Inspection on 23/09/08 for 1 Wharf Close

This inspection was carried out on 23rd September 2008.

CSCI found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Wharf Close 04/10/07

1 Wharf Close 24/11/06

1 Wharf Close 02/03/06

1 Wharf Close 15/11/05

1 Wharf Close 16/02/05

1 Wharf Close 25/10/04

1 Wharf Close 26/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOME ADULTS 18-65 1 Wharf Close 1 Wharf Close Goldingham Farm Estate Stanford Le Hope Essex SS17 0EJ Lead Inspector Michelle Love Unannounced Inspection 23rd September 2008 09:00 1 Wharf Close DS0000018081.V372272.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 1 Wharf Close DS0000018081.V372272.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. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Wharf Close Address 1 Wharf Close Goldingham Farm Estate Stanford Le Hope Essex SS17 0EJ 01375 360789 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) maggie.prakash@familymosaic.co.uk www.familymosaic.co.uk Family Mosaic Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 1 Wharf Close DS0000018081.V372272.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 - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 4 4th October 2007 Date of last inspection Brief Description of the Service: Wharf Close provides personal care and accommodation for four adults with a learning disability. The home’s facilities include one large living/dining area, four single bedrooms and one bathroom. The home is situated in a quiet cul-de-sac in a residential area close to the town centre of Stanford-le-Hope. There is a pleasant garden to the rear of the property and adequate car parking facilities. Public transport runs close by the home and all amenities are in close proximity. Service users within the home are encouraged to access leisure pursuits and community facilities. The home has its own vehicle available for use by the residents. Family Mosaic (formerly New Essex Housing Association and Mosaic Homes) manages the home. The Service User Guide and Statement of Purpose are available and are updated as required. The residents and their representatives are provided with this information and it is displayed for reference along with current Commission 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 5 for Social Care Inspection reports. At the time of this report the homes fees for current service users were not ascertained. The current scale of weekly charges at the home’s last inspection for residents is between £1050.00 and £1116.10. Additional charges are made for aromatherapy, chiropody, hairdressing, toiletries, personal clothing, activities and for the lease vehicle. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 6.5 hours, with all key standards inspected. The manager’s progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a full tour of the premises was undertaken and members of staff were spoken with and their comments are used throughout the main text of the report. We recognise that the people living at Wharf Close have a range of complex needs, including some communication difficulties. As a result of this, observations of their interactions with members of staff and observing non-verbal signs of communication were also used. Prior to the site visit, surveys for relatives, staff and healthcare professionals were forwarded to the home for distribution and for people to complete and return to us. It was disappointing that no surveys were returned to us from relatives, healthcare professionals or members of staff. The manager and other members of the staff team assisted the inspector on the day of the inspection. Feedback on the inspection findings, were given as a summary at the end of the day. The opportunity for discussion and/or clarification was given. What the service does well: The care home provides residents with a warm and homely environment that is spacious and meets their needs. Visitors to the home are made to feel welcome. Food provided to residents is of a good quality and one resident indicated they enjoyed the meals provided. There is a varied menu and various alternatives are available if required. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 7 People at the home are supported to lead an active life, to undertake a variety of activities, which meet their individual needs according to their personal preferences and to use the local community. Staff, have a good rapport with residents and interact well. The service is well run and managed. The needs of individual people are clearly documented, with clear guidelines for staff as to how to meet these. 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. The summary of this inspection report can be made available in other formats on request. 1 Wharf Close DS0000018081.V372272.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 1 Wharf Close DS0000018081.V372272.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect to be properly assessed prior to admission and assured that their care needs can be met. EVIDENCE: Since the last inspection, the Statement of Purpose and Service Users Guide has been reviewed and updated. This was seen to provide appropriate information about the service so that prospective residents and their representatives can make an informed choice as to whether or not this is the right place for them. The Service Users Guide is compiled in an appropriate format for potential residents (written/pictorial), however further consideration should be made to provide a more pictorial document. From discussion with the manager, no residents have been admitted to the home since 2004. There is a formal pre admission assessment format and procedure in place, so as to ensure that the management team are able to meet the prospective person’s needs. In addition to the formal assessment procedure, supplementary information is sought from the individual resident’s placing authority. The previous key inspection to the home stated that documentation for the last person admitted to Wharf Close was inspected and this was observed to be in 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 10 order. Additionally, the prospective person and/or their representatives are encouraged and enabled to visit the care home prior to admission and to undertake a period of transition dependent on their needs e.g. lunch/tea visits, overnight or weekend visits. 1 Wharf Close DS0000018081.V372272.