Inspection on 24/07/06 for Whiteheart Avenue, 3

This inspection was carried out on 24th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whiteheart Avenue, 3 27/10/08

Whiteheart Avenue, 3 09/12/05

Whiteheart Avenue, 3 06/05/05

Whiteheart Avenue, 3 23/11/04

Whiteheart Avenue, 3 17/05/04

Whiteheart Avenue, 3 30/01/04

Whiteheart Avenue, 3 11/08/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Whiteheart Avenue, 3 Hillingdon Middlesex UB8 3EP Lead Inspector Sarah Middleton Unannounced Inspection 24th July 2006 08:55 Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteheart Avenue, 3 Address Hillingdon Middlesex UB8 3EP 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) 0208 561 8098 Mr Koosraj Ramaya Unthiah Mr Koosraj Ramaya Unthiah Care Home 3 Category(ies) of Learning disability (0) registration, with number of places Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only service users residing in the home prior to their 65th birthday may be accommodated after their 65th birthday. 9th December 2005 Date of last inspection Brief Description of the Service: The home is a house in a quiet residential avenue about one mile from Uxbridge Town Centre. Public transport links to other neighbouring shopping centres are a short walk away. The home is registered for three adults with learning disabilities with an exception for those who pass the age of 65 and who have been residing in the home for a long period of time prior to this. The three Service Users are all male who have lived in the home since it was opened in 1988. The property is a bungalow that has been extended. It has a twin bedroom, a single bedroom, lounge and a kitchen/dining room. There is a staff team consisting of the Registered Person/Manager, the Deputy Manager (who is the wife of the Registered Person) and part time staff. The three Service Users attend day centres five days per week and have a programme of activities for weekends and evenings. The Registered Person owns another home for two Service Users with learning disabilities in the same road. The current fees for this service are £479.49 per service user, per week. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection was carried out from 8.55am-4.30pm. The Inspector viewed service user plans, staff files and maintenance records. The Inspector met with one service user and two members of staff. Two service users were at the day centre for the majority of this inspection. It must be noted that it can prove difficult to ascertain the views of service users with learning disabilities and mental health needs. There were no visitors at the time of the inspection. Two members of staff live in the home, but do not work every day in the home. The previous five requirements had all been met and eight new requirements were made during this inspection. The Registered Manager, Deputy Manager and trainee Manager assisted with the inspection process. All key Standards were assessed at this inspection. What the service does well: What has improved since the last inspection? The bathroom had been decorated, with a new bath panel in place, although the suite and tiles remain the same. The bathroom door had been fixed so that it opened and closed appropriately. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 6 Toothbrushes were now kept separate, to avoid any confusion when using them. There was no smell of dampness noted during the inspection. Finally the home has in place various systems to review the service, including obtaining service users views. What they could do better: The home must record in more detail the potential risks to service users health and welfare. This includes any risks service users pose to others. Detailed risk assessments are important as they inform and guide staff when supporting and working with the individual service user. Food that has been opened or prepared must be dated to ensure it is not out of date and used by staff or service users as this could pose a risk to their health and safety. The home must develop it’s own policy and procedure with regards to the protection of vulnerable adults. This document must dovetail with the Local Authority’s multi-agency documentation on this subject and include details of who to report any protection of vulnerable adults concerns. Staff applying to work in the home must complete a detailed application form. The application form must ask for information regarding education and include a full employment history, detailing any gaps of employment. The Registered Manager must be satisfied that the applicant has the necessary skills, experience and knowledge to meet the needs of the service users. There must be a record of the induction training new members of staff have worked through to ensure they have received a full and informative introduction to the home. Training must be clearly recorded to ensure it can easily identify when staff are due for refresher training or are in need of additional training. All staff must attend mandatory training and have regular training on specialist subjects in order to meet the changing needs of the service users. Fire drills must be held at different times of the day, to include evenings and night times, thus ensuring staff and service users can respond effectively in the event of a fire. Fire doors must remain closed until the home has consulted with the relevant fire authority and has, if necessary, fitted the fire doors with self-releasing equipment that will respond if the fire alarm is set off. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 7 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. