Inspection on 18/10/05 for Vaughan House

This inspection was carried out on 18th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Vaughan House 15/01/08

Vaughan House 02/04/07

Vaughan House 09/06/06

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 Linda Cappello Unannounced Inspection 18th October 2005 14.00 Vaughan House DS0000014979.V258056.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 Vaughan House DS0000014979.V258056.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. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 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 London Parkcare Limited 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.V258056.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum number of service users - 10 The category MD is for one service user only named in correspondence dated 24 June 2005, for a limitd period only, namely until 11 January 2006. No further service users in the category MD are to be admitted to the home. 22/06/05 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. The home is owned by Craegmoor Healthcare. 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 was being added to the side of the building at the time of this inspection. 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. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the afternoon of 18th October 2005 and was carried out by the Lead Inspector, Linda Cappello, and Louise Trainer, Regulatory Inspector. The purpose of the inspection was to assess whether the home was meeting the National Minimum Standards for Adults (18-65) and whether the home had complied with the requirements made following the previous inspection on 22nd June 2005. Due to the high level of concerns which arose about this home, additional visits were also made by the Lead Inspector on 26/07/05 and 24/08/05 and a visit by the Pharmacy Inspector was made on 17/08/05. An enforcement notice was issued on 25/08/05 in relation to continuing concerns about the way in which the home managed the administration of medication. An enforcement visit was carried out by Lynda Higgins, Regulation Manager, on 20/09/05 and she made a further additional visit on 29/09/05 to check compliance with the enforcement notice. During this inspection, the care of three residents was tracked by speaking with them, visiting their bedrooms and the communal areas they use and by talking to the staff on duty. The serving of the evening meal was also observed. The acting manager was on leave on the day of this inspection but the senior support worker on duty was able to assist the inspectors. A manager from a nearby establishment, who was providing management cover, also attended for a short time. The inspectors are grateful for the help they received from the staff and residents. What the service does well: What has improved since the last inspection? There have been a lot of serious concerns about the way the home is run and the effect this has had on residents and so extra visits by the inspector have been made. The company who owns the home have taken action to make a lot Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 6 of improvements in recent months and the home is still working hard to make sure that everything is being done in the way it should be. For example, the way in which the home gives out medication has improved which means that residents are safer and the way in which residents’ care is written down, so that staff know what to do, has improved. There are also some improvements in the building, such as in the top floor bathroom, the kitchen and the building of a laundry area. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 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.V258056.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the previous inspection. EVIDENCE: Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the previous inspection. EVIDENCE: Vaughan House DS0000014979.V258056.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): 17 Residents are regularly consulted about their choice of meal so that they enjoy their meals. EVIDENCE: The serving of the evening meal was observed and all but one of the residents enjoyed eating it. One of the residents chose to have a snack later as he was not hungry when the meal was served. The residents are regularly consulted about what they would like to eat and the menu is constructed from their choices. It was observed that fresh ingredients were used, including a selection of fresh vegetables. Staff were unable to sit at the table with the residents because there was insufficient space in the dining area. This situation will be improved when the laundry equipment is moved out into the new laundry area which is under construction and the fridge and freezer are returned to the kitchen area. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Staff are aware of residents’ preferences so that they receive personal support in the way they prefer and require. Overall, residents’ health needs are met although records need to improve. The procedures for administering medication had improved so that residents were safeguarded. EVIDENCE: The home has begun to develop care plans using a person centred approach and to develop health plan for each of the residents. This is gradually beginning to ensure that staff are more aware of the individual preferences and needs of each resident. The specific needs of one resident have now been assessed and identified and a management plan has been developed to assist staff to provide appropriate care for him. Residents confirmed that staff gave them support with their personal care in the way they wished. The records of visits to and from health professionals such as opticians, chiropodists etc should be better maintained as the information about appointments was, in some cases, only in the message book or diary. One resident said that he had had a temperature the day prior to the inspection but the home did not have a thermometer. Staff confirmed that the healthcare policy referred to using a thermometer and said one would be bought for the home immediately. It was noted in the Message Book that a resident had fallen and injured himself but this information was not in his daily notes or recorded on an accident form. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 13 There had been serious concerns at this home for some time about the way in which medication was administered, stored and recorded. The home had consistently failed to ensure that the systems were safe and this was putting residents at potential risk. An enforcement notice was, therefore, issued by the Commission for Social Care Inspection on 25/08/05, requiring the home to take specific action to address the concerns. The provider company put an auditing system in place and assessed the competence of staff and, during this inspection, it was found that the administration of medication in the home had improved significantly with no errors being found. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has listened to the views of residents and relatives. EVIDENCE: Some relatives of the residents had raised some issues such as the home’s transport and holidays and initially felt these had not been dealt with. A meeting was held with relatives and these matters were discussed. As a result, holidays for the residents were arranged, although these were taking place quite late in the year. Meetings are also held with the residents at which views are sought on menus and activities. Unfortunately, the minutes of these meetings were not easily accessible. The provider company has a complaints procedure and a complaints book is available in the main hallway for the use of residents or relatives. There were no entries in the book on the day of this inspection. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 15 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): These standards were assessed at the previous inspection. EVIDENCE: Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 16 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): These standards were assessed at the previous inspection. EVIDENCE: Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 A recent improvement in the running of this home is beginning to benefit the residents. The home does not have a formal quality assurance system but consults with residents and relatives. The home has adequate health and safety practices which are protecting the residents. EVIDENCE: As discussed above, there had been serious concerns about many aspects of the running of this home and this had resulted in an Enforcement Notice being issued. There was evidence during this inspection that improvements have been made in many areas and this is beginning to improve the outcomes for the residents. The provider company has instituted an improvement programme for the home which includes putting additional support and monitoring processes in place. The progress of the home towards meeting the timescales for improvement which have been set will continue to be monitored so that the health, safety and quality of life of residents is ensured. The home does not yet have a quality assurance system but the provider company are developing a thorough auditing and monitoring process and this will be in place next year. The home does meet with relatives and residents to Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 18 discuss issues and views but these need to be recorded and evidence seen that the consultation directly affects what takes place in the home. The records of maintenance and testing of equipment in relation to health and safety were assessed and found to be in order. Residents were able to tell the inspectors what they do to get out of the building when they have a fire drill. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 19 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 x x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vaughan House Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 X X 3 x DS0000014979.V258056.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 YA42 Good Practice Recommendations The home should appropriately record all injuries and accidents. Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vaughan House DS0000014979.V258056.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!