Care Home: Albemarle Road, 33

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What the care home does well The service deals with those residents who have enduring mental health problems many of whom have been in psychiatric services for some time .The home is a supportive environment which enables rehabilitation to a less supported accommodation and within this it has been successful. Staff are provided with good training opportunities from Community Options who have their own training coordinator.The home is supported by Community Options management and this incorporates support from other homes in the group and that provided through staff at Head Office. Community Options operates an open policy where residents can go to Head Office with issues and they are actively encouraged to attend Board meetings. The daily records were to a good standard. Medication records were well completed with supporting information to ensure safe systems are in operation. What has improved since the last inspection? The manager has been in post for almost a year and in that time has made improvements in the following areas. Rehabilitation for residents had improved and they were now accessing more local facilities as well as in house activities. The environment had improved with new carpets redecoration and some new furniture all to benefit resident`s lives. Staff felt well supported and that the regular supervision sessions were beneficial to them. What the care home could do better: Care plans need to specifically detail the actual problem, particularly relating to mental health problems, and general terms should be avoided. Interventions need to be specific and detailed, to address the problem with reviews reflecting progress made. This is particularly important as mental health issues can be complex and must be addressed with the correct interventions in a consistent way. The window restrictors on the windows, first floor an above were not in place. Without these residents may be put at risk. These needed to be addressed within 48 hours of receipt of the immediate requirement. Restrictors need to be on all first floor windows and above. The restrictors need to be at a limited width so residents cannot accidentally or otherwise exit the window. This was actioned within the timeframe. Regulation 26 reports need to be left in the home to evidence that monthly visits are undertaken. CARE HOME ADULTS 18-65 Albemarle Road, 33 33 Albemarle Road Beckenham Kent BR3 5HL Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 20th August 2008 09:10 Albemarle Road, 33 DS0000006881.V369687.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 Albemarle Road, 33 DS0000006881.V369687.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. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albemarle Road, 33 Address 33 Albemarle Road Beckenham Kent BR3 5HL 020 8663 6225 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) bernd.diegelmann@community-options.org.uk www.community-options.org.uk Community Options Limited Manager post vacant Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 7 Adults with a Mental Disorder Date of last inspection 27th September 2007 Brief Description of the Service: The home is an adapted building located in residential area of Beckenham. The house is located over two floors accessed by stairs. All communal accommodation is on the ground floor, with the smoking area located in the living room. The dining area is a no smoking area and this also provides seating, which is used by residents. There is a pleasant garden to the rear of the building and parking to the front of the building The home is part of the Community Options group, who manage the facility whilst Hyde Housing owns the building. The home provides accommodation for up to seven residents in the category of mental disorder. The residents in this home are all under the Care Programme Approach. At the time of the inspection there were no vacancies. The home has both male and female residents. The new Manager has been in post for about one year. Staff in the home support an unregistered facility in nearby Queens Road Staff shifts are allocated separately to those used to staff the home. Fees are £950 per week. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection was conducted over two half-day periods. The new manager facilitated the second site visit. Periods of observation were undertaken on the first site visit. Prior to the inspection the manager had completed the AQAA and forwarded this to the CSCI. Comment cards were provided during the first site visit although none returned to the inspector. During the visit the we met with several residents. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans, complaints information as well as health and safety records. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. Following the inspection members of the multi disciplinary team were contacted regarding the service. Favourable comments were received in respect of staff support to residents, communication with multidisciplinary team members and the environment. What the service does well: The service deals with those residents who have enduring mental health problems many of whom have been in psychiatric services for some time .The home is a supportive environment which enables rehabilitation to a less supported accommodation and within this it has been successful. Staff are provided with good training opportunities from Community Options who have their own training coordinator. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 6 The home is supported by Community Options management and this incorporates support from other homes in the group and that provided through staff at Head Office. Community Options operates an open policy where residents can go to Head Office with issues and they are actively encouraged to attend Board meetings. The daily records were to a good standard. Medication records were well completed with supporting information to ensure safe systems are in operation. 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. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albemarle Road, 33 DS0000006881.V369687.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 Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The pre-admissions procedures provide residents with a range of information, including visits to the service, to assist their decision making process, and enable them to establish whether the service is right for them. Staff are provided with comprehensive information on which they can base an initial care plan and address resident’s needs . EVIDENCE: The registration certificate was incorrect in terms of the Responsible Individual and the Registered Manager. This will be changed once the current manager has completed the CSCI process to become registered. The Statement of Purpose will need to be amended to reflect the staff changes. At the time of the inspection there were seven residents in the home, of which two were female and one male. The records and admission assessments information of two newly admitted residents was inspected. The residents are provided with a file of information, Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 10 which includes information on the service as well as support services and resources locally. The assessment information included comprehensive information on the resident’s mental health condition detailing previous admissions under the Mental Health Act 1983. In addition there was an occupational therapist’s report in relation to skills and a recent ward discharge summary including their care plan. Information in respect of CPA had also been received. Prior to admission the residents had been assessed on 3- 4 occasions, the Manager advised, and had been subject to a trail period. There was a licence agreement signed by the residents and the Manager. All prospective residents submit an application form for possible placement. The second file also contained CPA information Community Options assessments and reports from members of the multidisciplinary team. It was noted that the manager from another home had conducted this assessment. It is essential that the manager of the home to which they are admitted be actively involved in al assessment procedures. The manager did state that he had been involved in all parts of the assessment although not all of the assessment visits. The manager confirmed issues such as gender were considered with prospective residents as at one point there was only one female resident, which was unsatisfactory to her. Staffing levels and residents’ dependency was also considered. Staff are encouraged to view all information on residents and general discussion around new admissions is conducted during handover periods. Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service The information in care plans generally enables the staff to plan and deliver the care. Care plans are limited in the associated presentations and behaviour of the resident’s actual mental health condition, hence staff would not have the information to address those issues, this may negatively impact on resident’s health. Risk assessments were in place to address all activities of daily living. . EVIDENCE: The home allocates a key worker to every resident on admission. Residents were aware of who their key worker was, and that they coordinate their care within the home. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 12 The care plans of those residents involved as part of case tracking were inspected. The care plans included an overview of risks in a summary form, and fuller information on these areas identified in a risk assessment. They include those for missing persons, fire and those pertaining to the implications of physical ill health. These provide staff with information on how to reduce or eliminate any risk which has been identified. The risk assessment for aggression was without a date or an identified indication of how great the level of risk was. This needs to be fully completed. The care plan format is that used through out Community Options homes. The documentation of care and support are split in to two distinctive sections one headed “care plan”, which details those interventions, which are staff led, whilst the “support plan” is resident led. This is a confusing system although staff working with it seemed to understand it. The care plans provided information on physical and mental health needs although did not indicate what the objective or goals were in respect of identified issues. Without an objective it would be difficult to identify what the home was trying to achieve, in respect of that issue. In house reviews of care plans are conducted and recorded. These provide information on the progress on the issues identified within the care plan. In addition there is the Community Options support package that provides a tool for self assessment of how residents perceive their own health and wellbeing including their aspirations. The daily records which details the residents’ day, were to a good standard. Please see requirement 1. Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are well supported with all activities of daily living to maximise personal development and enhance rehabilitation for more independent living. Open visiting promotes and encourages people who use the service to maintain social networks. EVIDENCE: It was apparent that active rehabilitation was happening in the home and residents had more involvement locally. One of the residents was enrolling for a college course in mathematics, which would involve attending college two days a week. Another resident had been attending gardening classes at the MIND centre. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 14 A new activities folder had been developed which gave information on what local events were taking place. Many of the residents do attend MIND although not all, the MIND day centre is open seven days a week and provide support, recreational activities and a social network for residents. There is also a Sunday lunch club, which many attend. On going rehabilitation in respect of activities of daily living is promoted with all residents. In so much as they are expected to assist with daily chores, cleaning of their own bedrooms and preparation of meals. In addition skills in budgeting, accessing services, using public transport and integration into the community are all actively promoted. All residents’ have freedom passes allowing them free public transport travel. Three of the residents’ have some contact with their families and one on a regular basis. None of the current residents goes out for weekend leave or overnight stays. Residents who spoke to us confirmed that they attended various activities including social clubs MIND and local events. In addition, they stated that they were supported in activities such as shopping, cooking, household chores and finance. All residents are provided with a bedroom and front door key. One resident described their week and how they attends various church services not only locally but in central London, getting there with use of his freedom pass. Another resident was disturbed by the noise of other residents and felt this increased their anxiety. This was referred to staff for action. Each resident has fridge/freezer storage as well as kitchen storage for food purchases. Residents are supported with meal preparation; cooking and healthy eating is promoted when planning meals. One resident was able to prepare some meals and drinks although needed assistance with meals such as spaghetti bolognaise. The Environmental Health Officer had found the conditions satisfactory at the inspection July 08. Key workers to residents who were interviewed demonstrated a good knowledge of the individual resident including their needs family contacts and social lives. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health care is provided through the local community this promotes resident’s rehabilitation and engagement with services. Medications are safely managed by staff that are trained and proficient to do so. EVIDENCE: All residents in this home are under the Enhanced CPA. This is a system of after care where multidisciplinary support is provided and regular reviews of the residents are conducted. Within the home there is one resident who is prone to outbursts of violence and aggression. This person had been referred to, and seen by, the multidisciplinary team, their behaviour is closely monitored with supporting records kept. This intervention had provided staff with additional support to safely manage the resident in a community setting without putting others or the public at risk. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 16 Another residents was, in the opinion of the manager requiring more input from the multi disciplinary team and in particular, that of the psychologist. In his opinion they required on going and long term therapy for long standing issues. The manager was keen that one resident be seen by a professional therapist as this therapy was something outside the skills of staff working in the home. However it has been difficult to making this referral due to staff shortages in the relevant department. It is recommended that the manager refer this onto the Responsible Medical Officer or named Psychiatrist for action. In the care plan documentation contained weight charts to monitor Resident’s weight, this is particularly relevant as this type of resident is prone to fluctuation in weight. Residents are encouraged and supported to access services within the community. This promotes integration into the area and is part of active rehabilitation. There were multidisciplinary records, which identified visits by the multidisciplinary team. The entry included the date and a short summary and action taken. This could be expanded upon to fully reflect the visit to ensure all information is recorded. Within the accident /incident log there were reports and supporting Regulation 37’s received. Medications were inspected with the assistance of a senior care worker. The storage cabinet is located in the office. This was inspected and no overstocking evident. There were no controlled medications or eye drops in use. Staff who administer medications are subject to yearly competency assessments. Boots, who supply the medication, had provided training recently. Medication administration charts were inspected. They contained a photograph of the resident for identification purposes. Medications received and those returned are accurately recorded which provides information for auditing purposes. Two sets of initials were evident when those medications had been entered on to the medication chart, indicating that two staff had checked the medication thus ensuring that the information recorded is correct and reducing the margin for error. Any Medications that is to be given as required need to have full instructions recorded. One example was for the drug “lorezepam”, which was without any information on the maximum dose, duration or reason for administration of such medication. There is a separate sheet for recording of those PRN mediations given. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 17 Medications are subject to weekly audits including checking of the amounts of medications and supporting records. One medication was in the cupboard although not in current use. This should be returned to the pharmacy. Drug information leaflets were in place to assist staff who are administering medications. Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23.People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Complaints information is available for residents, staff and visitors to access. Complaints are taken seriously and responded to appropriately. Staff had a working knowledge and understanding of adult protection and whistle blowing, which provides safeguards to residents. Regular updating is required in these areas, to ensure that they are familiar with current guidance and contact points. EVIDENCE: The information on how to make a complaint is contained within several of the documents provided to residents, staff and in use generally. The complaints procedure was also on display in the hallway. Residents who were interviewed stated that they would refer complaints to the manager or their care co ordinator or in one case their family. In past contact when Community Options, have received concerns and complaints they have conducted an open and through investigation into the concerns thus ensuring that residents concerns are taken seriously and investigated appropriately. Residents can also visit head office to speak to the Chief Executive or her deputy should they have concerns. Residents are actively encouraged to voice concerns. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 19 There have been no entries in the complaints’ file since 2003. The manager stated that no formal complaints had been received since he had started. It is essential that all complaints are recorded and have supporting investigation information retained with details of whether the complainant is satisfied with the outcome of the investigation. The CSCI have received no complaints regarding this service. Community Options have a complaints monitoring form for recording of complaints. Staff who we interviewed, were asked specifically about adult protection procedures and whistle blowing. All staff demonstrated a working knowledge of both topics and where aware of the need to report such matters. They were aware of the internal reporting structure although less knowledgeable about the external contacts for such. Refresher training on this topic should provide details of relevant contact points. Community Options have comprehensive policies on whistle blowing and abuse which are available in the office. In addition the interagency guidelines were on site. It is recommended that these are subject to annual reviews to ensure they include recent legislation and good practice guidance Adult protection training is organised through the head office and staff confirmed that they received this and at regular intervals. Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good, quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment is maintained to a good standard, clean and hazard free. Residents have sufficient space in their bedrooms to personalise them to their own specifications. Comfortable communal areas provide space for socialising and relaxation. EVIDENCE: The home had significantly improved since the last key inspection. There had been some redecoration undertaken, new flooring in the bedrooms has improved the living conditions for residents. New furniture has also been purchased for bedroom areas. Bedrooms are different shapes and sizes and located throughout the house. Some bedrooms had little in the way of personal items this was the resident’s choice. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 21 The home has no lift of other equipment for residents with mobility problems. With the ageing population of residents in the home, this must be kept under review. When the redecoration had been undertaken the window restrictors had been taken off and not replaced, this meant that the windows could be fully opened and residents may accidentally or deliberately fall out of them. An immediate requirement was left regarding this. This was addressed the next day and during the second site visit all windows were found to be restricted to a safe width. One of the showers has been out of order for sometime and although there is one other shower facility in the home, this needs to be addressed. There is parking to the front of the building. The home has a large garden, which is very peaceful and quiet, and offers an area for residents to sit and relax, something one resident was doing during the inspection. Albemarle Road, 33 DS0000006881.V369687.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff are subject to robust recruitment procedures which affords protection to residents. Staff are provided in sufficient numbers to met resident’s needs. Staff receive training on the mandatory topics as well as those which are related to the current resident population, this ensures that staff are competent and capable to care for residents. EVIDENCE: At the time of the first visit three male staff were in duty during the morning shift. This was queried as there are female residents in the home and a mix of male and female staff should be planned. The reason given was that this due to staff changes which were unplanned. During the afternoon female staff were on duty. The staff team comprises of four male and five female workers to address the gender mix and needs of the residents living in the home. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 23 In the previous three months one staff had retired and another transferred to another home, a third has left. In addition one member of staff has transferred to Ablemarle Road. Leaving the home currently with two vacancies, one for a support worker and the second for a deputy manager. It is important with mental health residents, that consistency of staff and care is maintained and with staff changes this must be effectively managed to reduce disruption to the residents in the home. Staff who were on duty were spoken with as part of the inspection site visit. In the main, staff felt that they were well supported in the home particularly by the home manager. They felt that Community Opinions provided them with good training and that this was encouraged. One staff member had recently come back to the organisation after having left it. He confirmed that he had received induction in house for three days, and had received the five day company induction some time later. He confirmed that the induction addressed the mandatory topics. Probationary interviews and supervision sessions had been conduced. Supervision provides staff with a structure whereby open discussion can take place and training needs identified. The staff personnel files were inspected at the head office July 2000. Two staff files were selected from each service, including some manager’s files. These were inspected to identify evidence of