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are carried out to ensure the home can meet the prospective service users needs. Trial visits and overnight stays are encouraged prior to a service user moving into the home to enable them to make an informed choice about the home. EVIDENCE: All three service users have lived in the home for several years. The Registered Manager confirmed they had assessed the service users prior to them moving into the home, and completed a further assessment of their needs once they had moved into the home. The Inspector viewed pre-admission assessments and was satisfied that it covered the main necessary areas, such as service users mental health needs, physical needs and personal care abilities. Discussions took place with the Registered Manager to ensure they gather information and record any challenging behaviour or behaviour that could pose difficulties for other service users and staff. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 10 The Registered Manager informed the Inspector that the service users had all moved in slowly and had the opportunity to visit the home and stay for a meal and then overnight before they permanently moved in. Trial visits would be encouraged for any new prospective service user so that they could meet with the other service users and members of staff. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans were detailed and outlined the service users needs. Service users are supported to make decisions regarding their lives. Risk assessments were in place and were up to date, however they need to clearly reflect all the identified potential hazards and risks to a service user and/or others. EVIDENCE: The Inspector viewed a sample of service users individual files, including care plans. The Deputy Manager completes care plans and reviews and updates them every three months. Overall these were comprehensive and detailed the service users personal and social care needs including likes and dislikes, routines on retiring to bed and daily routines and abilities to take part in daily living tasks. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 12 Daily records were viewed and these noted the care provided and activities the service user had taken part in. The Deputy Manager stated that wherever possible service users are involved with completing and reviewing their care plans. Those service users who can sign their name on the care plan and contribute to this document had done so. Those members of staff asked confirmed they encourage service users to do as much for themselves as they can and to make decisions where they understand the consequences and implications of making the particular decision. As staff have known the service users for a long time they feel confident that they fully understand the service users abilities and capabilities regarding every day life decisions. All three service users have an independent advocate who has only visited them at the day centres they attend. This additional form of support encourages service users to voice their opinions and to seek support if needing to make a decision or discuss a concern. Service users are not able to manage their own personal finances. The Inspector viewed a sample of risk assessments. These recorded the individual risks and are reviewed on an annual basis or reviewed if there has been a change in needs. The Inspector was informed that one service user can, at times, be at risk of developing pressure sores, this was not documented on the risk assessment. Furthermore, relating to another service user, who can on occasion make accusations, mainly regarding members of staff, this had not been recorded in any great detail on the risk assessment. A requirement was made that staff must record all potential risks, however infrequent they occur and outline ways to minimise the identified risk. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are available offering stimulation and occupation for the service users. Community resources are accessed on a daily basis to include and involve service users with their local environment. The home promotes visiting by family and friends in order to maintain social relationships. Service users rights are recognised and respected by the members of staff. Service users are offered a well balanced diet that incorporates individual likes and dislikes. Food opened or prepared needs to be dated to ensure the health and welfare of service users and others is safeguarded. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 14 EVIDENCE: The three service users living in the home attend day centres five days a week. Each service user attends a different day centre and so have the opportunity to spend time away from service users they live with. Transport is arranged and service users are picked up from the home and returned at the end of the day. Two service users were briefly seen at the beginning and end of the inspection. The third service user, who was not feeling well, had a day off from their usual day centre. They spoke with the Inspector during the inspection and stated they enjoyed going to the day centre. Evening and weekend activities are promoted and offered, but due to the older ages of the service users, often they are too tired to take part in activities after a full day out at the day centre. Recently two service users went with a member of staff to a car show and day trips are offered, especially during the summer months. Some members of staff have their own transport and this is usually used to access places of interest for service users. Community resources are visited such as restaurants, bowling and places of worship. Often service users can have one to one support and time with a member of staff due to the high staff ratio and flexibility of the Registered Manager and Deputy Manager. Neighbours have known the service users for many years and staff stated there were no issues with