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure they have an individual plan of care in place and that this is reflective of their individual care needs and that these will be met. EVIDENCE: There is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these are to be met by staff who work in the care home. As part of this site visit 2 care files were examined. These were observed to be thorough and descriptive, evidencing the individual’s care needs in respect of their health and welfare and how these were to be proactively managed by the staff team. Good information was noted in relation to individual’s personal and medical history and there was evidence to show this had been compiled with the involvement of the individual’s family and/or representative. The care file also included a section relating to ‘Assessment of Abilities’ and there was good 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 12 evidence depicting individual’s strengths, abilities, areas of independence and personal preferences, likes and dislikes. The AQAA details, “all support plans for each service user is reviewed every 6 months or earlier if needed”. There was evidence to support this statement. Both care files examined, recorded individuals inappropriate and/or challenging behaviours. Each care file had information detailing the specific nature of the behaviour, how this manifests, known triggers and interventions to be used by staff to deal with issues as they arise. Formal recording systems were in place to record specific incidents, including what was happening prior to the incident, the behaviour exhibited, people involved and interventions provided. Risk assessments were observed to be devised for all areas of assessed risk. From discussions with the newest member of staff employed at Wharf Close, it was concerning that when spoken with they were unaware that one of the 2 people case tracked could exhibit physical aggression on occasions, however they did recognise that the individual could be intimidating. Formal monitoring forms and daily care records regularly recorded the person’s verbal and physical aggression towards other people living at the home and staff on duty. Healthcare records were observed to be well maintained detailing the rationale for the visit to a healthcare professional/service, actions and specialist recommendations and outcomes. Further information is recorded within the Personal and Healthcare Support section of the report. From discussions with the manager, support staff, 1 resident and from observations during the site visit, wherever possible people living at the home are encouraged to make decisions and choices about their lives. There was evidence to show that people can choose what time to get up in the morning, what time they go to bed, whether or not they participate in household chores or social activities etc. We recognise that the people who live at Wharf Close have a variety of complex needs and are reliant on support staff providing appropriate support and enabling individuals to take risks as part of an independent lifestyle. 1 Wharf Close DS0000018081.V372272.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their social care needs will be met and that they will receive a varied diet that meets their needs. EVIDENCE: From inspection of the activity plan and individual’s care files, evidence showed that residents have access to both formal and informal day care provision, within the home and within the local community. Activities include keep fit, music, arts and crafts, jewellery making for one person, cooking, sensory through communication, cinema, personal shopping, watching television, use of a trampoline, going out for a ride in the home’s transport etc. In addition to the above some people attend a local weekly evening club and visit other people in other care homes. Since the last inspection a piano has been purchased for one resident and music lessons commenced. Risk assessments are devised in relation to the activities individuals may take part in. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 14 Additionally there was evidence to show that people living at Wharf Close are enabled and encouraged to participate in activities within the home e.g. weekly food shopping, putting away their laundry etc. On the day of the site visit, 2 residents were observed to assist staff with the weekly shopping and appeared to enjoy the experience. The AQAA details under the heading of ‘what we do well’, “one of our service users is able to go to the local building society and withdraw their money for personal use and rent. They then walk round to the local post office and pay their rent”. There is an open visiting policy whereby visitors to the home can visit at any reasonable time. Residents are actively encouraged and supported to maintain close family links and friendships. Records for one person showed they visit their family regularly at weekends. This was confirmed by the resident and it was evident by their facial expression and body language that they looked forward to this experience. There is a rolling 4 week menu, however this is flexible so as to meet individual’s needs and choices. The menu evidenced a varied diet and included a cooked breakfast on some days. Additionally, people are enabled to access the local community for meals and takeaway meals are provided on occasions at the home. It was encouraging to note during the site visit that residents have access to crisps, biscuits and drinks and can help themselves. One resident is able to make their own drink and on occasions makes drinks for staff on duty. The emphasis at mealtimes is to encourage the dining experience for people at the home to be as relaxed as possible. As a result of this both residents and staff on duty sit and have their meals together. 1 Wharf Close DS0000018081.V372272.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive appropriate support so as to ensure their healthcare needs are met. EVIDENCE: As stated previously, the healthcare needs of individual people are clearly recorded and documented. Records showed that people living at the home have access to a range of healthcare professionals and services as and when required and these include, GP, attendance at hospital appointments, Continence Nurse Specialist, Chiropodist, Dentist, Consultant Psychiatrist etc. Residents are provided with a personal ‘Health Information and Health Action Plan’ booklet, detailing their personal information, known allergies, support needs, medical information etc. Healthcare records for those people case tracked were observed to be detailed and up to date. Information relating to known allergies and healthcare situations that some people find distressing were also recorded e.g. the records for one person recorded them as finding dental examinations very stressful and potential triggers for exhibiting inappropriate and/or challenging behaviours. There was 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 