recruitment procedures and those checks made prior to employment. In the main, those staff that had been recently appointed were selected as other files have been checked at previous inspections. Overall files were to a good standard. Evidence in respect of staff recruitment, and the checks made prior to employment were sufficient to ensure that staff are safely recruited for the protection of residents. The following is a summary of my findings. The staff personnel files were organised with information easy to access. Sections indicated where items could be located. The standard of information included was good. Evidence that recruitment checks are made prior to employment were on file including application forms, interview information, two references, CRB clearance, offer letters and contracts. Information relating to the CRB was retained in a separate file and in addition evidence recorded on the staff file that included the reference number, date of issue and an indication of whether it was satisfactory. Community Options are undertaking the recommendation that CRB’s be repeated every three years. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 24 Any gaps in application forms or conflicting information included within it, are now subject to further investigation by the personnel officer who sits on the interview panel. It was discussed at the head office with the training officer, the need to acquire more mental health training , this was something which she was in the process of arranging. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is managed by an experienced individual supported by other managers in the company and senior personnel of Community Options. Health and safety measures provide residents with a safe home for them to live in. Quality assurance measures include the views of resident’s relative’s staff and other parties involved in the home to further develop a better service. EVIDENCE: The Manager has been in post for almost a year and as yet has not completed the CSCI registration process. This is because of two factors, a delay in the Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 26 CRB process and a delay in receiving the RMA certificate. Once these two issues are resolved then this process will be completed and reflected within the certificate of registration. On discussion with the manager, he did say that he is sometimes included in the staffing numbers and not wholly supernumerary. This situation must be monitored to ensure that there are sufficient management hours provided to address all those areas which are required to effectively manage a service. This is particularly important as the home is without a deputy manager currently. Mr Diegelmann felt that this did not negatively impact on the home. He stated that he receives good support from the company and has a mentor from another Community Options home. The deputy manager had retired three weeks earlier and this post is currently out to advert. Resident’s money is checked twice daily. Money retained by the home is recorded on a balance sheet. A member of staff and the resident sign all incoming and outgoing expenditure entries. Receipts are kept when staff do shopping for the residents in cases such as a resident’s illness and if the resident provides them. The fire risk assessment had been reviewed July 08. Weekly fire alarm tests were recorded. Fire drills were conducted three times since December 2007. Only first names were on these records full staff signatures and the name, need to be retained as evidence of training. A selection of health and safety records were inspected and found to e satisfactory. The file containing the documents was well organised. Regular health and safety audits are conducted and a report on the findings left. The reports relating to Regulation 26 visits were viewed. The reports had a gap of three months between March 08 and July 08 although the manager stated that visits had been done although reports not received . The reports from Regulation 26 visits must be retained for inspection. Community Options has an annual development plan for the organisation in general and a specific one for each home. Community Options had conducted their annual quality survey “ Service User Satisfaction Survey”, two months previous. The results of which, will be collated and circulated. The Manager had received verbal feedback indicating a positive response to most areas. Manager’s meetings are held for all managers in the company. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 27 Staff confirmed supervision and that they were offered a copy of the notes taken during the session. This provides staff with a support mechanism to discuss issues individual to them in a confidential manner Records relating to residents and staff meetings were retained and circulated. In one staff meeting dated 15 January 08, residents we discussed at length . In cases where resident’s behaviour or conditions are discussed there should be a more suitable forum for this to be addressed . Please see requirement 2. Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 28 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 X 5 x 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 X X X 3 x Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 29 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 YA6 Regulation 15 Requirement The Manager must ensure that all care plans specifically detail the behaviours that they display as part of their mental health condition and the actions needed to address it, avoiding generic catch all terms such as “mental health”. Reports from regulation 26 visits should be retained in the home for inspection Timescale for action 30/12/08 2 YA39 26 30/09/08 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 YA27 Good Practice Recommendations The shower should be repaired for residents to use . Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Albemarle Road, 33 DS0000006881.V369687.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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