neighbours, most of who were friendly towards the service users. Two service users have some family, however contact is sporadic. Staff would encourage family members or friends to visit service users if this was agreeable for both parties. As noted earlier in the report, staff actively promote service users to do things for themselves. One service user spoken with confirmed that staff were caring and encouraged them to do as much as they can for themselves. The Inspector observed a member of staff encouraging a service user to shave independently and was informed that various tasks are given to those service users who can do them unaided. Staff were seen to interact positively with the service users during the inspection. Service users can choose when they wish to be alone or when they want to take part in an activity. The service user spoken with stated staff were helpful and available to seek support. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 15 Menus were available and individual meals were recorded. Menus reflected individual preferences and staff were aware of service users likes and dislikes. The Inspector was informed that where possible fresh produce is used in the preparation of meals. Members of staff prepare and cook the meals, although service users might observe or assist with minimal tasks in the kitchen. The kitchen was clean and tidy at the time of the inspection. Food in the fridge that had been opened had been covered and wrapped but had not been dated. A requirement was made for all food prepared or opened to be dated. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 16 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 in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users receive support and assistance with personal care tasks in the way that they prefer. Health needs are identified and recorded to ensure service users remain healthy and are monitored, where necessary, by the relevant health professional. Medication systems are robust to ensure service users health and welfare is safeguarded. EVIDENCE: The Inspector was informed that all three service users require support and assistance with personal care. This is carried out in private and where possible with members of staff that service users choose to support them with this sensitive task. Personal care is provided in the bathroom that has a lock fitted to offer further privacy where necessary. Health needs are highlighted on service users care plans and health appointments are recorded to enable staff to check when service users have Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 17 seen a health professional. Various health professionals are accessed such as, chiropodists, dentists, and psychiatrists. Care plans indicate where service users need support to ensure their health needs are met, for example, teeth cleaning and breathing issues. One service user was ill at the time of the inspection and staff were seen to act appropriately in order to meet the service users needs. Staff escorted the service user to both the local GP and then onto the local Hospital. Once returned to the home staff were observed to record the events regarding the service user and ensured the service user was comfortable, offering them drinks and talking to them to see how they were feeling. Medication systems were viewed. For the main part the Deputy Manager orders the medication and administers it. Staff are trained, by the Registered Manager and Deputy Manager, both of whom are trained nurses, to administer medicines to the service users. Discussions took place with the Registered Manager and Deputy Manager with regards to evidencing the training they offer to staff to ensure it covers all the necessary information staff need to safely administer medication. The Inspector made a recommendation for this to be considered. This was acknowledged by the Registered Manager and Deputy Manager, who will look into providing clear written evidence of the training they provide. Medication is not in blister packs, but the Deputy Manager stated the system they use works for the small home and all medication is stored in a locked cupboard. Service users do not self medicate and there were no controlled drugs stored or used in the home at the time of the inspection. Two service users medicines and medication administration sheets were viewed with no errors identified. There have been no medication errors noted since the last inspection. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 18 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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints policies are in place and service users are aware of whom to make a complaint to. The shortfall in the home’s own policy regarding the protection of vulnerable adults, needs to be addressed in order to ensure service users are protected from any form of abuse. EVIDENCE: The Inspector viewed the complaints book, where no complaints had been recorded. The Deputy Manager showed the Inspector a separate book used for each individual service user, where their comments, concerns and complaints are recorded, along with outcomes or action taken regarding the service users views and statements. The Inspector suggested that the complaints service users make are also recorded in the main complaints book, along with action taken, to ensure it is recorded in one main place and can easily be viewed for inspection or for Management to follow up where necessary. One service user who was asked, stated they would talk to the Registered Manager if they were unhappy about something in the home. The Inspector viewed the Local Authority’s policies and guidance regarding the protection of vulnerable adults, (POVA). In addition the home has a copy of the No Secrets