Care Home: Albion Road (44)

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What the care home does well What has improved since the last inspection? The first floor bathroom has been upgraded and redecorated. Decoration of other areas - including bedrooms - continues on a planned cycle of programmed upgrading. The kitchen is due to be refurbished in the next month or two. CARE HOME ADULTS 18-65 Albion Road (44) 44 Albion Road Sutton Surrey SM2 5TF Lead Inspector David Pennells Key Unannounced Inspection 28th July 2008 11:30 Albion Road (44) DS0000007156.V369022.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 Albion Road (44) DS0000007156.V369022.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. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion Road (44) Address 44 Albion Road Sutton Surrey SM2 5TF 020 8642 2092 020 8661 0502 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Catherine Lifely Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD 2. Maximum number of service users who can be accommodated is: 7 7th August 2006 Date of last inspection Brief Description of the Service: The service at 44, Albion Road is managed and staffed by Care Management Group (CMG). This care home provides residential care for up to seven adults with learning disabilities and associated mental health problems / behaviours that may challenge. Located in a ‘quiet’ residential road in Sutton (though new building works close by the home may cause some noise in the foreseeable future), the home is about a ten-minute walk from Sutton town centre with its variety of shops, eating & leisure establishments, and excellent transport links. The building is a large late-Victorian detached house. Communal facilities include a large lounge, dining room, hallway and kitchen. All people resident have their own single bedrooms. There is a staff / manager’s office situated on the first floor, and there is a sleeping-in facility on the second floor. A separate building adjacent the kitchen contains the laundry, a larder and a small - but underused - ‘sensory/relaxation’ room. There are sufficient bathrooms, showers and toilets throughout the home to meet the residents’ needs. There is a horseshoe driveway at the front of the home for parking, and a large very well maintained rear garden with a back patio area - and a patio area to the side of the house - close to the back door, which has tables and chairs to allow eating and barbecues outside - when the weather is fine. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We inspected the service from mid-morning to suppertime on a weekday. The home’s manager, Cathy Lifely, was present at the home and was able to assist in reviewing the requirements and recommendation set at the last inspection; we toured the entire home, and reviewed documentation. Staff members were met and service users engaged with by the inspector, as far as possible. As ever, both care staff and the manager were helpful and welcoming. We are grateful to the service users, staff and the manager for their warm welcome, for the hospitality and attention shown during the visit. What the service does well: What has improved since the last inspection? What they could do better: One relative commented: “ I don’t think they need to improve on anything, really.” Another comment was: “My [relative] is happy and settled where he lives and I know he is being well cared for.” Only one requirement is made at this inspection, relating to reinstating 1:1 staff supervision; this important for encouraging staff and developing best individual practice - as well as improving staff satisfaction / morale. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 6 A recommendation is reiterated - relating to an encouragement to replace the uneven shingle driveway with a firmer surface (to promote stability and reduce the risk of falls), and two further recommendations relate to ensuring a ‘global’ overview of fire drill training for staff, and to ensuring that records relating to specific issues - in this case medication advice - are centred on specific individuals’ case notes rather than the ‘collective’ communications book. 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. The summary of this inspection report can be made available in other formats on request. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective and current service users can be assured they will have their diverse needs assessed, recognised and appropriately recorded by the home. EVIDENCE: The seven people using the service have been the same since April 2004. The majority of the service users have been resident since well before then, with the sixth coming to the home in November 2002, and the most recent arriving in 2004. Ages span from mid thirties to early fifties, the average being about 40 years of age. We found that the consistency of people present - which is also mirrored by that of staff working in Albion Road, has been vital in ensuring the steady progress of a number of residents’ development; their behaviour programmes being well implemented - thanks to the stability this brings. People are only usually admitted on the basis of a full needs assessments made by an Assessment Team representative of CMG - and including a visit by the home manager - with information provided via the referral of the service user’s care manager/social worker. We found that all service users had been admitted with substantial care plans / other documentation. The ongoing assessments (including the involvement of other professionals as necessary) ensure that the progression of focused ‘assessment’ and review continues. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 9 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 & 9. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users can confidently expect to be provided with a care plan that addresses the specific needs and aspirations of the individual, recognising cultural and diversity needs; this being developed as far as is practicable with the involvement of service users and with their representatives also engaged in the decision-making process, where appropriate. Risk assessments form a fundamental part of the service’s care planning process, enabling independence and self-determination for service users within a framework of measures to promote safety and protection. EVIDENCE: We found that service users are central to the planning of their care and activities at the home; each of the samples of records seen showed comprehensive reviews being undertaken on a six monthly cycle and a monthly overview also being implemented. Issues such as individual religious practice and cultural needs were covered in both care plans and daily notes. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 10 Care plans we tracked were found fully comprehensive and current in content. They continue to be reviewed / updated, following the collation of the monthly review by the Keyworker; this enabling regular reflection on achievements and also on identifying changing needs resulting in amendments to the plan. The care plans and general ethos of the house are clearly person-centred in fact and intent. Reviews of each individual person using the service were well recorded and the review sequence of annual and biannual focuses was up-to-date -and well tracked by the manager. We found risk assessments in place for all people using the service, covering various aspects of care, including personal hygiene, community presence, and any specific behaviour likely to challenge the service. All risk assessments were easily accessible. Based on an assessment of ‘acceptable’ risk and safety criteria - staff encourage service users to take ‘reasonable’ risks whenever possible, and to live their lives to the full. Assessments identified the risk, likely consequences, and action required to minimise any risk’s negative effect. Individualised guidelines, such as risk management strategies for service users assessed as likely to be aggressive or to self-harm, have also been drawn up involving relevant specialist care professionals. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 11 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 - 17. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service can expect their lifestyles to be individually focused and aimed at personal development whilst providing a programme of engagement with fellow peers, friends, and with staff & families. Activities provided and pursued by people ensure positive engagement in the home and the local community as far as is practicable, whilst each individual’s needs and capacities are recognised. Service users can expect to receive a varied, healthy and nutritious, culturally appropriate diet - provided within a pleasant and comfortable environment. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 12 EVIDENCE: We found that people using the service are encouraged to both develop themselves individually and to maintain their living skills; these opportunities vary a lot in the home, due to the various levels of capacity of each individual. Service users are supported - to some extent - to explore their inherited religious persuasion; one service user’s bedroom reflecting their Islamic cultural / religious background. A copy of a translation of the Qur’an was available, alongside a video version - and dietary needs are acknowledged. We saw staff engage actively with service users, encouraging a good level of interaction; this being particularly important for those people who do not have a high level of verbal communication. Sensitive observation and ‘interpretation’ of their (re-)actions are employed to gauge pleasure, preferences and dislikes. Activities within the house include; music therapy (a separate practitioner provides distinct hours of input every week), reading / drawing and puzzles and gardening. Parties (for each and every possible occasion) are enjoyed. We found activities more recently planned outside the home have included: attendance at day care / education centres (Scola College, Orchard Hill College) providing sensory sessions, aromatherapy and keep fit, creative arts, cookery & aromatherapy. With the impending closure of the local authority ‘Cheam Centre’, the manager has been maximising opportunities at the Scola centre, and it is understood that CMG are planning to provide Day Centre activities themselves within a separate day care environment in Wimbledon. Staff time is provided to enable service users to engage with activities both at weekends and in the evenings. Sporting leisure activities (such as bowling and swimming) are enjoyed - as are meals out, shopping, and trips to the country / local parks and pubs. The house policy is to promote individual engagement with life outside the home; very rarely would more than two service users be seen out together - an ongoing positive ‘normalised’ approach to living life. Mini-breaks and holidays – and individuals visiting their relatives are encouraged; some visiting a holiday cottage in September 2008 for a break, whilst - for some - day trips are more valued and easier to ‘tolerate’ than a full trip staying away. The increase in drivers employed at the home has helped outside activity significantly. People using the service have unrestricted access to the home and grounds, and all have been offered keys to their bedrooms. A keypad system is in place at the front door, based on a global risk assessment of access to the street - Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 13 and especially important whilst demolition and building works proceed next door, on the same side of the road as the home. We found that contact with families is positively encouraged, but for some, the home is their ‘family’. The home does make positive efforts to keep in contact with families and associates. Three relatives replied to the Commission’s questionnaire, responding positively to the enquiry concerning their overarching satisfaction with the service provided to their loved ones. One relative reported that, whilst they would like their loved one to be closer, it would not be appropriate - because of the positive activity programme and ‘work’ activities they engage in, and thoroughly enjoy. Another respondent commented: “I am always made very welcome and it’s a pleasure to visit my [relative]’s home” The home provides a care service by both male and female staff to an all-male group of people living at the home. Whilst there are deep friendships between those resident (evidenced by the clear ‘missing’ of one person temporarily in hospital), the manifestation of sexual needs and their satisfactions is an individual preoccupation. The manager and staff are clear about respecting privacy and allowing appropriate expression. We noted that food is positively enjoyed - with most service users eating their meals unassisted, whilst members of staff actively support one service user. The spaghetti bolognaise served on the evening of our visit was appetising and well appreciated. Mealtimes are unrushed and relaxed - and in the summer period meals can be enjoyed on the patio area outside the kitchen. Appropriate eating equipment is available in the kitchen and is provided as needed. The House collectively plans menus around what the service users evidently ‘like’ or enjoy - with a number of staff members being positively recognised for their culinary skills - whilst food is also provided within the framework of a ‘healthy eating’ context. Those people with less communication / capacity are closely observed and reactions to food and drink are relied on to indicate their preferences. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 14 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 & 20. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service can be confident they will be supported in personal care according to their own preferences and assessed needs, and will receive physical & emotional health care support through the timely intervention of allied professionals (including prescribed medication) in an appropriate way. The home manages the administration of medication (including ‘prn’ stocks) well, within the supportive context of policy, training and good record keeping. EVIDENCE: We saw care and support being provided which was appropriate and sensitive to the needs of the individual people. Routines were clearly flexible, and guidance and support is ‘second nature’ to staff members, who clearly ‘live alongside’ people using the service, whilst ensuring their support and assistance. People continue, clearly, to chose their own clothes, and initiate their own home activities of choice, being well supported in activities and dayto-day routines by staff - and by their keyworkers especially. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 15 Respondents to the Commission’s questionnaire sent to relatives of six people living at the home indicated that they were, overall, happy with the care provided and thought staffing levels were adequate. One relative who is a frequent visitor to the home was confident “[my relative] is being well looked after.” People are supported to attend routine annual health checks covering general health, medication, vision, and dentistry / oral health needs. Chiropody is provided, where necessary, at the home on a bi-monthly basis; domiciliary visits of a private practitioner are charged per appointment. Comment cards provided previously from the home’s General Practitioner and the visiting Consultant Psychiatrist were both positive about the approach adopted by the home. The AQAA submitted by the manager confirmed that this positive attitude continues. We looked at medication storage and records and found they were generally well kept. Administration processes were observed and followed best practice. A relatively recent Boot’s inspection and advice visit had positive outcomes for the service. It was noted that some ‘full’ references to medication issues were being kept in the ‘collective’ communications book. It is strongly recommended that all such messages relating to individuals be kept separately in the appropriate record with only brief (but clear) reference made in the communications book. We found Health Action Plans (the ‘My Health’ booklet) to be in place in the home and kept up-to-date; this involving people using the service and staff together assessing and identifying regular - and specific - health care needs, and the local GP countersigning confirmation of this information. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 16 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 & 23. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural process and timescales. The service provides support to service users to ensure that they are protected from any form of harm, neglect or abuse. EVIDENCE: The three respondents to the CSCI questionnaire all knew of the CMG Complaints Procedure. Many issues arising relating to people living at Albion Road often have to be passed on by staff; a relative confirmed: “If there are any problems the manager phones me to tell me the nature of the problem.” The CMG complaints procedure is included (in symbols) in the Statement of Purpose / Information Handbook and also contains information about how a complainant can contact the Commission should they wish to do so. The procedure is clear and has timescales given. A record book for all concerns / complaints made about the service at the home is kept. The CMG policy and procedure for ‘Alleged Abuse’ is comprehensive. The home has the Sutton Borough Local Authority procedure, and is aware of reporting responsibilities and protocols to both local authorities and this Commission. Training for staff in Safeguarding and dealing with challenging behaviour is a priority to the manager; all staff are currently trained / have had a ‘refresher’. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 17 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 & 30. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service can expect their accommodation to be clean - and a generally pleasant & homely, comfortable environment to live in, meeting the needs of the individual and providing privacy and the chance to express their own character through furnishings and decoration. The home is generally well decorated and maintained with equipment being appropriately serviced, ensuring the safety of service users. EVIDENCE: The house is well maintained, with more than sufficient space for the people resident. The patio outside the kitchen, now fully established as an outside sitting / dining area now overlooks (behind a newly-replaced wall) the newly revealed building site, which was previously a single building. The expansive back garden is well kept and a pleasure for people to spend time in - it provides good ‘time out’ space for individuals. The home is comfortable, light and airy; furniture & fittings are overarchingly good quality. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 18 The first floor bathroom has now been refurbished, providing a better environment for those who use it. It is now expected that the kitchen will be refurbished within the next month or two after the inspection visit. Opportunities for redecoration - such as the current person being absent in hospital - has lead the manager to seize the opportunity for their room during his absence. The contractors were busily painting away during the inspection. A previous recommendation remains reiterated; that the registered provider should consider replacing the loose gravel / shingle surface driveway to the home with a more suitable (either tarmac or paved) surface to promote better safety and easier access for people who use the service (and others) from vehicles - and walking from the roadway - to the front door of the house. This surface is not ideal for such a category of home. We found the home to be generally tidy and clean and odour-free on the day of the visit. Cleaning materials are kept locked away in line with the Code of Practice for substances hazardous to health (COSHH). The Annual Quality Assurance Assessment (AQAA) provided to us by the manager - and random checks on the day of the visit - confirmed that all required maintenance checks and supporting documentation is in place and suitably up-to-date. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 19 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 - 36. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users can rely on the home providing adequate numbers of staff, being duly competent and well trained to provide a service that seeks to meet the service users’ individually identified needs. The home’s recruitment and staff support / training / mechanisms are organised so as to ensure the safety, protection and wellbeing of service users. Support for staff through 1:1 supervision should be focused on to ensure the best development of individual staff - and for the general benefit of the whole service. EVIDENCE: We found that, as in the past, a new staff member’s personnel file - which was actively examined - was found to be complete and comprehensive in content. Evidence of Criminal Records Bureau checks, a minimum of two references, the application form, medical check, an interview schedule and proof of identity was all well catalogued. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 20 Induction records - to common induction standards - were again found completed and signed off. All newly employed members of staff are subject to a sixth month probationary period. Performance reviews including selfassessment, and an individualised ‘Personal Development File and Training Plan’ were in place. We found that 1:1 staff supervision sessions had reduced in frequency, and sometimes ceased, in the past six months or so; this principally due to the long-term absence of one senior member and an unexplained absence of another senior, who would both usually support the manager in undertaking these regular sessions. It is important to maintain these points of contact with the individual staff member in a professional context - at least once every two months or so - to ensure individual support, development and training. It should be noted that the manager, however, has maintained staff meetings, without break, in their monthly regular slots. Staffing levels are provided at the home a minimum of three staff on duty for both the early and late shifts at the home - with extra staffing on days when outward bound activities are in higher quantity, and there is a staff member awake and one, on-call, on site. The manager’s hours are generally supernumerary, though she is keen to ‘keep her hand in’ and actively engages with life in the home. The gender of staff - for an all-male care home - is currently just two female staff and twelve male staff. Staff training records revealed again that adequate full time staff members are trained in First Aid (to ensure 24-hour cover), and many other ‘statutory’ qualifications are well supported. Four staff currently held the NVQ qualification at level 3, and four at level 2. One staff member is undertaking their Level 4 qualification - this amassing to a greater than 50 proportion of staff qualified at least to level 2. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 21 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): 37, 38, 39, 40, 41 & 42. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users and their relatives / friends can rely on the home being run well, and providing a professional service with the best interests of the service user being centrally held to the care provision. The registered providers can be relied upon to ensure best practice and take up issues through both the quality assurance and complaints mechanisms embodied in the Company’s policies and procedures, these elements contributing to both the wellbeing and safety of those residing at the home. The safety and welfare of service users is guaranteed by the home having a clear management and support structure - resulting in a well-organised establishment and service. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 22 EVIDENCE: The present registered manager, Catherine Lifely, has worked at Albion Road for seven years; she was previously the deputy at the home and she became the registered manager in January 2004. She has now completed the NVQ at Level 4 in Management and Care - leading to the Registered Manager’s Award. Staff and people using the service are encouraged to participate in the day-today operation of the home, and to voice their opinions at reviews, informal one-to-one meetings with Keyworkers, and through the home’s Quality Assurance and Complaints / Grievance procedures. A Company-wide consultation Forum for service users meets regularly, and CMG regularly publishes a global in-house magazine. Quality Assurance surveys are regularly sent out to relatives, friends and representatives / advocates of service users to encourage feedback about the quality of the service provided. The responses are received centrally and collated, prior to being sent on to the home itself. The home now has a substantial QA file - which requires focused work and administrative skills. Rigorous unannounced inspection visits - conducted by representatives of the registered provider - are being carried out on a regular basis (by the Regional Director and Quality Assurance team of CMG) and the subsequent reports are being kept as evidence of the visits. The visits are clearly thorough and hold the manager accountable to the findings. Finance records at the home are kept in concise and well-managed records. They have been recently audited for one specific individual, and the Quality Assurance department of CMG has completed a thorough audit of all records kept relating to all financial transactions in July 2008. CMG has a comprehensive set of policy and procedures - which cover the broad spectrum of needs identified for care homes; they have been quite recently revised and the clear focus and guidance provided by these documents are noted. Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 23 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 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 X 3 x Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA36 Regulation 18(2)(a) Requirement Staff supervision must be reinstated and provided for all staff on a regular basis. Timescale for action 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 YA20 Good Practice Recommendations All detailed recording of issues [such as medication] should be held singly in the appropriate section and NOT in the ‘collective’ communications book - where items cannot be separately kept and archived. The registered provider should consider replacing the loose gravel / shingle surface driveway with a more suitable (either tarmac or paved) surface - to promote safety and easier access from vehicles and from the roadway to the house. Fire drill attendance should be included in the staff training matrix record to ensure that all staff members do regularly experience an actual participation within a proper fire drill. 2. YA24 3. YA42 Albion Road (44) DS0000007156.V369022.R01.S.doc Version 5.2 Page 25 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. 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