Inspection on 24/04/06 for Wayfield Avenue Resource Centre

This inspection was carried out on 24th April 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 but made no statutory requirements on the home.

Other inspections for this house

Wayfield Avenue Resource Centre 30/05/07

Wayfield Avenue Resource Centre 19/12/05

Wayfield Avenue Resource Centre 10/08/05

Wayfield Avenue Resource Centre 08/03/05

Wayfield Avenue Resource Centre 30/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Wayfield Avenue Resource Centre 2 Wayfield Avenue Hove East Sussex BN3 7LW Lead Inspector Jane Jewell Key Unannounced Inspection 11:00 24th April 2006 X10015.doc Version 1.40 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 Wayfield Avenue Resource Centre DS0000031667.V289492.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 Older People. 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. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wayfield Avenue Resource Centre Address 2 Wayfield Avenue Hove East Sussex BN3 7LW 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) 01273 295880 01273 295900 sarahlines@southdowns.nhs.uk www.fosteringinbrightonandhove.org.uk Brighton & Hove City Council Sarah Louise Lines Care Home 24 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (24) of places Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-four (24) Service users must be aged sixty-five (65) years or over on admission Only older people with mental health needs are to be accommodated. Date of last inspection 19th December 2005 Brief Description of the Service: Wayfield Avenue was opened in 1997 and is owned by Brighton and Hove City council and is registered to provided accommodation and personal care for up to twenty-four older people with functional mental health needs. The vast majority of placements are long term with two respite placements also available. The home is a three story detached property situated in a residential area on the outskirts of Hove. Resident’s accommodation consists of all single accommodation with en-suite facilities. There is a range of communal space including rear gardens and patio areas. Parts of the ground floor is occupied by day care resource centre. The homes literature states that its overall aim is to provide the same range of opportunities for older people with mental health needs as exists for everyone else. The current rate of fees are: Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced site visit undertaken on 24/4/06 between 11am to 7pm and information gathered about the home since the previous inspection. This includes survey questionnaires, discussion with stakeholders involved in resident’s care and records relating to providers visits and notification of accidents and incidents. The site visit was undertaken with Sara Lines (Registered Manager) and there were twenty-three residents living at the home. The site visit involved a tour of the premises, examination of the homes records, discussion with staff on duty and residents. The focus of the visit was to look at the experiences of life at the home for people living there. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report. The inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? Information about the services provided have been expanded to provide more information to help potential residents make an informed choice as to whether they want to move to the home. Windows have been replaced contributing to a more aesthetically pleasing environment in which to live. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 6 Monthly quality audits are being undertaken by the manager, which has identified areas for service improvement. 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. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6 The quality outcome for this standard is poor. This is based on the available evidence including a visit to this service. The homes literature still needs further expansion to provide a range of information about the home in order to assist prospective residents in making an informed choice about whether to move to the home. The admission procedure needs further action to ensure that new residents needs are properly assessed and planned for. Most needs are residents are being addressed by living at the home with the majority of residents feeling that their experiences at the home are positive. EVIDENCE: In line with previous requirements information about the homes services and facilities have been updated to include a greater range of information about the home. Although updated the statement of purpose and guide to residential care still requires further review to ensure that the full range of information required in the National Minimum Standards is available in these documents. The manager reported that the homes literature is made available to prospective and current residents and other interested parties. No residents interviewed said that they had seen any of the homes literature. This is in spite Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 9 of staff confirming that these documents are discussed with residents during the admission process. It was discussed that these documents need to be more readily accessible to current residents and their representatives. Records inspected showed that the home obtains a copy of a care management assessment from the placing authority, and also conducts its own needs assessment, prior to a resident moving into the home. Poor standards of recording were noted on the homes assessment, which consisted of a tick sheet to indicate level of need. There was no indication when, where and who completed the assessment. Therefore the assessment did not provided adequate information upon which to help base the decision whether needs could be met at the home. It has been required that assessments are in line with the homes admission criteria and that of the National Minimum