Inspection on 27/10/05 for 1, 3, 5, 7 Exmoor Drive

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1, 3, 5, 7 Exmoor Drive 07/05/09

1, 3, 5, 7 Exmoor Drive 25/04/07

1, 3, 5, 7 Exmoor Drive 11/05/06

1, 3, 5, 7 Exmoor Drive 23/06/05

1, 3, 5, 7 Exmoor Drive 03/03/05

1, 3, 5, 7 Exmoor Drive 15/09/04

1, 3, 5, 7 Exmoor Drive 18/03/04

1, 3, 5, 7 Exmoor Drive 12/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Exmoor Drive, 1 1 Exmoor Drive Bromsgrove Worcs B61 0TW Lead Inspector P Wells Unannounced Inspection 27th October 2005 11:30 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Exmoor Drive, 1 Address 1 Exmoor Drive Bromsgrove Worcs B61 0TW 01527 576591 01527 871853 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) Worcestershire County Council Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 4 persons may be accommodated in each unit. The home may accommodate people with a learning disability over 65 years of age. The home may accommodate existing service users who have an additional physical disability or mental disorder. An amended Statement of Purpose will be submitted to the Commission by 31 October 2005. 23rd June 2005 Date of last inspection Brief Description of the Service: Exmoor Drive is operated by Worcestershire County Council Social Services Department. It is a care home for 12 adults with learning disabilities. The responsible individual is Stephen Chandler and the service manager has just changed to John Peakman. The home does not have a registered manager. The home is purpose built on one level and opened in 1992. It is located in a residential area approximately one mile from the centre of Bromsgrove, on a bus route and there is a range of community facilities within close proximity to the home. The accommodation consists of three, self-contained units. Each unit has four bedrooms, a bathroom, a separate toilet, an open plan lounge/dining room/ kitchen. All of the service users’ bedrooms have a wash hand basin but no ensuites. Two of the units provide long-term care and one of the units provides respite care. Respite care is provided for 40 service users for varying periods. The staff also offer support to three former service users now living in their own accommodation in the community and to one service user who attends the home each week as part of a long standing commitment. The aim of the service is to provide appropriate support, advice and guidance in order to enable the service users to develop their individual potential and to participate as fully as possible within the community. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that commenced during the day of Thursday, 27th October 2005. For this inspection, time was spent preparing reading the monthly reports from the service manager and other information about the service. The inspectors spent 5 hours in the home. A brief second visit took place on 28th October to give feedback to the acting manager. On arrival the inspectors were greeted by the new, acting manager, Lascelles Chisholm (known as Tim). He had started at the home on 11th October 2005, just two weeks prior to this visit. This inspection focused on meeting with the new manager, the outstanding requirements listed in the last report, the records kept on the respite service users and following up on an incident of which CSCI had been advised. Therefore the majority of the time was spent with the new manager and a senior member of staff. One of the inspectors met briefly with five of the permanent service users. The other two permanent service users and the respite service users were attending day placements. Also inspectors met the staff on duty. The manager had commenced with the understanding that all previous requirements had been met. It is acknowledged that the new manager will need time to address the outstanding matters; hence timescales for requirements have been extended in agreement with him. A follow up visit will take place early in the New Year. The co-operation and time the acting manager, service users and staff gave the inspectors was appreciated. What the service does well: Maintaining a home for the existing permanent and respite service users, whom the staff have known for some years. The group know each other well and the atmosphere is relaxed, secure and safe with the service being run as a home for 12 (8 permanent and 4 respite service users at any one time) in a traditional way. This atmosphere has been sustained by the staff in the absence of a manager for the last twenty one months. The permanent service users spoke positively about living at the home and the support they received form the staff. Two service users in particular were observed as more settled and well. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The information about the home needed updating and circulating and a contract/agreement introduced. The current service users needs were being met. EVIDENCE: An amended statement of purpose was submitted to CSCI, as per the condition of registration, by 31st October 2005. However it was an incomplete version and needs further discussion, which is being arranged with the manager. The service user guide and the copy in a more suitable format for some of the service users, need finalizing and circulating to all - permanent, respite, prospective service users and their families. The service was introducing a prospective (permanent) service user to the home and introductory visits were appropriately taking place. It was pleasing to hear that the person is known to some of the relief staff and service users who considered the person could be suitable for the home. Assessments from the person’s day placement and social worker were evident. However the home had not carried out it’s own assessment, including recording introductory visits. This would help ensure that the service could meet the individual’s needs and that the person and the other service users would be compatible. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 9 The staff and service users had supported a service user, who had been admitted to the home a few months ago, to settle. This person’s and another permanent service user’s special needs were being met. The County Council had produced a draft contract/agreement but as yet this had not been introduced to this service. The rules on smoking, alcohol and drugs need to be included in the service users’ contract. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9.10 The service user plans and risk assessments need further development and reviewing, with a person centred approach. The plans and risk assessments need to be detailed indicating how the needs of an individual are to be met and regularly reviewed. EVIDENCE: The manager advised that within the last two weeks he had identified that the service users’ files needed reviewing. For the permanent service users’ plans, the comments in the previous report should be considered. At this inspection a sample of plans for the respite service users were viewed. The service users plans had only been partially completed and did not detail how any assessed needs were to be met. This was of particular concern where a service user had a special need such as poor mobility, epilepsy, and continence problems. Following a recent incident, the home had been required to compile a detailed care plan for a respite person but this had not yet been completed, nor the risk assessment and epilepsy protocol. Another respite service user, who was staying, was on a short course of medication but the care plan had not been updated to reflect this. The member of staff who Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 11 assisted in selecting the sample of respite service user plans was unaware that one of these individuals suffered with epileptic seizures. This showed that the plans need to be clear, detailed, and regularly read and by staff. Records relating to one service user were found on another person’s file. Information about each service user must be kept separately to respect their confidentiality. The service user plan format must be completed in full or an alternative format introduced and completed. The staff would benefit from further training in care planning and risk assessing. The home do have a form for parents/carers to complete if there are changes in the respite service user’s situation but these forms were not routinely being used for every respite admission. Completion of such a form would ensure the home had up to date information about the respite service user’s circumstances (including current medication) and could act as a review. The manager agreed to ensure that each respite service user had an up to date plan and risk assessment prior to their next admission, particularly for those with special needs. Further guidance would be beneficial and could be obtained by liaising with the other two Social Services respite services. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,17 Service users need more opportunities for personal development and with activities in and out of the home. The records of food provided must be detailed to evidence that the service users are being offered a nutritious, varied and balanced diet. EVIDENCE: Standards 11-14 were not fully inspected on this occasion. However the following was noted: A few of the permanent service users were attending day placements and respite service users. Other service users did not have regular activities in or out of the home. These service users were choosing when they got up and had breakfast, also free to sit and move about the home. Some service users watched television in the communal lounge. They appeared contented and felt able to ask for support when needed. The manager had discussed activities in a recent staff meeting and just introduced a book for staff to record activities that had been offered/taken Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 13 place and indicating which service users and staff were involved. There was one entry for the day of the inspection recording a service user and member of staff had played a board game. Development of the range of activities offered to service users is welcomed. Previous recommendations should also be given due consideration to ensure that each service user is encouraged and supported with personal development, in gaining independent living skills, being involved in the running of their bungalow/home, involved in activities in and out of the home and in the community. It appeared that respite service users’ regular activities, other than attending day centres, were not maintained during their stays, which was disappointing. The appointment of support workers, who have worked in other Social Services establishments and have experience of supporting service users with their