had given permission staff did not enter rooms. The manager and two staff members informed the Inspector that Service Users are helped to choose the weeks menus by the staff with the aid of a menu book that has pictures to help people have a wider choice. The manager assured the Inspector, as the Service User meeting book could not be located, that there are regular User Forums and that issues that arise from there are discussed at the team meetings. One Service User had received training in travelling independently to enable him to be able to travel on his own and routinely goes out to do shopping and travels to the daycentre on his own. Risk Assessments were seen to support the decision. The Staff have received training in confidentiality during their induction training and it was observed that all the files were kept in a locked cabinet and the access was restricted to those who needed to have the information in respect of their work with the Service Users. No files or personal information was left inappropriately in areas of the house that would threaten confidentiality. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The Inspector accessed outcomes for standards 11 to 17 on this inspection. The food prepared was wholesome and well prepared and the Service Users are given some opportunities to access the community and social activities within the house are arranged and regular family contact is maintained. EVIDENCE: Residential Care Review Meetings are held annually where the Service User has the opportunity to put forward his plans and aspirations and structures are put in place to enable them to achieve their personal goals. Each Service User has a day allocated when they will have a day off from their day centre when they are given opportunities to work on areas of personal development on a 1-1 basis with an allocated staff member. All the Service Users have places at a local day centre, although some choose not to attend every day. They are also given the opportunity to attend an evening club. Service Users are offered opportunities to attend activities out of the house such as going to the cinema, visiting local pubs and shops. One Service User states in his Registered Care Home Review that he enjoys tenpin bowling, pubs, eating out, using public transport, going to church and participating in St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 12 group activities, however there is no evidence that the Service Users get out and about much, some monthly activity sheets were filed in the Service Users files as part of the monthly summery and they were blank; seemingly indicating that the Service User had not taken part in any activity that month. It is suggested that there is an activity plan drawn up in consultation with the Service Users and that it is signed as the activity occurs or the reasons why if it fails to happen. Please see Recommendation 3 The Service Users are in contact with their families and have regular visitors; one has weekly trips to a health club with his mother. Most of the Service Users have visits and overnight stays in their family’s homes. One goes on holiday with his mother every year. The house holds parties and social gatherings that all the families are invited to. During the Inspectors visit one of the Service Users had a visit from a family member. Service Users are helped to draw up the menus and go shopping weekly with staff. The Inspector observed the staff knocking on the Service Users doors, to offer them choices of food and to check that it was all right for me to talk to them and go into their room. The Service Users care plans reflect the ethos that their rights should be upheld and their opinions sought in all manner of their care. The menus available were varied and well balanced, the food is cooked and prepared by the care staff and the lunch that was prepared for one of the Service Users was well prepared and of sufficient quantity. There was some fruit available, There was little food in the fridge, the Inspector was assured that shopping was due but because the manager was new and had not yet been authorised to draw monies for the house she had to rely on others to get the money for her. At that time there was little money for food shopping. A requirement has been made to ensure that any new manager has immediate access to the funds they will need to efficiently run an establishment. On the Inspectors second visit she was informed that the manager was now authorised to draw money. Please see Requirement 3 The freezer did have a selection of food and the evening meal was well cooked and was of sufficient quantities for all. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards were inspected on this occasion. Service User needs and preferences are reflected in the care plans and the staff members are familiar with them. Some work needs to be done around balancing a persons preference to care for themselves and their actual abilities. EVIDENCE: How each Service User prefers to be supported with personal care is reflected in their individual care plans and conversation with staff indicated that they are familiar with these preferences and uphold them. One of the service users, who is partially sighted, does not like assistance from staff during her personal care or in keeping her room clean and tidy and staff respects this, she is not completely successful and this leads to conflict between the house and her family. The Service User’s father’s partner raised concerns with the Inspector. Meeting notes show that this is a longstanding concern of the family. In discussion with the manager the Inspector recommended that she refer the Service User to outside agencies such as occupational therapy to seek training, support and guidance. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 14 In the past it was agreed that advice would be sought from the Kent Association for the blind. A letter acknowledging the referral saying there was a short waiting list was on file dated August 04 but there was no indication of further contact, the manager was not aware of any action occurring from the referral and it is recommended that she should contact them again either to follow up the first letter or to seek further assistance. Please see Recommendation 4 The tenants are registered with local doctors and attend as necessary, one of the Service Users refuses to see a doctor since she has registered but is supported to go when needed by her family. Health care needs are covered by the care plans and reviewed at the annual review meeting. One Service User is epileptic and there is a good procedure process in place to record the number and nature of the seizures he has, which is numerous. However he sleeps in a downstairs room and the sleep in room is based upstairs. He has in the past used a seizure