16 evidence this had been discussed with the person’s GP and measures put in place to minimise the distress to the individual person. The majority of medication is managed through a monitored dosage system (blister pack). In general terms records were seen to be well maintained, however there were a few occasions where there was no record of some medicines having been given to a resident when they were due, as the entries on the MAR (Medication Administration Record) record had been left unsigned/initialled by staff. It was positive to note that weekly audits undertaken by the manager had been completed and errors highlighted. Storage facilities for medication are not appropriate and require reviewing. The registered provider should consider relocating the current storage facilities, as the laundry room is deemed inappropriate (potentially may become too hot/too damp). Medicines may not be maintained at a safe level (not exceeding 25°), as failure to store medicines at the correct temperatures may result in residents receiving medicines, which are not effective. Records showed that where residents receive PRN (as and when required) medication, protocols were devised and up to date. From discussions with the manager it is evident that where a resident requires PRN medication to be administered, staff must obtain permission from an, ‘on-call’ manager before the medication can be administered. This is seen as not good practice and requires reviewing as people who are ‘remote’ from the situation are currently making decisions. The success of the above is reliant on competent staff administering medication in line with regulatory requirements and following clear detailed and comprehensive PRN protocols for individual residents. Training records showed that medication training for staff was undertaken in September 2007 and was due for renewal in September 2008. There was evidence to show, that competency assessments for 4 members of staff had been completed by the manager. The manager was advised that as part of good practice procedures, these should be undertaken 3-4 times annually. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there are appropriate systems in place to ensure that residents are safeguarded and that any concerns raised are dealt with proactively, not all staff have up to date training. EVIDENCE: A corporate complaints policy and procedure is readily available. A pictorial complaint procedure is displayed, however this needs to be reviewed to reflect that we no longer formally investigate complaints. It was not possible to ascertain from any resident as a result of their poor cognitive development as to their understanding of the above procedures and who, they would go to if they were unhappy. However staff on duty, were observed to have a good rapport with individual residents and to pick up on both verbal and non-verbal signs expressed by residents. The manager advised that no complaints have been received at the home since the last key inspection. Concerns have in the past been expressed by the home’s neighbour, with regards to issues relating to one resident. The manager advised that she has fostered positive relations with the neighbour and they meet regularly. No record of compliments was available. Policies and procedures relating to safeguarding were readily available. The manager and 2 members of staff spoken with demonstrated an understanding and awareness of safeguarding procedures. Since the last key inspection, no safeguarding referrals have been highlighted. Training records showed the majority of staff had undertaken training relating to breakaway techniques, 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 18 however for some people this is overdue. Not all people working at Wharf Close have up to date safeguarding training according to the training matrix. The AQAA details under the heading of ‘what we do well’, “all staff but one within the scheme have attended the safeguarding training provided by Family Mosaic for this year”. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained and comfortable environment. EVIDENCE: A full tour of the premises was undertaken with the manager. Since the last key inspection to the home a new kitchen has been installed, new dining table and chairs/kitchen equipment has been purchased, new flooring laid to the dining area and the lounge has been redecorated. All areas of the home were noted to be clean, tidy and odour free. On inspection of resident’s bedrooms, all were seen to be personalised and individualised, reflecting their personalities and interests. Vanity units within 2 bedrooms require maintenance or replacing, as the units do not close properly and some taps were noted to be stiff and difficult to turn off. The garden area is secure and well maintained. One resident was noted to spend a lot of time in the garden on their swing. Appropriate garden table and 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 20 chairs have been purchased to enable people to enjoy the garden more frequently. The garden is maintained by an external contractor. It was positive to note that since the last key inspection, window restrictors have been fitted to one person’s bedroom window. The registered provider should consider the use of toughened glass for one person’s bedroom as it currently poses a potential health and safety risk. Health and safety checks are carried out on a weekly basis by staff and the manager completes a monthly check. A fire plan and fire risk assessment for the home was readily available. Records for monthly fire checks and fire drills evidence these are conducted regularly. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living at the home benefit from an effective staff team, however further development is required in relation to recruitment practices and procedures and ensuring that staff receive appropriate training to meet residents needs. EVIDENCE: The manager confirmed that staffing levels at the care home remain at 2 members of staff between 07.00 a.m. and 21.30 p.m. and 1 sleeping in person between 21.30 p.m. and 07.30 a.m. each day. The manager advised that they receive 1 supernumerary shift per week to encompass completion of audits as required by the registered provider, undertake supervision for staff and manage the day- to- day running of the care home. This is seen as inadequate and requires reviewing. On inspection of four weeks staff rosters following the site visit, these evidence that staffing levels as detailed above have been maintained so as to ensure residents safety and wellbeing. One resident receives 2-1 staff ratio for 10 hours per week so as to enable them to access the