personal development and activities, should assist in the implementation of this at Exmoor Drive. The home would benefit from an unmarked mini bus or people carrier(s) to assist with taking the service users out. There were no menu plans. The record of food provided was insufficient in detail for the inspector to be able to assess whether the service users were having a nutritious, varied and balanced diet. This was an outstanding requirement, which was discussed with the manager who gave an assurance that the records and food provision would be reviewed by the end of the month. For example - the records of food provided for a service user with a known dietary need were variable and did not indicate if and when the person was offered additional meals and snacks when a meal had been missed. The records did not detail when fresh foods were served such as vegetables and fruit or available for service users as snacks and deserts. Hence the previous judgement remains ‘The meals and snacks offered to the service users need to be healthy, nutritious and varied promoting healthy eating with the service users being more involved at every stage from shopping to consuming meals’. Menu plans agreed with the service users in each bungalow may well be a way forward. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 The service users were supported by staff with their personal and healthcare needs. However the records needed to be more detailed and up to date in order to assure comprehensive information these needs and to evidence outcomes. EVIDENCE: Standards 18-20 were not fully inspected on this occasion. However the following was noted: The healthcare needs and medication for respite service users must be documented and kept up to date in their service user plans. See comments on page 11,12 & 14 of this report. If the respite service users have health action plans, it could be requested that these plans are brought with them for stays to promote continuity. The introduction of a respite admission form would be beneficial. Risk assessments (relating to health problems) and epilepsy protocols need to be in place and kept up to date for all service users. Following a recent incident, it was pleasing to hear that a community nurse had been requested to update these for a respite service user. Also that a specialist nurse for epilepsy was reviewing the situation with staff for a permanent service user. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 15 A service user had been supported by staff in settling into the home and her health had not been adversely affected, which is commendable. Another service user who had previously been unwell was much improved, again reflecting that this person received appropriate support. Nine staff had attended a course on ‘care of medicines’ (previous requirement). It was pleasing to observe that two staff administered medication to the service users and that medication administration forms were being completed. A monitored dosage system was in use for the permanent service users and printed forms received from the pharmacist. These forms were handwritten by staff to record medication brought in by respite service users and administered to them. A trolley was said to be on order to replace the carrying case. Alternatively medicine cupboards could be installed in the two bungalows with permanent service users, similar to the one in the third bungalow for the respite service users. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home had a complaints procedure and a policy and procedure for protecting vulnerable adults. EVIDENCE: Standards 22,23 were not fully inspected on this occasion. However the following was noted: The home is known to have a suitable complaints procedure and policy and procedure for protecting vulnerable adults. The file recording complaints, the investigation and outcome was viewed. The last entry was in 2003. The file needed reorganising. A senior member of staff said that the opening of bank/building society accounts for each permanent service user was being arranged. This would enable service users, with support, to manage their monies. Standing orders for payments of personal and mobility allowances needed to be set up which do not involve the provider. The manager advised that lockable bedside cabinets were being delivered on 07.11.05 so that service users would be able to retain and keep safely their personal monies rather than having to use the home’s safe and relying on staff to access it. Therefore the policy recommended regarding service users’ money and financial affairs needs to reflect the new arrangements as well as indicating how fees and personal monies for respite service users are handled. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The self-contained units/bungalows have potential but need upgrading to meet the changing needs of the service users. A programme for upgrading the home should be introduced. EVIDENCE: Standards 25-30 were not fully inspected on this occasion, having been assessed in June 2005 and there had been no changes to the premises. See previous report for details. However the following was noted relating to previous requirements: The communal areas of the home were to be redecorated, commencing in November 2005. The home was free from offensive odours and an area of previous concern had been thoroughly cleaned which had resolved the issue. The cookers in the bungalows had been replaced/repaired since the last visit. However the oven door in bungalow 3 had been broken and a new door was on order. For the time being the oven in the communal kitchen was being used so service users in this bungalow were not being disadvantaged. A full audit of the bedrooms still needed to be undertaken and was discussed with the manager. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 18 Lockable bedside cupboards and lounge suites were being transferred from another home in November 2005. It was said that a quote for installing bedroom door locks with single action release had been requested. It was confirmed that the decorating and installing of shelves in a service user’s bedroom had been completed. The County Council were obtaining quotes for the upgrading of the bathroom and toilet facilities. A review of the equipment in the home still needed to be undertaken. This is considered necessary with service users who have additional physical disabilities being accommodated, and with some of the service users ageing and becoming frailer. However it was pleasing to hear that a referral to an occupational therapist had been made on behalf of one service user and this should include a re-assessment of the mobility aid. An alternative piece of equipment to a hoist was being considered in case a service user needed assistance in getting up. The inspector was advised that the bungalows have been re-numbered: Bungalow 1 is for four respite service users Bungalow 2 is for four permanent service users Bungalow 3 is for four permanent service users who may have physical disabilities. A service user had moved bedrooms (and bungalows). This person confirmed that the new bedroom was larger and more suitable. The previous bedroom was about to be let to a prospective service user. During the year the permanent service users have moved bedrooms and bungalows, some on more than one occasion. This needs monitoring to ensure that any move is service user led and not for the convenience of the service. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 The manager has started to address the staffing situation. The home needs a full, permanent staff group including a cleaner. A staff training assessment needs to be carried out and a training programme introduced. EVIDENCE: The staffing situation in the home had improved since the last inspection, despite continuing sick leave amongst the staff group. At the time of the visit the service was covering this by using relief staff on a daily basis. The service now has a full-time manager supported by two deputies and two senior support workers. Also, two experienced support workers had transferred from other Social Services care homes. The bank of relief staff had increased and many of the relief staff were experienced and knew the service users from other services. Therefore there is a wealth of experience and skills within the permanent and relief staff to develop the service for the service users. The new support workers (permanent and relief) have relevant, valuable skills and experiences in supporting service users with their personal development and activities. This will be beneficial to this service and it’s users should be tapped. Agency workers were no longer being used. The manager had reviewed the rotas and increased the number of staff on duty when the majority of service users were at home. This should enable the Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 20 staff to spend time with the service users promoting activities in and out of the home and personal development. On the day of the inspection this number of staff were on duty, yet no planned activities and some staff were undertaking domestic tasks in the home which did not involve the service users – cleaning, laundry and preparing drinks and snacks. Staff may benefit from training in the principles outlined in ‘Valuing People’. Nevertheless the staff treat the service users with respect, converse with them and listen to them. Since his arrival the manager had arranged two meetings with staff, which were minuted. The staff appeared positive and a senior commented that the new rotas, about to be introduced, were an improvement allowing for better senior cover throughout the week and increased staffing. The vacant cleaner’s post had not been filled and the manager had raised this with the responsible individual. If this post were filled it would free up support workers’ time. The manager had identified that the staff records needed to be organised and these will be viewed at the next inspection. As yet there had been no progress with identifying the training needs of the staff group and for individuals (previous requirements). A sample in-house induction training record was shown to the inspector. The onus was on the new member of staff to find out about all aspects of how the service ran and to sign the record when this was completed. Consideration should be given to the home using the County Council’s induction training manual. The home should also have a checklist for introducing a new member of staff on their first shift to the service and the person’s personal details and training. The manager was proposing monthly supervision sessions for all staff, which would be beneficial. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42, The newly appointed manager needs time to develop the service so that service users benefit from a well run home which safeguards them and encourages their involvement in the running of the home. EVIDENCE: The County Council have appointed a temporary manager from an agency, Mr Lascelles Chisholm, who is known as Tim. This temporary arrangement is welcomed, until such time as a permanent manager is appointed. He is an experienced and qualified manager who has managed care homes for Birmingham Social Services. He presented as enthusiastic and committed to developing this service with the staff, for the service users. In two weeks he had already identified priorities. A quality assurance programme was still being devised by Social Services and yet to be introduced to the home. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 22 The manager is familiar with the records that are required to be kept in a care home and is commencing by reviewing the service users’ and staff files. The complaints file also needed attention. All policies, procedures, records and documents need to be signed and dated. It would then be clear when the document needed reviewing and whether it was the latest version. The standard on Safe Working Practices is wide ranging and the following was noted on this occasion, relating to previous requirements. Also see comments on pages 11,12,15,18. A record needs to be compiled indicating when staff individually last received training in safe working practices and a training programme to cover training needed. 9 staff had attended course on ‘care of medicines’. The full risk assessment still needed to be located and then reviewed in house. The home had a suitable accident book and system for reporting accidents to the County Council. However the last incident had not been recorded in the accident book and the reporting form could not be found. The wardrobes had been secured to the walls. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 3 2 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Exmoor Drive, 1 Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X 2 X X DS0000037488.V264503.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5,6 Requirement Timescale for action 31/12/05 2 YA1 4,6 3 YA5 3 A service users’ guide, that includes all of the information detailed in Regulation 5 and Standard 1, must be finalized, available in the home and copies given to all current, and any prospective, service users and their families. (timescale of 31.08.05 not met). The statement of purpose 31/12/05 must be updated, to reflect the service that is now being provided, and a copy sent to the CSCI. Service users and their representatives must be notified of any revision within 28 days. (timescale of 31.10.05 partially met). A contract/statement of 31/01/06 terms and conditions, that includes all of the information detailed in Standard 5.2 and in a format appropriate to the service users’ needs, DS0000037488.V264503.R01.S.doc Version 5.0 Page 25 Exmoor Drive, 1 4 YA6 15,13 5 YA6 15,13 6 YA9 15,13 7 YA9 15,13 8 YA23 YA7, 20 must be provided for all of the service users. The rules on smoking, alcohol and drugs must be clearly stated in the service users’ contract. (timescale of 31.08.05 not met) For permanent service users: Service user plans must cover all of the aspects of care as set out in Standards 2.3,6-21 and Schedule 3, in particular personal and health care. All service user plans must be clear, fully and accurately maintained and reviewed with the service users at the request of the service user or at least once every six months and updated to reflect changing needs. (timescale of 30.09.05 not met) For respite service users, prior to their next admission, the requirement above applies and an admission form introduced for each admission detailing the service users’ current situation and signed by the next of kin/carer. For permanent service users risk assessments, where needed, must be detailed and up to date. For respite service users, risk assessments, where needed, must be detailed and up to date prior to their next admission. The practice of senior 31/12/05 01/11/05 31/12/05 01/11/05 31/12/05 Page 26 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 9 YA17 17 10 YA20 13 11 12 YA24 YA26 13,23 16 13 YA26 16,13 staff acting as appointee for service users must be reviewed and the service users supported in managing their own finances. (timescale of 30.09.05 partially met) The record of the food provided for service users must be developed and maintained in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. (timescale of 30.09.05 not met) The method of carrying medicines around the home must be reviewed and either a trolley purchased or medicine cupboards installed in each bungalow. (timescale of 31.08.05 not met) The oven door in bungalow 3 must be replaced. An audit of bedroom furniture and facilities must be carried out as listed in Standard 26. If the provision of any item poses an unacceptable risk to the service user or they decline the provision, details of the discussions and decision about this should be recorded in the service user’s plan. (timescale of 31.08.05 not met) The bedroom door locks must be single action release internally. (timescale of 31.08.05 not met) 30/11/05 31/12/05 30/11/05 31/12/05 31/12/05 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 27 14 YA27 23 15 YA29 13,23 16 YA29 13,23 The bathing and toilet facilities must be upgraded so that