Inspection on 15/01/08 for Vaughan House

This inspection was carried out on 15th January 2008.

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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vaughan House 02/04/07

Vaughan House 09/06/06

Vaughan House 18/10/05

Vaughan House 22/06/05

Vaughan House 15/03/05

Vaughan House 09/12/04

Vaughan House 03/03/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Vaughan House 21 Studley Road Luton LU3 1BB Lead Inspector Mrs Louise Trainor Unannounced Inspection 15th January 2008 11:00 Vaughan House DS0000014979.V358044.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 Vaughan House DS0000014979.V358044.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. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vaughan House Address 21 Studley Road Luton LU3 1BB 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) 01582 734812 01582 415196 Vaughan.house@craegmoor.co.uk Craegmore.co.uk Parkcare Homes Ltd Vacant Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 18-65 years. Maximum number of service users - 10. The category MD is for one service user only named in correspondence dated 24th June 2005. No further service users in the category MD are to be admitted to the home. 2nd April 2007 Date of last inspection Brief Description of the Service: Vaughan House provides accommodation for ten adults with learning disabilities and currently all the residents are males. Craegmoor Healthcare owns the home. The home is situated in a pleasant residential area of Luton at a short distance from the town centre, which can be accessed on foot if necessary. Accessible facilities in the centre included a cinema, swimming pool, bowling alley and league football team. The building has been converted from a domestic dwelling to provide ten single bedrooms, with en-suite shower facilities to five of these and four with en-suite toilets. The remainder have wash hand basins. The bedrooms are located on all three floors of the house. Combined bath and toilet facilities are provided on the first and second floors and there is a communal toilet on the ground floor. Also on the ground floor there are a lounge, kitchen with dining area and an office. A laundry area had recently been added to the side of the building. Two further staff rooms are provided on the top floor. There is an enclosed rear garden, which is mainly laid to grass, and at the front of the house there is a paved parking space for three or four vehicles. The fees for this service presently range from £415.22 to £1633.66 per week. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for Younger Adults that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the second Key Inspection for this service this year. Regulatory Inspector Mrs Louise Trainor carried it out on the 15th of January 2008, between the hours of 11:00 and 16:45 hours. There is a new manager in place that was appointed in December 2007. She was present throughout the inspection to assist as necessary. The focus of this inspection was to monitor compliance of the requirements made at the previous inspection in April 2007. There are presently ten permanent residents living at this home and all of them were present for periods of the day during this visit. Personal files and documentation for two of these people were examined in detail during this visit. The inspector also had the opportunity to informally interview and chat with both people who live here and staff who work at the home. A tour of the premises was undertaken. Other documentation examined during this inspection included, documents relating to staff recruitment, training and supervision, Medication Administration Record (MAR) sheets and medication stocks, Personal Allowance records, maintenance checklists. The inspector would like to thank everyone concerned for their assistance and support during this inspection. What the service does well: This service has a detailed Service User Guide and Statement of Purpose. The Service User Guide is produced in an easy to read format ensuring that people who use this service understand the information and know that the home will meet their needs. People who live in this home are consulted on, and encouraged to participate in all aspects of life in the home. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 6 Individual care plans for each person identify the level of support and assistance they require in all aspects of daily living. The Person Centred documentation used in this home indicates that individuals’ wishes and feelings are considered in the way their care is managed by staff. Residents meetings are held at least once a month and the people who live here are encouraged to put forward their ideas and opinions regarding all aspects of life in this home, including activities and menus. A tour of the premises took place during this inspection. The ground floor communal areas are furnished in a homely way and are clean and well maintained. Individuals’ rooms are decorated to meet with personal tastes and needs, and include furnishings that have been chosen by the individuals’ and reflects’ their hobbies and lifestyles. What has improved since the last inspection? What they could do better: There are opportunities for educational and occupational development, but leisure activities are rather limited for some people who live in this home. It was also suggested during interviews, that the ‘cost’ was a factor contributing to the lack of activities, such as cinema trips and other things that the residents said they would like to do. One resident said. “I would like to join the snooker club”, but staff confirmed that the funding resources are not available to enable this to happen. There is a medication policy in place, however some of the documents in the file with the Medication Administration Record (MAR) sheets, were not accurate and could result in errors occurring, so that people living in this home may not be protected at all times. The complaints policy is sufficient to ensure that service users know how and where to address their concerns. However feedback received from some relatives indicated that there was some dissatisfaction in the way the company manages complaints. The records and funds of personal allowances and expenditure for three residents were examined. Only one of the three was correct. It was evident Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 7 that the staff do not always record individual’s expenditures as they occur. This is not acceptable. Some areas of the home remain in need of attention to complete the refurbishment that was ongoing and due for completion by the end of April 2007. The training of staff is presently in need of improvement to ensure that the specialist needs of the people who use this service have their needs fully met at all times. Some of the systems in place to safeguard the people who live in this home, are insufficient to ensure that their health, safety and welfare is protected at all times. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service has a detailed Service User Guide and Statement of Purpose. The Service User Guide is produced in an easy to read format ensuring that people who use this service understand the information and know that the home will meet their needs. EVIDENCE: The home has a Statement of Purpose that had been reviewed and updated just prior to the last inspection in April 2007. Everyone who lived in the home had been issued with a Service Users Guide that had been simply written and included pictorial symbols. Each individual living in the home had been helped to read and understand these documents and had signed to confirm their receipt. Since the last inspection in April 2007, there has been another change in Manager in the home, however there have been no new residents admitted to the home since this time. Therefore as the present service user files had been inspected to confirm pre admission assessments were evidenced at the previous inspection, these particular documents were not re inspected during this visit. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 10 Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in this home are consulted on, and encouraged to participate in all aspects of life in the home. EVIDENCE: The new manager stated that she is in the process of reviewing all the care plans, however the two files that were examined during this inspection contained, clearly detailed care plans that included personal goals and aspirations and the level of assistance required to achieve them. They also included individual’s likes and dislikes, indicating that all these factors are considered when care is being delivered. One person’s care plan identified that they needed reminding to brush their teeth, and that they liked to use mint-flavoured toothpaste. It also identified that they could make a sandwich without assistance, but would like to learn to cook Toad in the Hole and Pizza. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 12 Dislikes that were identified included loud noises and dogs, and the care plan indicated that both of these ‘dislikes’ were triggers for outbursts of aggressive behaviour. Another person’s care plan identified ‘management behavioural strategies’. This included the importance of the tone of voice used, a consistent approach and ‘praise and reward strategies’, such as listening to radio 4 or playing CDs of the individual’s choice. These care plans were being reviewed on a regular basis to address changes in needs. In addition to these care plans Annual reviews are carried out involving other professional disciplines. These are clearly documented. Most of the documents were signed by the people who live in this home, and although their capacity to understand all of the details is limited, it indicated that they are consulted and involved in the care planning process. Each service user has numerous risk assessments in place relating to all sorts of health and safety issues. Residents meetings are held at least once a month and the people who live here are encouraged to put forward their ideas and opinions regarding all aspects of life in this home, including activities and menus. Vaughan House DS0000014979.V358044.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): 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are opportunities for educational and occupational development, but leisure activities are rather limited for some people who live in this home EVIDENCE: In April 2007 the previous manager had discussed plans for a summer- house that would double up as an activity workshop, with a potters’ wheel, an organ and a flower press, it was disappointing that none of these things has materialised. This was also reflected in the questionnaires that were completed and returned to the Commission for Social Care Inspection (CSCI), from relatives, prior to this inspection. With the exception of two residents, all attend either college or some occupational activity regularly. One of those that does not, told us. “I’ m Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 14 usually here during the day”. He was sitting in front of the television, but gave the impression he was bored. The manager said that since the closure of the Woodstock Day Centre, people in the home are individually being more actively encouraged to make decisions about how they spend their time both in the home and in the local community. However there was no evidence of individual activity timetables, and no records kept to identify what people were doing on a day-to-day basis. The relative of one of the residents informed us that since the closure of Woodstock, their loved one does not go out, and ‘spends all day looking at the same four walls’. Each individual who lives in the home has one day each week, which is dedicated to doing their household chores such as laundry and tidying their rooms. The Activity Coordinator talked about ideas that she has, to introduce ‘educational projects’, which will involve the use of the local library, however at present there is no evidence to indicate anything like this is happening. Leisure activities, such as evening clubs, and swimming, which is a favourite, are limited. People that we interviewed informed us, that this is due to a lack of resources. One particular problem is apparently the lack of male staff to assist in changing rooms. The residents in this home are all male, and most would need assistance or supervision. The comment. “You can only walk around the park so many times”, was made by several of the people that were interviewed. This suggested that there is a distinct lack of imagination used when planning leisure activities, and often it is just a walk around the local park. However four people did go to play games at a local leisure centre on the afternoon of this visit. It was also suggested during interviews, that the ‘cost’ was also clearly a factor contributing to the lack of activities, such as cinema trips and other things that the residents said they would like to do. One resident said. “I would like to join the snooker club”, but staff confirmed that the funding resources are not available to enable this to happen. Observations of staff / residents interactions indicated a relaxed atmosphere of companionship with a mutual respect. The residents all appeared content whilst going about their daily routines whether independently or with support from the staff team. The menus offer a wide variety of healthy meals. People in the home are encouraged to contribute ideas towards menu planning, and also participate in food preparation. Vaughan House DS0000014979.V358044.