document. The Inspector had difficulty in viewing the home’s own policy and procedure for POVA allegations and this was made a requirement. The home must develop and have their own POVA guidance to ensure staff are Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 19 familiar with what action to take and who to report any POVA issues. Some staff have attended POVA training, which is run by the Local Authority, other members of staff will also attend this course when it is next held. One service user is prone to making allegations usually regarding members of staff. One such allegation was made earlier in the year regarding verbal abuse made towards the service user. Social Services visited the service user to establish whether to investigate this allegation. There were no indications that the allegation was true and therefore no further action was taken. Staff are aware that this situation can arise and have documented the potential risk of allegations being made when working and supporting this particular service user. The Inspector had no concerns regarding members of staff and this service user at the time of the inspection. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 20 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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is welcoming and personal for the benefit of service users. The bathroom has been updated and provides the privacy service users need when receiving support with their personal care. The home was free from odours and was being satisfactorily maintained. EVIDENCE: The Inspector carried out a tour of the home and overall rooms were being maintained satisfactorily. The home was free from offensive odours and offered service users a homely place to live in. The home is near to good transport links and is near to a main road into large towns. The home is updated, including rooms and fixtures and fittings on an as and when basis. Staff are aware of what needs altering or updating, as it is a small home. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 21 The Inspector viewed the bathroom as there had been previous requirements relating to this room. The bathroom had been decorated, the bath panel had been replaced and there was a new radiator cover. The tiles and bathroom suite remain the same and at some point might benefit from also being updated. The bathroom door had been fixed so that it opened and closed appropriately. Overall the home was clean and tidy. The service users toothbrushes are now kept separately to ensure they are stored hygienically. There was no smell of dampness during the inspection. Staff informed the Inspector that any soiled items of clothing would be washed externally in the community. The home has a domestic washing machine located in the kitchen. Risk assessments had been completed for using the washing machine in the kitchen. Service users assist minimally with the laundry tasks. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a small staff team who are competent and effective to meet their needs. The shortfalls in recruitment procedures need to be addressed in order to safeguard service users. Written evidence of induction training needs to be devised to ensure new members of staff are appropriately introduced to working in the home. The recording of the training attended by staff need to be clearly recorded. Staff also need to attend training on a regular basis in order to meet the needs of the service users. EVIDENCE: The home comprises of a small staff team, two of whom live in the home. Staff are committed to supporting and understanding the changing needs of the service users. Three members of staff have obtained an NVQ level4 and one carer has begun to study for an NVQ level 2. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 23 Staff have built relationships with the relevant health professionals as the home has been running for many years and the same service users have lived in the home for the same amount of time. The home always has at least two members of staff working on a shift and so often service users can receive one to one support. The Registered Manager and Deputy Manager live locally to the home and can assist other members of staff should the need arise. The home does not use agency members of staff who would not be familiar with the service users and their individual needs. Staff meetings take place on a monthly basis and staff asked stated that the staff team work well together. The Inspector viewed staff employment files and identified some shortfalls. The application form was basic and did not ask applicants for details of their employment history, also there were no details of one of the applicants education history. The Inspector made a requirement that this must be addressed as any applicant must give full details of their employment history, including any gaps in employment, along with details regarding the education they have received. The Registered Manager acknowledged the need to address this shortfall and will review and alter the application form accordingly. Criminal Record Bureau (CRB) checks had been carried out along with health declarations that had been signed by the applicants. In addition two references had been obtained and there were recent photographs of the members of staff. The Inspector viewed training staff attend, however there was no clear detailed information regarding the induction a new member of staff would receive and a requirement was made for this to be addressed. Furthermore the training staff had received was not up to date and so it was difficult to identify the exact training each member of staff had undertaken. Therefore a requirement was made for training to be clearly recorded and to ensure all members of staff attend mandatory training and any additional specialist training relevant to the needs of the service users. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 24 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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home and they are familiar with the Registered Manager and they maintain a regular presence in the home. Systems are in place to review the care offered in the home, views are also obtained from the service users and their opinions are noted and acted on within the home’s capabilities. The shortfalls regarding fire drills being held at different intervals and keeping fire doors closed, need to be addressed to ensure the home protects all those living and working in the home. The manager was proactive in starting to address these issues during the inspection. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Registered Manager is also the Registered Provider and has owned and managed the home for many years. They obtained the Registered Managers Award two year ago. There is a long-term aim of the trainee manager, who has just completed the Registered Managers Award, to take over as the Registered Manager. Currently they are becoming familiar with the role and are working closely with the current Registered Manager. The Registered Manager maintains a visible and regular presence in the home and staff stated he was approachable and offered guidance where needed. The home has various systems in place to review the care offered in the home. Service users surveys are offered to the three service users once a year and they are supported to complete these surveys. External surveys are also sent to GP’s and any other professional who has contact with the home. Internally once a year an environment assessment is carried out to ensure the home is safe and offers a homely environment to live in. Finally a review of the different aspects of the home are assessed, such as, training, assessments, activities and medication. Alterations and improvements are then made accordingly. Service user meetings are also held on a regular basis in order to obtain service users views and opinions regarding the home. Servicing and maintenance records were viewed at random. Water temperatures had been taken on a weekly basis and boiler temperatures had been taken on a monthly basis. The Gas Safety record and testing for Legionella was up to date. Fire drills had been held monthly but had always been held on the first of the month at the same time. The Inspector made a requirement for the home to hold these fire drills at different times of the day to ensure staff and service user can respond effectively to the fire alarm. The Inspector noted that several fire doors were propped open and were not fitted with door releasing equipment that responds to the fire alarm being set off. The Inspector made a requirement for the home to consult with the London Fire and Emergency Planning Authority and an organisation that fits door releasing equipment to ensure the home does not compromise or jeopardise the welfare of those living, working and visiting the home. In the meantime the Inspector insisted that all doors remain closed until the home has sought professional advice regarding this matter. All doors were then closed during the inspection and the Deputy Manager put signs on all of the doors reminding service users and staff to keep them closed. The Registered Manager acknowledged the importance of addressing this issue and subsequent to this inspection they did make contact with the London Fire and Emergency Planning Authority and are waiting for a visit from them and will forward on to the Inspector confirmation when the work has been carried out. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 26 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 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement Risk assessments must clearly detail any potential risk to the service user or others, to include risk of developing pressure sores and the risk of making allegations regarding members of staff. Food that has been opened or prepared must be dated to ensure out of date food is not used. The home must have a policy and procedure regarding the protection of vulnerable adults, (POVA). This must include details of whom to report any POVA concerns to, e.g. Local Authority, Social Services and the CSCI. Staff employment files must contain all the necessary information as outlined in Schedule 2, e.g. full employment history and education/training history. Timescale for action 31/08/06 2. YA17 13(4)(c) & 16 (2)(i) 12(1)(a) & 13(6) 25/07/06 3. YA23 31/08/06 4. YA34 19(1)(b) Schedule 2 31/08/06 Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 28 5. YA35 17(2)&18(c)(i) There must be available a record of the induction training new members of staff receive. 31/08/06 6. 7. YA35 YA42 18(1)(a)(c)(i) 8. YA42 Staff must receive training 30/11/06 appropriate for the work they are to perform. 23(4)(e) Fire drills must be held at 31/08/06 suitable intervals to ensure service users and staff are aware of how to respond in the event of a fire. 12(1)(a)13(4)(a)(c) Fire doors must be fitted 30/09/06 with door releasing equipment that respond and close in the event of the fire alarm being set off. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that training offered in-house, e.g. medication be clearly recorded, to include details of the topics covered in the training. Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hammersmith Area Office 11th Floor, West Wing, 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Whiteheart Avenue, 3 DS0000027094.V303135.R01.S.doc Version 5.2 Page 30 - 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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