Standards. The manager reported that the assessment form is in the process of being reviewed The vast majority of placements are long-term with residents having a wide range of mental health needs, which several residents having complex mental health needs to some who live independent lives. The evidence seen indicates that most needs of residents are being met. Further work is however needed to the care planning process to ensure that the range of resident’s assessed needs are being identified and addressed. The manager reported that each placement is reviewed six monthly to ensure that the home is able to continue to meet their needs. Where residents had expressed concern that their needs were not being met the manager has sought additional support or advice from health care professionals to review the placement at the home. The majority of residents consulted spoke positively about their experiences at the home saying the following: “Don’t have to worry about anything here” “the best thing I like about here is knowing that there is always someone around” “I feel a lot safer now I am living here” and “I am free to come and go as I please”. Intermediate care is not offered. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The lack of consistency in care plans means that there is not always suitable guidance for staff on how to meet the assessed needs of each resident. There is regular input from health care professionals to support resident’s health care needs. Some of the homes medication practices places residents at potential risk and must be addressed as a matter of priority. EVIDENCE: Four individual plans of care were inspected. These comprised of several documents including risk and needs assessments, basic information, daily notes and a plan of care. Varying standards of recording were noted with some good practices evident, in particular a mental health care plan noted for one resident. However for the most part little progress had been made to address the previous shortfalls in the care planning process. This has resulted in not all resident’s needs being identified. Permanent staff consulted demonstrated a good understanding of the needs and preferences of residents but were not always clear on the agreed actions on how to meet them. Bank/agency workers rely more heavily on the care plans to guide them in their work with residents and to identify any changes Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 11 since they last worked at the home, therefore it is essential that care plans reflect the range of assessed needs. Of additional concern was the lack of regular review of care plans to ensure that any changes in needs are promptly identified and communicated to staff. This includes each time residents are admitted as part of a rolling programme of respite care, or return from hospital. Not all of the risk faced and posed by residents had been assessed or the actions needed to manage or reduce them identified. This includes challenging behaviour, leaving the home unescorted, self-medication and manual handling. All residents consulted expressed little or no interest in the development and review of their care plans, but felt that they could ask to see what is recorded about them at any time. Some care plans had been signed by the residents when it had been first written. All but one resident said that they felt staff treated them with dignity. Residents were dressed appropriately, in accordance with preserving their dignity and the prevailing weather. Records of medical intervention showed that the home works closely with health care professionals including GP’s, District and specialist nurses, to ensure residents receive the necessary health care intervention. Residents consulted said that when they have asked to see a Doctor or a CPN then this has been sought promptly. Staff who administer medication undergo medication training with the supplying pharmacy. It is recommended that senior staff who have delegated responsibility for medication undertake additional training in order to gain greater understand of good practices and legislation in medication administration, in light of the following issues raised. Several concerns were noted regarding medication practices that must be addressed. These were: • The recording on Medication Administration records (MAR) charts was often poor with gaps where there was no record if medication had been administered or explanation as to why it had not been administered. An example was noted whereby the dosage of medication was not being recorded therefore it was not possible to ascertain how much was being administered. • Not all “As required” medication had clear individual instructions for when these medications are to be administered. • There was not a record of all medication awaiting disposal. This is needed in order to provide a clear audit trail of all medicines and to reduce any risk of misappropriation. In order to promote accuracy it is recommended that where prescribed instructions are hand written on MAR charts these should be checked and countersigned for accuracy by a second member of staff. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome for this standard is good. This is based on the available evidence including a visit to this service. Residents are able to exercise choices and independence, within the constraints of their own individual needs and preferences. Links with families are valued and supported by the home. The meals are good offering both choice and variety. EVIDENCE: Various activities are organised including Bingo, board games, videos and colouring. The home has its own car, which is used to take residents out for appointments and outings. The majority of the residents consulted said that they do not participate in the organised activities but instead preferred to occupy their own time. Several residents commented that staff do not always appear to have the time to spend individually with them with one resident saying “No one says very much to each other, can be a bit boring if the staff don’t talk either to you”. The inspector did observe a resident and staff member enjoying watching a film together during the course of the site visit. The manager is in the process of redefined the keyworker role and felt that once staff’s responsibilities under these new guidelines have been fully introduced this would enable staff to spent more individual time with residents. Observation of the daily routines and discussion with residents confirmed that staff accommodate resident’s personal wishes with regard to meal times, going Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 13 to bed, rising and bathing. One resident spoke of how important their independence was and the support given by staff to enable them to go out as often as possible another spoke of being enabled to attend church if they wanted. One resident said that staff “encourage you to do things for yourself”. Several bottles of shampoo and bars of soap were noted in communal bathrooms. This is often synonymous with them being used communally. This practice is not in line with the promotion of autonomy and choice. The right to have individual toiletries is stated in the homes residents’ charter. This was fedback to the manager for addressing. Residents spoke of their visitors being able to visit at any time and were always made to feel welcome. Feedback received from relatives was that they felt their relatives were receiving the appropriate care, with one relative saying “Wayfield Avenue is a well run efficient, friendly place which provides clean comfortable accommodation, good care and facilities”. The home has worked closely with a relative to ensure that their views, although considered, in the care of their relative it is the residents needs and wishes that remain the homes priority. Residents described the food as “very good” “excellent” “they come around the day before and ask what you want” and “always get a choice”. The meal being served at inspection looked appetising and all residents consulted said how nice it was. There was a variety of meals being served with resident’s individual preference being respected. For example residents were asking for large or a small meal or additional vegetables. There is a kitchenette on each floor, which some residents use to make their own snacks and drinks. For others staff were regularly observed offering drinks throughout the course of the site visit. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome for this standard is poor. This is based on the available evidence including a visit to this service. Staff and residents advocates were not always aware of their roles and responsibilities under adult protection guidelines placing residents at further risk. Complaints raised directly with the manager have been acted upon promptly. EVIDENCE: The homes complaints procedure is contained within the homes literature with the majority of resident’s and relatives consulted aware of how to make a formal complaint. All residents consulted felt able to raise any concerns they had directly to staff or management. One relative said that where they have had to raise minor concerns then they have been addressed promptly by the manager. There have been no complaints received by CSCI regarding the home since the last inspection. An independent advocate chairs monthly residents meetings, where residents can also raise concerns/complaints. The process for passing information onto the manager from these meetings was lengthy, thereby often causing a delay in the manager being able to address any issues /concerns promptly. Of particular concern was a disclosure made by a resident during such a meeting, which was not handled in accordance with adult protection guidelines and placed the resident at further risk. It was previously required that staff undergo adult protection training, this had not yet been undertaken for all. Although staff consulted knew what to do in the event of a disclosure by a resident, not all staff showed an understanding Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 15 of what constitutes a disclosure or poor practices. This was of particular concern and once raised with the manager they took immediate action to safeguard the resident. It is recommended that the current system for the manager to receive relevant feedback from residents meeting be reviewed to ensure that information is passed on in a timely and appropriate manner. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 The quality outcome for this standard is adequate. This is based on the available evidence including a visit to this service. Residents live in a clean and homely environment with parts of it decorated and furnished to a good standard. The home ensures that resident’s private accommodation is equipped to provide comfort and privacy. Residents must be able to call for assistance when needed and feel confident that their calls for help will be answered promptly. EVIDENCE: The home is a large detached building in its own grounds. Although on the outskirts of Hove there are some shops a ten-minute walk away and there are bus routes into Brighton and Hove close by. Parts of the home are decorated to a good standard with much effort made to create a homely and comfortable environment. The home was found to be warm and comfortable, with good levels of light and ventilation. All areas of the home inspected were observed to be clean with a good standard of hygiene maintained. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 17 The fitting of new windows has recently been completed. The scaffolding was still erected around the building limiting access to certain areas. The inspector was assured that the scaffolding this was due to be removed in the near future. There are small patio areas located around the garden interlinked by pathways and flowerbeds. The garden areas are not currently well maintained or inviting. One resident who uses the garden regularly to smoke in, said that they were a “bloody disgrace”. The inspector was assured that once the scaffolding has been removed then access to the full garden can be obtained in order to improve it. Some minor maintenance issues were identified which the manager agreed to address but in general the home was maintained to a good standard. It was previously required that action be taken to improve the decorative state of the upper floor communal area. This had not yet been undertaken and during the course of inspection additional areas were also noted in need of minor redecoration. A plan of redecoration and repair has been required to be developed, which addresses all areas and includes timescales for there completion. Resident’s bedrooms are fitted with locks, with many residents choosing to lock their rooms when they are not using them. All rooms seen had been individualized with personal belongings and in some cases items of small furniture. All residents consulted said that they liked their bedroom and that they provided everything they needed. There is sufficient number of toilets and bathrooms located the home, including all bedrooms providing at ensuite facilities. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, hoists, varying height beds, grab rails, assisted baths and showers. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. These are also an intercom enabling staff to talk to the caller. A staff member said one resident who is prone to falls has recently been supplied with a neck call alarm. Call points checked were not all in working order. Feedback was received that calls for help are not always answered promptly. A staff member said that delays were often caused by the handsets, which received the calls, being left around the building accidentally. This has now been addressed by staff carrying them in bags attached to their body at all the times whilst on duty. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The quality outcome for this standard is poor. This is based on the available evidence including a visit to this service. There are sufficient staff on duty to meet the needs of residents who were observed to interact sensitively with residents. Training needs to be more effectively organised to ensure that staff received all the necessary training to undertake their roles safely. The procedures for the recruitment of staff are not sufficiently robust to safeguards residents. EVIDENCE: The staffing structure is for five staff to be on duty throughout the waking day plus a senior carer. Staff felt that this staffing structure was appropriate to be able to undertake their duties effectively and timely manner. Staff said that there was some flexibility in staffing levels and gave examples where levels had temporarily been increase where a residents needs had changed or increased. Some residents felt that staff did not always appear to have the time to spend individually with them. This was raised with the manager who was in the process of redefining the role of keyworker, which would facilitate more one to one time being spent with those residents who wanted it. There is still some use of agency/ bank workers, however in the main it is the same staff used in order to promote some consistency. Residents described staff as: “OK” “very nice” “friendly” and “every single one is lovely” and “helpful”. When staff were observed interacting with residents this was done sensitively and sometimes with humour. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 19 Concern was noted regarding the competences of persons left in charge in the absences of the manager and senior care officers. Although care staff had to undergo duty officer training before they were allowed to be left in charge many had not however undertaken core training topics such as adult protection, first aid, manual handling and fire safety. It was previously required that staff undergo all training appropriate to the work, this had not yet been undertaken for all staff and must be addressed to ensure staff are safe to undertake their duties and to be left in charge. A member of staff who was undergoing induction at the time of inspection felt that they had received sufficient information to be able to work safely until they received their formal induction training which was due in the near future. A recruitment process is followed which includes the use of an application form, interviews, CRB checks and written references prior to employment commencing. However an example was noted whereby the information gathered had not been thoroughly checked and the inspector noted discrepancies. Once highlighted the manager reported prompt action being undertaken to verify the information. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 The quality outcome for this standard is adequate. This is based on the available evidence including a visit to this service. The home is managed by a suitably qualified and experienced manager. The home has started to develop a system for the self-monitoring and review of its own practices to help inform future service development and maintain standards. Care staff are appropriately supervised however closer monitoring of delegated management tasks needs to be undertaken. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: The registered manager has been in post since September 2004 and holds the required qualifications. They have many years experience of working with people who have mental health problems. All those consulted spoke positively about the manager with particular reference to their approachability and knowledge of residents needs. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 21 There are several mechanisms in place for obtaining feedback from residents on the homes services and facilities in order to monitor the quality of the services being provided. This includes individual placement reviews, formal recorded visits by the registered provider, recently introduced monthly quality audits and residents meetings. In addition, a consultation week is planned in the near future with one of the aims to seek feedback from other stakeholders involved in residents care for example GP’s and relatives, on the services and facilities provided. The current arrangements for residents meetings being chaired by an independent advocate places restrictions on the manager being able to share information with residents regarding changes to practices and service developments. It is recommended that the format of residents meetings should be reviewed to enable more information sharing of issues affecting the services. This is in response to feedback received that not all residents felt that they were kept informed of events, staff changes and future changes. Key management tasks are delegated amongst the senior team. This includes areas where shortfalls in practices have been noted for example: recruitment, training, medication and care planning. Senior staff have additional time to undertake their delegated responsibilities but closure supervision/monitoring of these management tasks is needed to ensure the required standards are being maintained. Care staff said they received regular supervision from their line manager and felt able to approach their manager with any concerns that they had in the interim periods between supervision. All care staff consulted felt well supported to undertake their roles. There are extensive policies and procedures related to health and safety and systems to assess and manage risks. Risk assessments have been completed on safe working practices including radiators, hot water and windows. This does need to be extended to assess the risk of toppling over of freestanding wardrobes. A member of staff was observed not following good practice guidelines in the handling of cleaning chemicals. This was fedback to the manager who agreed to address the matter for the future. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 2 x 2 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x x 3 x 3 Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP11 Regulation 4(1)(c) & Schedule 1 Requirement The Statement of Purpose must be reviewed to ensure compliance with the Care Homes Regulations 2001 and the revised National Minimum Standards. (Timescales of 31/03/06 not met). The Service Users Guide must be reviewed to ensure compliance with the NMS and a copy made available to all service users and the Commission. (Timescales of 31/03/06 not met). That the needs of prospective service users are assessed by a suitable qualified person and in accordance with the homes admission criteria and that of the National Minimum Standards. The care planning system must be reviewed to ensure that they are consistent and set out in detail the action which needs by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. (Timescales of 31/03/06 not met). DS0000031667.V289492.R01.S.doc Timescale for action 30/06/06 2 OP1 5(1&2) 30/06/06 3 OP3 14(1)(a) 30/06/06 4 OP7 15(1) 30/06/06 Wayfield Avenue Resource Centre Version 5.1 Page 24 5 OP7 6 OP7 7 OP9 8 OP18 9 OP18 10 OP19 11 OP19 12 OP22 13 OP29 That care plans are reviewed at least once a month to reflect changes in the needs and preferences of service users and recorded as having been reviewed. 13(4)(c) That comprehensive written personal risk assessments are completed for all service users which are reviewed regularly and records the actions to manage identified risks. 13(2) That suitable arrangements are in place for the recording, handling, safekeeping ,safe administration and disposal of medicines received into the home. 18(1)(c) Provide training in adult (1) protection for staff as needed. (Timescales of 31/03/06 not met). 13(6) The Registered person shall make arrangements by staff training or by other measures to prevent service users being harmed or from suffering abuse or being placed at risk of harm or abuse. 23(2)(d) That a plan of re-decoration and repair be developed, which addresses the areas of redecoration and repair identified at inspection and includes timescales for their completion. 23(2)(m) Action must be taken to improve &(4)(c)(1) the decorative state of the upper floor communal area. (Timescales of 31/03/06 not met). 23(2)(n) That a call system with an accessible alarm facility is provided and accessible to all service users. That employment and 19(1)(b) recruitment documentation (i) necessary to establish proof of identity is obtained prior to DS0000031667.V289492.R01.S.doc 15(2)(b) 30/06/06 30/06/06 24/04/06 30/06/06 30/06/06 30/07/06 30/08/06 24/04/06 24/04/06 Wayfield Avenue Resource Centre Version 5.1 Page 25 Sch 2(1) 14 OP30 18(1)(c) (i) 18(1)(a) employment commencing. Staff must undertake all training appropriate to the work they perform. (Timescales of 19/12/05 not met). That suitably competent persons are left in charge in the Managers absence. 30/09/06 15 OP30 30/06/06 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 OP9 OP9 OP16 OP33 Good Practice Recommendations That senior staff who have delegated responsibilities for medication practices undertake additional training on good practices and legislation in medication administration. That hand written prescribed instructions on MAR charts are checked and countersigned for accuracy by a second member of staff. That clear procedures and protocols be developed for the manager to receive any relevant feedback raised during residents meetings chaired by independent advocates. That the format of residents meetings be reviewed to enable more information sharing of issues affecting the services. Wayfield Avenue Resource Centre DS0000031667.V289492.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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