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, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a medication policy in place, however some of the documents in the file with the Medication Administration Record (MAR) sheets, were not accurate and could result in errors occurring, so that people living in this home may not be protected at all times. EVIDENCE: All the people living in this home have numerous risk assessments in place, including one for the self-administration of medication. However at present no one self medicates. Individual care plans for each person identify the level of support and assistance they require in all aspects of daily living. The Person Centred documentation used in this home indicates that individuals’ wishes and feelings are considered in the way their care is managed by staff. However feedback from one relative suggested that some issues, such as incontinence are not always managed with the sensitivity they deserve. A sheet that addresses illness and dying is included in each file. One person had identified that they would like their mother to explain this to them. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 16 The MAR sheets for everyone on prescribed medication living in the home were examined. These sheets were completed accurately, with signatures and omission codes being recorded appropriately. The sheets reconciled correctly with stocks remaining. Each individual had a Personal Profile Sheet with their MAR sheet. This listed the medication each person was prescribed. Unfortunately these had not been reviewed regularly and therefore did not correspond with medication prescribed on the MAR sheets. This could contribute to mistakes being made. One person’s MAR sheet identified that Diazepam 5mg should be given once each day. There were no signatures recorded, indicating that this had not been given. The manager informed us that this person was no longer prescribed this drug, however it had not been discontinued on the prescription sheet. Two other peoples Personal Profile sheets identified medication that did not correspond with their MAR sheets. One person was prescribed two depot injections to be given every two weeks. Both injections were signed as given on the 12/12/07. We could not find any further signatures on the December / January MAR sheet. Later during the inspection, the manager found a second MAR sheet for this individual for this same period. Having two MAR sheets running for the same individual, for the same period of time is a dangerous practice, which could result in medication being given twice. One person in the home receives a ‘controlled drug’ on a regular basis. The records and stocks for this medication corresponded accurately. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints policy is sufficient to ensure that service users know how and where to address their concerns. However feedback received from some relatives indicated that they are not always informed of outcomes following investigations. EVIDENCE: There is a satisfactory complaints policy in place and it is summarised in the service user guide and accessible to everyone entering the home. There are also comment cards situated in the entrance hall, so that anyone wishing to raise any concerns anonymously has the facility to do so. There had been no formal complaints to the home since the new manager had been appointed in early December 2007, therefore it was difficult for her to comment on issues that had occurred prior to her appointment. A letter found in one persons file identified an incident that had occurred involving a confrontation between a member of staff and the relative of a resident, regarding his care. Although documentary evidence indicates that the matter was satisfactorily resolved. The relative concerned stated the they remain dissatisfied with the outcome in this instance, but feel there is little point in pursuing the matter any further, and hope that the recent reallocation of a key worker for their loved one may aid to improve the situation. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 18 Another relative informed us that she has often complained about issues relating to the laundry, but has never received any written response to these matters, and they reoccur regularly. The records and funds of personal allowances and expenditure for three residents were examined. Only one of the three was correct. It was evident that the staff do not always record individual’s expenditures as they occur, particularly over the weekend. This is a poor practice to adopt. The manager and the staff interviewed were able to demonstrate that they had a clear understanding of Safeguarding issues and related procedures, including Whistle blowing, however records indicated that some staff have not attended the mandatory training relating to this matter. Vaughan House DS0000014979.V358044.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, 27, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home remain in need of attention to complete the refurbishment that was ongoing and due for completion by the end of April 2007. EVIDENCE: A tour of the premises took place during this inspection. The ground floor communal areas are furnished in a homely way and are clean and well maintained. Individuals’ rooms are decorated to meet with personal tastes and needs, and include furnishings that have been chosen by the individuals’ and reflects their hobbies and lifestyles. Toilet and bathroom facilities do however remain in need of attention, as they did at the inspection in April 2007. The floor covering on the staircase and first floor landing also requires replacing. There are presently bare boards in some places, and it is badly stained in others, causing an offensive odour. Although we do appreciate that the reason for its’ present condition is due to the Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 20 behavioural problems of one particular person, it is important that this problem is resolved now. Vaughan House DS0000014979.V358044.