monitor placed under his mattress to alert the staff if he fits during the night. The monitor is no longer used and the manager does not know why. It is recommended that she find out why the monitor is no longer in use and a requirement has been made that she carries out a risk assessment around the Service Users safety when he seizes at night. Please see Recommendation 5 and Requirement 4 Two of the Service Users have mobility problems, one of which is deteriorating; he has been assessed as needing a hip replacement. It is believed that the operation and the lengthy recovery time would be difficult for the Service User to manage so the doctor has advised that he receives pain management as an alternative to undergoing surgery for the time being, this decision will be reviewed regularly via hospital appointments. This Service User has received an occupational therapy assessment and has been give an exercise program to help maintain mobility. Future consideration of his mobility needs and review of the placement will have to be made as his condition develops because the house is not adapted for Service Users with mobility problems. None of the Service Users self medicate and all medication is stored and administered by the staff. The medication recording sheets were complete, had photographs attached and the medication cupboard was in order and any medication inspected was in date and appropriately labelled. The Service Users are mainly older, one being above retirement age and another close to it, there is a policy on death and dying in the house and the staff members are aware of it. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 15 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): Both were inspected, the Service Users are well informed about making a complaint but there is still a need for a copy of No Secrets to be obtained and discussed within the staff group. EVIDENCE: The Inspector was able to talk to three Service Users and none expressed concerns, two of the tenants were able to tell her who they would go to if they needed to complain, the other tenants have poor communication skills. The staff members spoken to assured the Inspector that if they felt that any Service User appeared unhappy they would do what they could to ascertain why and if needed they would instigate the complaints procedure on their behalf. There is a copy of the Adult Protection Policy in the house and staff undertook adult abuse training at the beginning of the year. The manager was not sure if there was a copy of the “No Secrets” guidance as raised at previous inspections so the Inspector has restated the requirement for it to be located or obtained. Please see Requirement 5 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 16 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): All standards were inspected the Service User rooms are comfortable and reflect their interests and the home appeared clean and hygienic. The communal areas are need redecoration. EVIDENCE: The house has a homely and relaxed atmosphere; it is warm and free from offensive odour. The decoration and furnishing in the communal areas are in need refreshing but is mainly bright and comfortable with pictures on the wall and ornaments around the house. The Service Users rooms observed were well furnished and reflected their interests and character. All the bedrooms have previously assessed as meeting the required standard of having at least 10sq meters of usable space and appeared to be larger than requirement as all gave the impression of being large and spacious. The toilets and bathrooms were clean and appointed to the needs of the Service Users. There is a shower available to people who find it difficult getting in and out of a bath. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 17 The garden is accessible from the kitchen, however the gardens were sadly neglected and the overgrown and rubbish strewn appearance of the front garden and a broken wall lends an air of neglect to the whole building as you approach it, a program of maintenance would improve the Service Users accessibility to the garden and the uplift first impressions. Please see recommendation 6 One of the Service Users who has mobility problems is able to walk within the house, but finds it difficult out in the community he is being assessed for use of a wheelchair to make it easier fro him to get out and about more. There did not appear to be many adaptations within the house, there are no lifts or hoists and The Inspector was not made aware of any adaptations that have been made for the Service User with partial vision. Overall the house was clean and tidy and the laundry was in good order. Cleaning materials were stored in a separate cupboard, the Inspector was informed that the house had a COSH manual but it was not stored in the same cupboard as the cleaning materials, A requirement has been make that a copy is kept in the same cupboard. Please see Requirement 5 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 18 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): All standards were tested and staff appeared to be competent and to be aware of their roles and responsibilities. Supervision and training is offered. However none of the information regarding staff recruitment required to accessible to the Inspector was available. EVIDENCE: The staff spoken with informed the Inspector that they had contracts and job descriptions and felt that they were clear in their roles. They also confirmed that they had undertaken an enhanced police check that had come back as nothing recorded and had been asked to produce two references one from a previous employer. The manager stated that she held regular supervision sessions and staff confirmed this. On the day of the inspection supervision had been booked for a staff member and it took place. The house has attained minimum requirement of 50 of staff qualified at NVQ level 2 or above, the manager is new in post and is working towards obtaining her Registered Managers Award and has NVQ4 in care. Two support staff have NVQ3, with one other is working towards it and a fourth staff member is presently doing her LDAF training. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 19 There is an ongoing training program and staff members have their training needs assessed in supervision and during Personal development interviews that are carried out annually and reviewed every six months. At the start of the inspection the manager and one care staff were present, one care staff member having gone off shift at 9.00am, and three staff came on duty for the PM shift, all were permanent staff. The rotas correctly reflected this and showed that part time staff (with little use of agency staff) mainly covered vacant shifts and sickness. The Inspector was informed that there are no staff records retained in the house and that they and the recruitment records are maintained in the London Borough of Bromley personnel department. The Inspector reminded the manager that there had previously been a requirement that all records required under Schedule 2, 3 and 4 must be available for inspection in the home. It is acknowledged that there are difficulties in storing sensitive and confidential information relating to the staff group in an unsecured environment and having them available for inspection at any time of day or night irrespective of the availability of the registered manager, arrangements must be sought that would satisfy both the need to uphold staff confidentiality and the requirement that the Regulatory Inspector is able to ascertain that the Service Users are supported and protected by the homes recruitment policy and practice by being able to inspect records related to staff members as set out in schedule 2. This is a restated requirement. Please see Requirement 6 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 20 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): Standards 37, 38, 41and 42 were assessed on this occasion, the manager appeared knowledgeable and staff found her approachable and the Service Users seemed to like her. Health and Safety records are maintained and are mainly in order. EVIDENCE: The manager has only recently taken up post and therefore has not completed all the necessary processes required to become the Registered Manager. The commission had not been informed that the previous manager had left post or that a new manager had been appointed. It is a requirement that the commission is notified immediately there are any changes to the registered person as set out in regulation 39. Please see Requirement 7 The manager was found to be knowledgeable and able to respond appropriately to questions. She has been in post as an agency manager since August 2005 and has gotten to know the Service Users and staff in that time. Staff interviewed said that she is approachable and friendly, observed interaction between her and the Service Users and the staff confirmed the St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 21 accuracy of that statement. One of the Service Users indicated to the Inspector that he likes the manager and said she was “good”. The manager informed the Inspector that she has had management experience working with this client group prior to taking up post; she has NVQ4 and is in the process of attaining her Registered Managers Award. She has received her contract of employment and has undergone an enhanced CRB check. Completed records of accidents and injuries were observed and placed on each individual Service Users file. It is suggested that the records are also kept in one in one folder for ease of collating the information and to give a clearer overview. Please see recommendation 7 The fire procedures in the entrance hall states that there are four and not five Service Users living in the house, this needs to be updated and amended. Please see Requirement 8 A selection of Health and Safety records was viewed. Fire Drills are recorded as being carried out in sufficient number and fire point testing is mainly carried out weekly with a few breaks in recording. The fridge temperature recordings were taken regularly and showed that the fridge temperature varied from –160 C to 120 C. There was no indication on the sheet what temperatures the fridge or freezers should be or any indication what action had been taken to make correction. It is recommended that the sheets should be redesigned to show what the reasonable temperature range should be and what action should be taken if they deviated from the norm, also any necessary actions should be recorded on the sheets and the manager should check and sign the sheets to indicate audit. Please see recommendation 8 The water temperature recording sheets are included in the previous recommendation. The water temperatures were recorded as ranging from 47.50 C to cold with no indication what the expected range was or what actions had been taken. On checking one of the Service Users sinks I found the water to run cold, the manager immediately reported the tap for adjustment vie the LBB maintenance team. Water temperature at point of delivery should be close to 430 C. Please see recommendation 8 There was evidence that a general Health and Safety Check had been carried out by the Central Safety Unit LBB on 12th April 2005. There were no outstanding actions recorded. St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 1 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Blaise Avenue (2) Score 2 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 2 X DS0000038974.V269702.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 Requirement New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. The registered person ensures that service users are safeguarded from physical, DS0000038974.V269702.R01.S.doc Timescale for action 25/02/05 2 YA3 14.1 25/02/05 3 YA17 16.2 25/02/05 4 YA19 12.3 25/02/05 5 YA23 13.6 25/02/05 St Blaise Avenue (2) Version 5.0 Page 24 6 YA34 19.1 7 YA33 39 8 YA40 13 financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 25/02/05 25/02/05 25/02/05 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 3 Refer to Standard YA1 YA6 YA12 Good Practice Recommendations It is recommended that each Service User have their own copy of their Service Users Guide kept in their individual file. Care Plans and other documents should be dated when they are written or updated and a date for the next planned review should be inserted. An activity plan should be drawn up that indicated what planned activities there are and it should indicate whether DS0000038974.V269702.R01.S.doc Version 5.0 Page 25 St Blaise Avenue (2) it took place or not. 4 YA18 Advice should be sought from outside agencies such as occupational therapy to seek training, support and guidance for a Service User who refuses assistance. The Manager should find out why a seizure monitor that was used by one of the Service Users is no longer in use. The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. It is suggested that the records are also kept in one in one folder for ease of collating the information and to give a clearer overview. It is recommended that the recording sheets should be redesigned to show what the reasonable temperature range should be and what action should be taken if they deviated from the norm, also any necessary actions that are taken should be indicated on the sheets and the manager should check and sign the sheets periodically to indicate audit. 5 6 YA19 YA24 7 8 YA41 YA41 St Blaise Avenue (2) DS0000038974.V269702.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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