Inspection on 22/06/05 for Vaughan House

This inspection was carried out on 22nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Vaughan House 15/01/08

Vaughan House 02/04/07

Vaughan House 09/06/06

Vaughan House 18/10/05

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 Beds LU3 1BB Lead Inspector Linda Cappello Unannounced 22 June 2005 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 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 Stationary 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 I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Vaughan House Address 21 Studley Road Luton Beds LU3 1BB 01582 734812 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) London Parkcare Ltd care home 10 (10) (10) Category(ies) of LD - Learning Disability registration, with number PD - Physical Disablilty of places Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/03/05 Brief Description of the Service: Vaughan House provides accommodation for ten adults with learning disabilities and currently all are males.The home is owned by Craegmoor Healthcare. The home is situated in a pleasant residential area of Luton within walking distance of the town centre, with access to the railway and bus stations. The building was converted from a domestic dwelling to provide ten single bedrooms. Five have ensuite shower facilities and four with ensuite toilets. 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 are a lounge, dining room adjacent to the kitchen and an office. There is an enclosed rear garden mainly down to grass and at the front of the house there is a paved parking space for three or four vehicles. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours during the afternoon and evening of 22nd June 2005. The purpose of the inspection was to assess whether the home was meeting the National Minimum Standards and whether the home had complied with the requirements made following the previous inspection. The care of one resident was tracked in detail, including looking at his care records, talking to him and staff on duty and looking at his bedroom and the other facilities he used in the home. Many other residents were also spoken to during the course of the inspection and the administration of medication and the evening meal were also observed. The manager was present for the first 3 hours of the inspection and the Area Manager for the provider, Craegmoor Healthcare, was also present for the first hour as she was carrying out her monthly monitoring visit to the home. What the service does well: What has improved since the last inspection? The home was told it must draw up a new guide to the home and a contract which the residents can make use of and these have been done but now need to be discussed with each resident and their relatives if they wish. The home was told it must make sure that the resident’s records are kept in a safe place and they are now locked in a cupboard in the office, and the keys to the medicine cupboard are also now kept safely. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 6 There were a lot of things wrong with how medication was dealt with in the home and a lot of those things have been put right. A new bath, sink and toilet have been put into the bathroom on the first floor and a new floor has been put down. The bathroom on the top floor has been redecorated but more work needs to be done to it and new worktops have been put in the kitchen. What they could do better: There are a lot of things that this home needs to do better and three things were very urgent so the home was told to do these straight away. The home was told to sort out two things about how one resident’s medication was given to him and was also told that it must do something about how hot it was in the home on a sunny day. The home needs to get better information about people before they move into the home and write it all down so that it very clear what that person needs and what the home needs to do to look after them properly. The home has to write out a plan to show how residents are to be looked after and these have got to set out everything about each person so that staff can be very sure that they know what to do to look after each person. One resident said “I know there is a plan but its not finished because staff are too busy.” The home has to think very carefully about whether there are any situations which might put residents at risk and make sure they write down what those risks are and how they are going to stop people hurting themselves, but also let people do as much for themselves as they can. The home needs to talk to all the residents about what they really like to do and what they are really interested in and then find ways to make that happen. These might be things to do around the house or garden or might be things they want to do outside the home. Some of these things might be done as a small group or on their own with the support of staff and there needs to be enough staff on duty so that this can happen. Residents said “We hardly go out anymore” “I couldn’t go out because there wasn’t enough staff on duty.” “I’ve only been to the shops and park, that’s all.” In order for these things to happen, the home needs to think carefully about what transport is used as some people think that the minibus is not used enough and is not big enough, but there are other good ways of getting around, like ordinary buses and taxis. The house needs quite a lot of work to make it better for people to live in, for example, the top floor of the house is right under the roof and the ceilings are very low in some places “I bang my head” one resident said. There are also other things to put right like the smell in some parts of the home and making sure that everyone has a comfortable mattress. The home also needs a separate laundry so that the washing machine is not in the kitchen and the tumble dryer and ironing board are not in the dining room. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 7 The manager needs to make sure that all the things that need to be improved are put right and to make sure things are noticed before the next inspection. She also needs to make sure that the staff go on training courses and that she or someone else sits down with them regularly to see if there are any problems. 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. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5 The home had now produced a Service User guide and contract in a more suitable format which meant that most service users could understand them. However, the lack of a detailed assessment of needs meant that it was not clear whether the home could meet residents’ needs. EVIDENCE: There had been outstanding requirements since November 2003 for the home to produce their Service User Guide and Contract in a format which would make them accessible to residents. On the day of this inspection, the manager was completing the collation of the guide and contract. These are now in symbol format and individualised for each individual and residents were involved in developing the guide and contract. Some minor adjustments are needed to the style of language used but, overall, they now meet the standard. The home now needs to ensure that both of these documents are discussed with each individual service user and their relatives. At the last inspection it was found that the home was not making a copy of the inspection reports available to staff, residents or their families and a recommendation was made that the report should be shared with residents. The home must provide a copy of the latest inspection report with the Service User Guide to prospective residents and their families and should share it with staff and current residents. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 10 The records of one service user were assessed who had recently moved into the home. The assessment of his needs was not complete and lacked significant detail. There was no record of any of the discussions which had taken place to show how this home was able to meet his needs nor whether any discussion about potential restrictions on choice, freedom or facilities had taken place. The only information about his needs prior to admission were contained in a care plan which had been developed at his previous permanent placement and no information from the respite placement immediately preceeding his placement at Vaughan House. The care plan produced by the social worker involved in his placement was not with his records. In the absence of this information about the assessment of needs prior to his admission, it was, therefore, difficult to see how the resident and his family could be confident that this home could meet his needs. During the last inspection, it was found that the home was not able to meet the needs of one of its residents and requirements were made in this respect. During this inspection, it remained clear that his needs were not able to be met by this home. The resident who had recently been admitted to the home had made some visits to the home but had not stayed overnight. No records of these visits were seen in his care records. However, the resident said that he did know which bedroom was going to be his and he had met the other residents and some staff. His admission had been reviewed after six weeks at a meeting with his social worker, advocate, parents and managers. However, the social worker had not yet provided the formal minutes. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10, The individual plans do not contain sufficient detail about the needs and goals of residents and do not contain all the necessary individual risk assessments so that it would not be clear to staff how to meet their needs. Residents have been consulted on, and participated in some aspects of life in the home recently. EVIDENCE: Following previous inspections, the home has been required to improve the detail in the individual care plans so that it is very clear how each resident’s needs are to be met, whether there are any restrictions on their choice or freedom and what individual procedures are in place if a resident causes selfharm or is aggressive. The care plan examined during this inspection was not complete and lacked a great deal of information. Only two aspects of the resident’s care had been addressed and, in the absence of a full assessment of his needs on the file, it was not possible to see what needs had been identified and how these were to be met. The resident confirmed that he had been involved in drawing up the elements of the care plan which were on file but said that staff had been too busy to finish the plan. When staff were questioned about elements of another resident’s care, they were unclear about Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 12 what the strategy was to deal with what was, without adequate safeguards, a worrying situation. The residents’ rights to make decisions about their lives and the aspects in which that right is limited should be included in the individual care plans and this again was not seen during this inspection. Residents had been consulted about the new service user guide and contract and had provided useful ideas and opinions. This type of participation should be encouraged and maintained. Some residents had also offered to assist with the redecoration of one of the bathrooms which they had enjoyed. The individual care plan examined on this occasion only contained standardised risk assessments rather than assessments carried out in relation to the specific risks for the individual. Following the last inspection the home had been required to undertake such risk assessments. The home was required to make sure that resident’s records were kept secure and confidential and, during this inspection, it was noted that they were now kept in a locked cupboard in the office and staff were aware of the need for confidentiality. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16, The home supports residents to maintain contact with their families and to attend education or daycare facilities. However, the home needs to create more opportunity for residents to enjoy other leisure and community activities, according to individual choice, so that they lead more fulfilling lives. EVIDENCE: Residents have a training day each week when they undertake tasks around the home such as cooking, cleaning their rooms and clothes washing. The home must ensure that there is good structure to these days and clear aims and objectives for each individual. The home will no longer have domestic help shortly and the home must ensure that, if residents are to be involved in cleaning communal areas, this is made clear in the service user guide, in individual plans and clear at the point of admission, and that the purpose of such activity is clear with all appropriate risk assessments in place. Residents at the home are supported to attend daycare facilities and to attend local colleges as appropriate to the individual. However, the home was required following the last inspection to take a more person-centred approach Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 14 to planning activities and must also ensure that there are sufficient staff available to enable residents to pursue their interests. Several residents said that there were not enough staff available during part of the previous weekend for planned activities to take place. On the day of the inspection, however, one resident went to a local Mencap club during the evening and another said that he had recently joined the local library. Residents and parents have also complained that the home does not have sufficient transport available and this is partly due to a lack of drivers amongst the staff group. There must be a good balance between individual and group activities, based on individual need and preference and the facility to access appropriate transport, which would include public transport. Residents spoke positively of the contact they maintained with their families and friends and some residents go to their parents’ homes at weekends. However, the home must ensure that families are kept fully involved and informed about issues which concern them, with the resident’s consent. The daily routines in the home should promote independence and choice. Residents again raised with the inspector their dislike at being woken up by staff in the mornings at a set time to have their medication. This has been discussed at a residents meeting previously but the home should look at whether this is necessary and whether the process of handing out medication to all residents in a group is appropriate. Residents did confirm that they have a key to their rooms and that staff knock before entering their bedrooms. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, The system for administering medication to a resident who is working towards self-medication was unsafe which could leave him at risk. EVIDENCE: Residents are issues with their medication at about 8pm in the evening and at about 07.30am in the morning. The 8pm issue was observed during the inspection, when all the residents who were in the home at the time went to the office. Most of the residents have their medication administered to them but one resident said that he was self-medicating and this was confirmed by staff. However, there was no clear plan for how this is to be carried out and, in fact, the resident’s medication is kept in the medication cabinet with the other residents’ and he was given the basket which contained all his medication. The member of staff signed the Medication Administration Record but was unclear whether he was signing to say the medication had been taken or just that the resident had been given the basket. On examination, it was found that there was no risk management framework for the resident in relation to taking medication. There was also no protocol to cover taking medication which was prescribed to be taken “when required” and this would need to state under what circumstances he was to be given it. Staff had been signing each day for the previous two weeks as if he had been taking it every day, rather than “as required”. The home was issued with immediate requirements to review this resident’s medication. If a resident is selfVaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 16 medicating, he should be able to keep the medication in his room in secure storage but where a risk assessment shows that this is not appropriate, the care plan should contain a clear plan showing the steps to be taken towards the goal of achieving full independence. The competence of all staff who are administering medication must be kept under constant review through regular re-assessment by someone who is competent to do so. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 There are policies and procedures in place which aim to protect residents however all staff must receive training so that they are fully aware of the potential for abuse. EVIDENCE: The provider company, Craegmoor Healthcare, has robust policies and procedures in place to protect residents from all forms of abuse. This home has recently had an incident which potentially placed a resident at risk and this had been dealt with appropriately. However, it is important that every member of staff has received training to ensure they are able to identify potential abuse and understand how their own work practice should protect residents. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27,28,30 These premises had been converted from a large old private house some years ago and requires some major work and on-going maintenance to make it more suitable to the needs of the 10 residents. EVIDENCE: The home does not have a separate laundry and the home has been required to provide one so that the washing machine is not in the kitchen and to free up space in the dining room which is not a very large space and currently contains the tumble drier and the ironing board when it is in use. Although quotations for the work have been obtained the work had not been commenced by the time of this inspection. The original conversion made several rooms in the eaves of the home which includes two bedrooms and a bathroom. The bathroom on the top floor has very restricted head height because of the roof eaves and has no natural light. The home was required to review the use of this bathroom following the last inspection. Consideration has since been given to moving the bathroom and it has been redecorated. However, the floor must be replaced because there was a very offensive odour in there and the ventilation increased pending a solution to the restricted head height. One bedroom on this floor was visited during the inspection and was, again, found to have very restricted head height. The resident told the inspector he Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 19 bangs his head on the ceiling when he goes to open the window. The use of this room must be reviewed. A number of other issues arose in this bedroom. The shower in the room does not work, the home had not provided a chair in the room, the window restrictors on the rear window were broken. The mattress was felt to be uncomfortable and must be replaced and there was a hole in the ceiling plasterboard. The whole of the top floor was extremely hot but no fans had been provided to residents and the home was immediately required to address this matter. There were further issues of maintenance around the home which included addressing the ventilation for the shower in the groundfloor rear bedroom and installing a new floor in the kitchen. The home used to have a member of staff responsible for maintenance but now has to bring contractors in for each job that arises. This system needs to be improved so that maintenance is carried out promptly and a planned maintenance and renewal programme must be drawn up for the fabric and decoration of the premises. A method of managing the recurring offensive odours must be drawn up and appropriate action taken promptly. Since the last inspection, some jobs had been carried out, such as replacing the worktops in the kitchen, installing a new bathroom suite in the first floor bathroom and replacing a toilet compactor. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35,36 Staff have not attended all of the necessary training courses, are not receiving regular supervision and none of the care staff have achieved NVQ Level 2 which affects their ability to meet the needs of residents effectively. EVIDENCE: The record of training maintained by the home shows that many staff have not completed the basic mandatory training and this must be addressed as a matter of urgency. A member of staff who has been in post since February 2005 has not completed their induction training. No members of staff have completed NVQ Level 2 although 6 members of staff are working towards it. An examination of staff files showed that one member of staff had not had supervision for at least six months and a member of staff was not receiving sufficient supervision given that they were new to this home. All of these factors will affect the ability of the home to effectively meet residents’ needs and they must be addressed as a matter of urgency. Several staff and residents were spoken to during this inspection and many interactions between staff and residents and with the manager were observed. Staff were observed to be relating well to residents and dealing with issues which arose in an appropriate way. However, the staff did not seem clear about the level of decision-making delegated to them and seemed to be Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 21 required to refer to the manager for decisions which they should have been able to make themselves, for example, whether a resident could go out on an activity midweek. He had not been able to go out at the weekend because of a shortage of staff and it was observed to be inordinately difficult for a decision to be made, which placed stress on the resident. The manager is reluctant to use agency staff because she wants to retain consistency for residents but this can result in too few staff being on duty. There also seemed to be some tension amongst the staff group and between some staff and the manager. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 There are indicators that this home has not been effectively managed and this is affecting the quality of life and care for the residents. EVIDENCE: This home has been inspected 3 times in the past 7 months and a number of significant issues have arisen which have resulted in the home being required to take remedial action. Whilst some matters have been addressed, a disappointing number have not. Of particular concern are the assessments of needs, care plans, risk assessments, administration of medication, supervision and training of staff all of which directly affect the well-being of residents and all of which require improvement. The manager has achieved NVQ Level 3 and is currently working towards NVQ Level 4 and the Registered Managers Award. She has applied to the Commission for Social Care Inspection to become the registered manager but this process is not yet complete. The management arrangements of this home Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 23 and the other home nearby which has the same manager have been reviewed and the manager will, shortly, only be responsible for Vaughan House. As has been discussed above, there are issues which need to be addressed in order to improve the management approach in the home to ensure there is clarity for staff, and a more positive and inclusive atmosphere in the home. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 1 2 2 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 3 1 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 1 1 x 1 Standard No 11 12 13 14 15 16 17 2 3 2 2 3 2 x Standard No 31 32 33 34 35 36 Score x 1 1 x 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vaughan House Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 1 2 x x x x x I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 12(1)(a) Requirement In relation to the service user whose needs are outside of the current registration conditions, a management plan and care plan must be submitted which detail how the service users needs are to be met, pending a reassessment of his needs. Original date of 30th April 2005 not met A copy of the most recent inspection report must be provided with the service user guide to prospective residents and shared with currrent residents, their relatives and staff A full assessment of each service users needs must be undertaken prior to admission, must be kept under review and be revised at any time when it is necessary to do so, having regard to any change of circumstances. Specific training needs for staff arising out of the assessment must be provided. Original date of 30th May 2005 not met Care plans must be reviewed and updated and include all of the Timescale for action New Date: 15th July 2005 2. 