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, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The training of staff is presently in need of improvement to ensure the specialist needs of the people who use this service are fully met at all times. EVIDENCE: The files of two permanent staff and one bank staff were picked at random and examined during this inspection. All contained fully completed application forms, terms and conditions of employment clearly signed and dated, various forms of identification, references and proof of address, POVA list checks, passports and job offer letters. However the manager was unable to locate an Enhanced Criminal Record Bureau (CRB) check for the bank carer. Records showed that since the appointment of the new manager, the staff are receiving regular supervision from her or her deputy, and staff that were interviewed said that generally they felt well supported, and were happy with the recent change of management. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 22 Unfortunately evidence of training that had been attended during the last year was very limited. The people who live in this home have very specialist needs, At the previous inspection in April 2007 it was identified that specialist training in Autism, Epilepsy and Promoting Independence, and Mental Health was imminent. There was no evidence that this training had happened, and it was reflected in discussions with some staff, that they felt unable to meet some of these needs. So although the staff appear competent and caring, many are inadequately trained for their role. Feedback received from two different relatives that we contacted following receipt of their ‘Have your say about…….’ questionnaires, told us that certain staff had made comments to them, such as, “His behaviour is not part of his illness, it’s because he’s been allowed to get away with it!” This shows that some staff lack compassion and understanding of some of the conditions endured by these residents. In order for the needs of all the people who live in this home, to be met satisfactorily, it is important that specialist training, to equip staff with the appropriate understanding, knowledge and skills, is introduced without delay. Vaughan House DS0000014979.V358044.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, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the systems in place to safeguard the people who live in this home, are insufficient to ensure that their health, safety and welfare is protected at all times. EVIDENCE: There is another new manager in post in this home. She is an experienced practitioner who is new to the company, and appears keen to make improvements in this home. However this was her first experience of the CSCI inspection process, and she seemed rather overwhelmed and surprised by the detail of information we required. We would have expected the company to prepare any new manager more robustly for this. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 24 Unfortunately the deputy manager was on annual leave, and this made some areas of inspection difficult, as the manager has only been in post a few weeks and was unable to locate some of the documentation required. The staff in this home have been unsettled for many months by the changes in management. One member of staff told us that this is the fifth or sixth manager they have seen at the home. However discussions with some staff indicated that they are happier with the new manager, whom they say ‘listens’, and they hope to be able to work with her to improve standards. The records of key management systems, detailed elsewhere in this report, including, recruitment, training, medication and personal finances, were found to have minor discrepancies and shortfalls, which could compromise the safety and welfare of people in this home. We appreciate that when a new manager comes into post, it takes time for audit processes to be established, and the manager to take ownership of these processes, however due to the repeated changes in management of this home, CSCI can no longer make exceptions where these shortfalls occur and they must be addressed through statutory requirements. Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 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 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 3 2 X 2 X 1 1 X Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 26 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 YA14 Regulation 16(2)(m) Requirement Arrangements must be made to ensure that people who live in this home are encouraged and assisted to participate in the leisure activities of their choice. People who live in this home must be protected by Medication Administration procedures and records. People who live in this home must be cared for by staff that are appropriately trained in Safeguarding procedures. All the refurbishments in this home, including the stairways and bathrooms must be completed so that the people who live in this home have a clean, safe environment to live in. The date was previously extended because of the delay in the new floor being laid in the lounge area. Extended timescale 30/09/07 remains unmet. People who live in this home must be cared for by staff who have been appropriately DS0000014979.V358044.R01.S.doc Timescale for action 28/02/08 2. YA20 13(2) 31/01/08 3. YA23 13(6) 31/01/08 4. YA24 23(2)(d) 31/03/08 5. YA34 19(1)(b) 31/01/08 Vaughan House Version 5.2 Page 27 6. YA35 18(1) (c )(i) 13(6) 17(2) 7. YA41 8. YA39 24 (1)(a)(b) recruited. All information and documents specified in paragraphs 1-7 of schedule 2 must been obtained for each employee. People who live in this home 31/03/08 must be cared for by staff that are appropriately trained to manage their specialist needs. People who live in this home 31/01/08 must be protected from financial abuse by clear, accurate personal allowance records. These must not be completed in retrospect of spending. The home must have an effective 28/02/08 quality assurance system that influences the annual development plan for the home. This standard was partially met 01/09/07 The record keeping systems in this home must protect the people who live here. 9. YA42 17(3) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vaughan House DS0000014979.V358044.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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