all service users can safely toilet, bath or shower in their own bungalow. (timescale of 31.07.05 partially met) A review of the equipment in the home must take place to ensure that the service users needs can be safely met and any necessary equipment installed, including a call bell system and suitable monitors,if identified as needed for individual service users. Also a review of the sleeping arrangements for one service user. (timescale of 31.07.05 not met) A walking frame in use must be repaired or reviewed by an occupational therapist. (timescale of 31.07.05 partially met) The vacant cleaner’s post must be filled. (timescale of 30.06.05 not met) There must be records kept, in the home, relating to all staff who work there, Regulation 17, 19 and Schedules 2 and 4. (timescale of 31.08.05 partially met) A record must be kept of the introduction and induction training given to all new staff, including relief and agency staff. 31/03/06 31/01/06 30/11/05 17 YA33 18 30/11/05 18 YA34 17,19 31/12/05 19 YA35 13,18 31/12/05 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 28 20 YA42 YA35, 18,12,13 21 YA35 18,13 22 YA37 8 23 YA39 24 24 YA41 17 25 YA43 YA39 24 (timescale of 31.08.05 partailly met) There must be a training programme for to ensure that all staff have up to date training in safe working practices, care planning, risk assessing, supporting service users with learning disabilities and special needs.(timescale of 31.09.05 not met) A training needs assessment must be carried out for the staff team as a whole and for individual members of staff. (timescale of 31.08.05 not met) A permanent manager must be appointed. (timescale of 31.08.05 partially met) A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and all of the aspects of Standard 39. (timescale of 30.09.05 not met) All the records that are required to be kept, must be compiled, detailed, confidentially maintained and made available for inspection at all times in accordance with Regulation 17 and Schedules 1, 2, 3 and 4. (timescale of 31.09.05 not met) An annual development plan for the home based on a systematic cycle of planning, action, review, reflecting aims and 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 29 26 YA42 YA24, 23,13 outcomes for service users must be provided.(timescale of 31.09.05 not met) The full fire risk assessment must be located, reviewed and available for inspection. (timescale of 31.07.05 not met) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA6 Good Practice Recommendations The home should carry out and record it’s own assessment on a prospective service user. Service user plans should be in a format, which the service user can understand and be held by the service user unless there are, clear (and recorded) reasons not to do so. The staff should have training in care planning and risk assessing. Consideration should be given to the home having a mini bus or people carrier(s) to take the service users out. The previous recommendations, Nos. 5-18 should be given due consideration: Service users should have opportunities to participate in activities that enable them to influence key decisions in the home as outlined in Standard 8.3. There needs to be a review as to whether this is a care home for 12 service users or a service being provided in three self contained bungalows. There should be a review of the permanent and respite services being provided in the same home, particularly with the admission of new, permanent service users with high dependency needs. The home’s statement on confidentiality setting out the principles governing the sharing of information should be issued to partner agencies. DS0000037488.V264503.R01.S.doc Version 5.0 Page 30 3 4 5 YA9 YA6 YA11 YA8 6 7 YA1 YA3 8 YA10 Exmoor Drive, 1 9 10 11 12 13 14 YA11 YA18 YA20 YA21 YA23 YA31 15 16 YA35 YA40 17 18 YA1 YA30 Opportunities for the service users’ personal development should be provided based on care planning and assessment, covering NMS 11-17. The staff should have training in caring for service users who have increased personal and health care needs If a service user is self-medicating an assessment should be undertaken and recorded to confirm that this is a safe practice. The staff should have training in dealing with ageing, illness and death. A policy regarding service users’ money and financial affairs that includes all of the issues referred to in Standard 23.6 should be provided. A review should be undertaken to ascertain whether service users could be involved in domestic tasks in their bungalows and some of the communal domestic duties undertaken by the waking night staff. All staff should receive equal opportunities training, including disability equality training provided by disabled trainers, and race equality and anti-racism training. All of the home’s documents including the policies and procedures should be signed and dated by the manager of the home and written evidence provided to show that all of the staff have read and understood them. The previous recommendations, outlined in the inspection report of 03.03.05, relating to information in the service user guide should be implemented. Consideration should be given to instaling dishwashers in the bungalows and relocating the washing machines to the laundry. Exmoor Drive, 1 DS0000037488.V264503.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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