Inspection on 09/06/06 for Vaughan House

This inspection was carried out on 9th June 2006.

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

Other inspections for this house

Vaughan House 15/01/08

Vaughan House 02/04/07

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 Sally Snelson Unannounced Inspection 9th June 2006 08:40 Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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.V292354.R01.S.doc Version 5.1 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.V292354.R01.S.doc Version 5.1 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 Parkcare Homes 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.V292354.R01.S.doc Version 5.1 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. 18th October 2005 Date of last inspection Brief Description of the Service: Vaughan House provides accommodation for ten male 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. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Vaughan House was unannounced and took place on 9th June 2006. The inspection was the first inspection of the year for this service and was a key inspection. The inspector was Sally Snelson, lead inspector for the home and the manager Kate Orwin was present throughout. The inspector was in the home for seven and a half hours and spoke either formally or informally to five of the 10 service users. The manager, the two care staff on duty, additional day care staff and the area manager who arrived to supervise the manager were also consulted. During the inspection one visitor was spoken to. The care of three service users was tracked. This involved looking at the care provided to the service user in relation to the documentation for them. Fees for the home varied depending on the care package provided and started from £698.67 per week. What the service does well: The staff team at Vaughan House have a good understanding of the needs of the service users and offer person centred care. There is a good relationship between the staff and the service users and the home has a friendly atmosphere. The home produces clear documentation for new service users and their relatives in the form of a Service Users Guide and a Statement of Purpose. These documents are available in pictorial form and staff ensure that the service users understand the contents and what it means to them. Care plans are carefully written ensuring that the care provided is what the service user requires. The information written about service users is shared with them and they are given the opportunity to express their feelings. Service users are offered choices and can make decisions about when and what they eat, when they go to bed and what they wear. Staff are provided with a range of training opportunities and are supported by the company to do training and to attend courses. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality of this outcome area was good. This judgement was made using the available evidence, including this visit. A comprehensive and easy to read Statement of Purpose and Service Users Guide ensured that service users and their families were aware of the facilities and care offered by Vaughan House. EVIDENCE: The home had a Statement of Purpose that had been reviewed and updated. All service users had been issued with a Service Users Guide that had been simply written and included pictorial symbols. The service users had been helped to read and understand these documents and had signed to confirm their receipt. Since the last inspection, and since the manager had been in post, no new service users had been admitted to the home, therefore it was only possible to theoretically assess the assessment process for a new service user. The manager was able to relate the assessment process and the tools that would be used during an assessment were viewed. These appeared to be satisfactory and should ensure that only service users whose needs could be met by the home would be admitted. At the time of the inspection the home’s registration allowed for one service user with mental health problems to remain in the home while his needs could be met. To ensure that the home was offering this service user the best possible support and care, the majority of the staff had Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 9 attended a mental health training day. The manager had also tried to contact the social worker involved in this service users care to bring forward review meetings and look at the possibility of some one-to-one support at times. Care files confirmed that service users had been given the opportunity to visit the home before making the decision to move in and only once they had made the decision to live at Vaughan House were they issued with a contract. Copies of these contracts were held on the service users file. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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): 6,7,8,9,10. Quality of this outcome area was good. This judgement was made using the available evidence, including this visit. The care plans had been well written and there was evidence that service users had had involvement in the process. This ensured that staff provided a consistent needs-led service. EVIDENCE: During the inspection the care plans of three service users were sampled. All the care plans looked at had been sensitively written, appeared to cover all aspects of daily living and had been reviewed regularly and the necessary changes made. The home had agreed to be a pilot home for the introduction of person centred planning (PCP) and there was evidence that this was already underway with files reflecting service users choices in much more detail even when the choices appeared to be unrealistic. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 11 During the inspection one service user wanted his mother’s phone number. He was able to tell the inspector where, in his care plan, this was recorded. This was proof that he had been involved in the writing of his plan even though he had chosen not to sign the plan. Most service users had between 10 and 15 individual care plans in addition to health assessments and risk assessments. Risk assessments had been thoughtfully compiled and were written in a way that encouraged service users to take some risks. A service user who had recently left the home during the night had a risk assessment in place and clearly indicated to staff the possible trigger factors and what might be done to de-escalate any potential situations. The manager stated that parents and families had noted that service users were making more choices and expected to be consulted. One mother stated that she could no longer put a meal in front of her son when he visited, but had to offer him a choice. Staff were aware of confidentiality and there were policies in place. Service users were aware that they could talk to a staff member in private and have their confidentiality respected. During the inspection one service user was very aware of the inspector and requested a private meeting with the manager. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 12 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): 11,12,13,14,15,16,17 Quality of this outcome area was adequate. This judgement was made using the available evidence, including this visit. Service users were provided with a range of activities that were tailored to suit their individual needs. However the closure of the day care facility could make this more difficult. EVIDENCE: Service users attended a variety of day care facilities including work experience placements. One service user spoke in length to the inspector about his ‘job’, the payment he received, and what he intended to do with the money. Craegmore had its own day care centre that provided service users, from three Craegmore homes in the area, with the opportunity to learn life, social and educational skills. This centre was due to close at the end of June. The company had provided the CSCI with a proposal to close, based on research. It suggested the change would provide a more client focused service within the Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 13 individual homes. The main reason cited for the decision was the remoteness of the location of the day centre, which prevented social integration. The inspector was concerned that although most of the service users had at least one other day care provision on a Monday, for example, there would be eight male service users in the home, plus the additional staff that would be necessary. This was particularly concerning as the home was not very large, had limited communal space, and there were plans for decorators to be working in the home in the next few weeks. The inspector discussed these concerns with the area manager who visited the home during the inspection. She reported that the day care facility was not sold and could be made available for longer if needed. The manager had produced a weekly plan of activities for the service users to pursue within the home but this had not been tested and did not take into account service users who chose not to join in and how they would be occupied. Service users had been part of the plan and had requested more activities that involved exercise. The managers from the three homes affected by the closure of the day care provision had met and agreed that they would rather provide activities in each home than join together as the behaviour of some of the service users was not compatible with their home. This would reduce the amount of social interaction service users were having with peers other than those they lived with. During the inspection a visitor arrived at the home to take her son home for the weekend. It was obvious that she was welcomed into the home and felt comfortable with the staff. She spoke highly of the care that was provided by Vaughan House for her son. All of the bedroom doors had a lock and service users were risk assessed for holding a key. Some of the service users had written notes on their bedroom doors reminding others that they should not walk into their bedroom before being given permission. The inspector was concerned that the kitchen door was locked about 9pm. However staff reported that the door could be unlocked if service users wanted food and drink and that not locking the door put more that one of the service users at risk of bingeing At the start of the inspection most of the service users were up, dressed and preparing for their daily routines. One service user, despite being due to participate in an activity, chose not to get up until early afternoon. Staff had reminded him of the time and the need to get up but he had chosen not to. Two of the service users told the inspector about a disco they had been to the night before and the names, both male and female, of other people they had socialised with. Another service users was looking forward to going bowling with an ex member of staff who now worked as a volunteer. As the weather had turned warmer a Bar-b-que had been arranged for the next evening, which was a weekend. Another home had been invited and service users had been given the opportunity to ask friends and family. It was Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 14 usual practice for the home to invite a service users family and friends to join in birthday celebrations. Food available in the kitchen was adequate and included fresh produce. There was evidence that service users could make choices about their meals, for example what they had and when they had them. Snacks and drinks were available at anytime. The inspector was concerned that some cold meat for sandwich fillings that were not at their sell by date and did not state that it was suitable for home freezing, was found in the freezer. Shopping was done at a local supermarket and service users could be involved. Extra items such as meat were ordered directly from a local butcher. The small dining area did not lend itself to 10 service users having a meal together and did allow for staff to join with service users. Service users were regularly weighed as an indication that their diet was nutritionally adequate. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 the following standard(s): 18,19,20 Quality of this outcome area was adequate. This judgement was made using the available evidence, including this visit. Service users are able to make some lifestyle choices but would benefit from regular check-ups by dentists and opticians. EVIDENCE: Service users were able to make choices about the time they got up and went to bed and what they ate. The staff team only consisted of one male so service users had limited choice in the gender of the staff providing their care. One service user’s care plan suggested that a male carer should provide his care; this was obviously not happening all the time. On the day of the inspection staff were overheard to suggest to service users that they might prefer to wear shorts or lighter weight clothes because of the weather, but it was clear that the ultimate choice was left to the individual service user. All of the service users were mobile and did not require any mobility aids. The manager stated that during the decoration work she was hoping to provide a handrail for the two steps from the kitchen to the dining area. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 16 Each of the service users was registered with a General practitioner. A community chiropodist visited the home and the manager was looking into asking an optician to visit. Currently service users were not taken to an optician unless they required emergency treatment so were not routinely seen for regular eye tests. Not all of the service users had regular dental checks. Service users files did include information about health professional visits and visits by service users to out patient appointments. The one service user who had mental health problems had detailed information about his condition and the treatment. None of the service users were self-medicating although this had been considered in the past for a service user who was keen to move on towards independence. There was no clear documentation as why this trial of selfmedication had stopped or why other service users were not considered for this. The medication records were sampled and had been completed appropriately. The controlled drug book had been filled in clearly with the exception of one entry where it was not clear that a service user had been given a supply of medication to take with him to the day care centre and looked as though the service user had been given a weeks tablets all at once. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 the following standard(s): 22,23 Quality of this outcome area was good. This judgement was made using the available evidence, including this visit. The homes complaints procedure ensured that anyone making a complaint would receive a response in a timely fashion. EVIDENCE: The home had a satisfactory complaints procedure that safeguarded the service users. Since the last inspection the CSCI had received a complaint that was passed to the provider to investigate. This had been done and the complainant had been satisfied with the outcome. Shortly before the inspection the inspector received an anonymous list of concerns about the home mainly involving the environment, which as will be seen in the next section of the report, was poor. The complaints procedure was displayed and was part of the Statement of Purpose and the Service Users Guide. Situations were appropriately reported to CSCI as part of regulation 37 and there was evidence that, when necessary, staff had worked with the Local Authority Adult Protection team. Staff were aware of the protection of Vulnerable Adults and had attended training and updates. Information was available for staff and service users about how to Whistleblow if necessary. The personal monies of those service users who were tracked were checked. These were found to be correct and where possible had the necessary receipts to evidence expenditure. The only receipts not available were from occasions Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 18 when service users had gone out for a drink and did not get a receipt. The inspector was confident that the amount of money being withdrawn for an activity, where a receipt was not available, was appropriate. One service user told the inspector that he had bought a new bed and was planning to buy himself a wardrobe. The inspector checked with him and the manager, that this was his choice and that the company would normally supply these items. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30 Quality of this outcome area was poor. This judgement was made using the available evidence, including this visit. The home was in a poor decorative state and did not provide service users with a comfortable homely place in which to live. EVIDENCE: The home did not look clean or well cared for either from inside or out. From the outside the home was in need of painting, particularly the back windowsills, the windows needed cleaning and curtains were poorly hung and falling off curtain rails. The conversion of a property next door but one was creating a lot of dust and could be responsible for the dirty windows and for the difficulty in wiping the external paintwork. However once inside the home all of the communal areas had been stripped of wallpaper since the middle of May. The redecoration plan had been, initially to redecorate a room at a time, however because once the first room had been stripped of wallpaper major problems had been found, for example damp, the contactors had asked for the all the communal areas to be stripped of the wallpaper so that the situation could be assessed. Unfortunately once this had been done the contractors had been off sick and had only recently returned to reassess the situation and to Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 20 provide a new quote for the necessary work and additional lining paper. The redecoration must be completed as soon as possible and no later than September Service users and staff had worked to help with this task. One service user said, “ I liked taking the wallpaper off and I was good at it”. The home’s maintenance person was redecorating service users bedrooms. At the time of the inspection one room had been completely redecorated and another was being done. Each service user was choosing the colour they wanted their bedroom done and were being given the opportunity to help with the work. Service users also had the opportunity to personalise their bedrooms. Communal areas in the home were small and not fit for purpose. The furniture in the lounge, the room with the TV, would accommodate nine in chairs and was very cramped. Two tables and dining chairs (including those that were obviously garden chairs) also filled the dining room. The ground floor toilet, the only one close to the dining room, was out of action because the door did not close correctly, also a sign suggested that it was not available for anyone to use. The floor in the kitchen was lifting and could be a potential health and safety hazard. On a positive note the laundry area was operational but the washing machine, which was a domestic one, broke during the inspection. The home had a strong smell of urine because two service users were prone to urinating in unacceptable places. Consideration must e given to the possible treatment of these behaviours and the type of flooring in all areas of the home. Requirements have been made about the environment over the last three inspections. The area manager was made aware that if all the environmental work was not completed by the end of September the CSCI would consider possible enforcement action, as it is not acceptable for service users to live in poor conditions any longer. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality of this outcome area was adequate. This judgement was made using the available evidence, including this visit. Adequate numbers and a good skill-mix of staff provided care to the service users ensuring that for periods of the day one-to-one attention could be given to a service user if required. EVIDENCE: The staff on duty appeared to work well as a team although staff were aware of the different management styles between the manager and the deputy manager and the area manager was addressing staff grievances. At the time of the inspection the care staff were also responsible for the cleaning of the home. This was another practice that would need to be considered when service users were in the home more often following the closure of the day care provision. One member of staff was working towards NVQ level 3 and had level 2. Another 4 had almost completed level2 and 2 were working towards it. The manager reported that problems with the college, and not the commitment of the staff, had caused some delays. On duty, on the day of the inspection, Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 22 were two care staff who had not been with the company very long; they were the only staff members not working towards an NVQ. Duty rota suggested that there were always sufficient staff on duty to meet the assessed needs of the service users. There was currently one full time vacancy for a care worker. Recruitment files were sampled and found to include all the information required by schedule 2 of the national Minimum Standards. One of the files sampled had a leave to work certificate that expired in 2004. The member of staff was currently on unpaid leave and the manager and the area manager believed that the head office had seen a new certificate. Staff were offered a good and varied selection of training opportunities, however there was, no easy to sample, record of the training that staff had had and what they needed or needed to update. With the exception of the manager staff were not receiving regular supervision. This deficit had been noted in other homes in the company and should be addressed promptly or again the CSCI will need to consider what future action will be taken. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality of this outcome area was poor. This judgement was made using the available evidence, including this visit. There were no systems in place to ensure effective development of the home. Inaccurate recording of health and safety checks could put service users at risk. EVIDENCE: A manager had been in post since 12.05 but had not submitted an application for registration. Following the inspection an up-to-date application form was sent to her. She was waiting to hear the outcome of her NVQ level 3 assessment and had started the Registered Managers Award. The home did not have an effective quality assurance system although Reg 26 reports were undertaken monthly and some internal auditing was in place. These appeared to identify any shortfalls but were not influencing the necessary changes in a timely fashion. To be effective audit should include a Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 24 range of stakeholders and the results should influence change. Service users and staff had had minuted meetings in May and the manager was aware of the need to arrange a relatives meeting as soon as possible. The manager confirmed that maintenance person was carrying out heath and safety checks but there was no current documented evidence of this. The manager and the area manager promised that this would be rectified immediately therefore an immediate requirement was not made, but the seriousness of this failure was stressed. Records were securely kept in the office but there was a lot of information in the office and some of this was on display and could be easily misplaced. This was concerning as throughout the day, staff, service users and visitors came freely into the office. A current insurance certificate was on display. Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 x 2 X 2 X X 1 x Vaughan House DS0000014979.V292354.R01.S.doc Version 5.1 Page 26 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 YA12 Regulation 16(2) (m)(no) Requirement Following the closure of the day care centre service users must have the opportunity to continue to pursue the full range of activities that the centre provided. Service users must be asked for their preference about the gender of the staff that care for them. Where it is recorded that service users prefer a particular gender of staff to provide their care this should be upheld. Service users must be supported to attend regular health, optical and dental checks. All service users must be assessed for their ability to selfmedicate. This assessment should be reviewed regularly and the appropriate support offered. Consideration must be given to the amount of communal and individual space available for the number of service users accommodated. All the redecoration in the home, including service users bedrooms, must be completed by September. DS0000014979.V292354.R01.S.doc Timescale for action 31/07/06 2 YA18 18 (1) (a) 01/09/06 3 4 YA19 YA20 13(1)(b) 13(2) 01/09/06 01/09/06 5 YA24 23(1)(a) 31/07/06 6 YA24 16(2)(c)) 01/09/06 Vaughan House Version 5.1 Page 27 7 8 YA27 YA29 23 (2) (j) 23 (2)(n) 9 10 YA30 YA35 13 (3) 18 (1) (c) 11 12 YA36 YA39 18 (2) 24 (1)(a)(b) 23 (4)(5) 13 YA42 There must be a serviceable toilet, suitable for all service users, close to the dining room. The company should risk assess all areas of the home and detail the actions needed to make it safe. For example replace lifted flooring in the kitchen. A way to eliminate the smell of urine in some areas of the home must be found. The home must produce a training matrix that easily identifies what training staff have had and need. Planned staff training must be as broad as possible. All staff must be offered regular meaningful supervision. The home must have an effective quality assurance system that influences the annual development plan for the home. All health and safety checks, including fire, must be carried out regularly and documented. 01/09/06 01/09/06 01/07/06 01/09/06 01/08/06 01/09/06 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA30 YA31 YA34 YA37 Good Practice Recommendations The management should consider purchasing a second washing machine so that when one breaks down there it is not necessary to take dirty washing to another home. The home will need to consider which staff are to clean the communal areas of the home and when this cleaning is undertaken. The manager should audit all staff files to ensure that a copy of the necessary documentation is held in the home in addition to head office. The manager should start the process to become the registered manager. DS0000014979.V292354.R01.S.doc Version 5.1 Page 28 Vaughan House 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.V292354.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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