1 5(1)(d) 31st July 2005 3. 2 14 New Date: 31st July 2005 4. 6 15 Schedule New Date: 31st July Page 26 Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 3(1)b 5. 9 12(2)(3)( 4) 18(1)(a) 6. 13,14 16(2)(m)( n) 7. 20 13(2) 8. 20 13(2) 9. 20 13(2) relevant details as to how the needs of each service users in respect of their health and welfare are to be met. The plans must include how aspirations and goals are to be met and how the service users rights to make decisions are to be respected and promoted. Original dates of 28th February 2005 and 30th May 2005 not met Risk assessments relating to the risks identified in each service users plan must be undertaken. the following issues were specifically identified: overnight monitoring, seizure management in the community, management of challenging benhaviour in the community and self-medication. staffing levels must be reviewed in light of these risk assessments to ensure they are appropriate within the home and when service users are accompanied in the community. Original date of 30th May 2005 not met. A person-centred approach to the arrangement of social activities must be developed to take account of individual preferences and choices. Original date of 30th June 2005 would not be met. The medication for the identified resident must be reviewed to ensure that medication is administered correctly. A protocol for administering medication PRN for the identified resident must be drawn up and staff made aware of it. Develop and utilise a risk management process to permit service users to handle their own medication. This must be applied with urgency to the 2005 31st July 2005 31st July 2005 23rd June 2005 23rd June 2005 15th July 2005 Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 27 10. 23 13(6) 11. 24 23(2)(p) 12. 24 16(2)(k) 13. 24 23(2)(b) (d) 23(2)(b) (d) 14. 24 15. 24 23(2)(d) 16. 25 23(2)(f) 17. 26 16(2) identified resident. Original date of 30th June 2005 would not be met. All staff must receive training to prevent residents being harmed or suffering abuse or being placed at risk of abuse. Steps must be taken to improve the ventilation on the top floor for residents comfort, and review needs of all residents in the home in hot weather. The home must take appropriate steps to manage the recurring offensive odours in the home, including the replacement of floor coverings where necessary.. The flooring in the kitchen area must be replaced Original date of 31st January 2005 not met The home must have a planned programme for the maintenance and renewal programme for the fabric and decoration of the premises, with records kept. The home must review the arrangements for cleaning the communal areas and ensure appropriate risk assessments are in place and residents involvement is fully recorded in their care plans, with objectives and goals. Their involvement must also be included in the Statement of Purpose and Service User Guide and contract. The use of the bedrooms on the top floor must be reviewed to ensure that their use safely meets the needs of residents. The identified resident must be provided with a chair in his room and a new mattress. The condition of all mattresses in the home must be kept under regular review and replaced 31st October 2005 23rd June 2005 15th July 2005 New date: 31st August 2005 31st August 2005 31st July 2005 31st August 2005 31st July 2005 Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 28 when necessary 18. 26 The ventilation available in the shower area of the ground floor rear bedroom must be addressed. 23(2)(j) The shower in the identified top floor bedroom must be repaired. 16(e)(f)(j) The home must relocate the 23(g laundry facilities to a more suitable place. Original dates of 1st September 2004 and 30th April 2005 not met 18(1c(i)) Staff must attend and complete foundation and induction training within the stated timescales and training relevant to the needs of residents within a timescale which ensures residents needs are met. 18(2) Staff must receive regular supervision at intervals of no less than 2 months and more frequently in the case of new staff. 13(4) The positioning of the bathroom on the top floor under the eaves must be reviewed and arrangements made to increase the headroom available to service users and to increase ventilation. 13(4) Risk assessments must be in place in relation to the use of window restrictors in residents bedrooms and, where they are necessary, they must be kept in working order. 13(2) The competence of all staff who are administering medication must be regularly re-assessed by someone who is competent to do so. 23(2)(p) 31st July 2005 15th August 2005 New Date: 30th November 2005 31st October 2005 19. 20. 27 30 21. 32,35 22. 36 15th August 2005 23. 42 30th September 2005 24. 42 15th August 2005 25. 20 31st July 2005 Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 16 15 Good Practice Recommendations Residents wishes and preferences should be discussed in relation to routines in the home, for example the time and way that medication is issued Regular communication with residents relatives should be maintained to ensure that their concerns are heard and discussed and they are fully informed about any developments. Vaughan House I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Clifton House 4a Goldington 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 I51 s14979 Vaughan House 220605 v235194 stage 4.doc Version 1.40 Page 31 - 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!