community. The manager stated that agency staff are utilised at the service as and when 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 22 required as a last resort, however wherever possible the same staff are requested so as to ensure continuity of care for people living at Wharf Close. The manager does not have autonomy to book agency staff and permission must be gained from their line manager and/or the person ‘on call’. From discussions with the manager, she advised that staffing levels are appropriate to meet the numbers and needs of the current residents, however these are increased as and when required to enable residents to participate in community activities. The AQAA details that there is an established staff team at the care home, several have been employed within the organisation for a long time. A random sample of 3 staff files were requested including those for newly recruited staff. No file was evident for the most recent addition to the staff team. The majority of records as required by regulation were evident for two members of staff, except there was no evidence of a recent photograph for one person, no copy of a job description for one person and no formal induction for the manager from another service to Wharf Close. The manager advised that there had been a handover with the previous manager, however this was not documented/formalised. The newest member of staff employed at Wharf Close confirmed they received a 15-20 minute induction and were not sure if this had been conducted in line with Skills for Care. Profiles and records of induction were also randomly examined for 3 agency staff utilised at Wharf Close. Evidence showed there was no evidence of either document for 2 out of 3 files inspected. The AQAA details under the heading ‘what we do well’, “staff recruitment records are in order to requirements of CSCI, holding information on each staff who work in the scheme”. This did not concur with the inspector’s findings. The training matrix provided to the inspector evidences training previously undertaken, but does not include updated training that has been attained for the majority of staff working within the care home. There was evidence of the corporate training schedule, however there was evidence to confirm gaps in training for the majority of staff working at Wharf Close. The manager stated that she has completed individual learning and development forms for staff and evidence was available on the day of the site visit to verify this. The inspector was advised that the learning and development forms had been provided to the organisations training section in February 2008 (verified by the organisation that these had been received in March 2008), however at the time of the inspection (6 months later), the manager was still waiting to hear from them as to the number of places/courses provided to individual members of staff. To date only 1 member of staff had been successful and received a place on 1 course. The AQAA details that 5 members of staff have attained NVQ Level 2 or above and 1 member of staff is currently working towards an NVQ qualification. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 23 A random sample of staff supervision records were examined and these showed that staff, are receiving regular formal supervision in line with National Minimum Standards recommendations. There was also evidence to show that the manager has devised and implemented supervision sessions for ‘bank staff’. The AQAA details under the heading of ‘what we do well’, “staff all have regular supervisions, I try to do this on a monthly basis”. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at the home, benefit from a well run home. EVIDENCE: The manager has been in post for approximately 1 year. The home manager has over 17 years experience of working with people who have a learning disability and has attained a HNC in Business Management and is awaiting confirmation of her NVQ Level 4 qualification. The registered provider’s ethos of the service as detailed within the Service Users Guide is to “provide a home for four service users with learning disabilities, with minimal challenging behaviours. A home that will provide security and that will meet their assessed needs and allow them their own identity, privacy, status and respect”. The manager further stated that the 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 25 staff team aim to promote individual’s independence, to enable them to have a ‘full life’ but recognising and accepting each person’s limitations. The manager stated that staff morale within the home is very positive and there is a good “team spirit” and “the staff team compliment one another and gel well”. It is recognised that this provides positive outcomes for the people living at the care home. The manager stated that she feels generally supported by the organisation and receives regular formal supervision. Both members of staff stated they found the manager to be approachable and supportive and that the home was well managed and that residents needs were being met. All sections of the Annual Quality Assurance Assessment were completed and the document returned to us when requested. Information recorded was informative providing a reasonable level of information about the service. It is evident from this inspection that progress has been made to address some of the previous identified shortfalls. Further development is required to ensure that robust recruitment procedures are adhered to, that issues highlighted relating to the storage of medication are addressed and that staff working within the care home receive training so as to ensure that staff have the skills and competence to provide care to residents. Quality assurance surveys so as to seek people’s views about the quality of care and services provided at Wharf Close have been completed, however the outcomes of these were not available at the time of the site visit. The manager was advised to consider seeking the views of healthcare professionals and other external agencies/professionals. There was evidence to show that Regulation 26 visits are conducted by the registered provider, however not all monthly records were available at the time of the site visit. There was evidence to show that regular staff and resident meetings are conducted at the care home. A health and safety policy was observed within the home. Accident records were inspected and records were well maintained and included all necessary information. A random sample of safety and maintenance certificates showed that these had been serviced, and remain in date until their next examination. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 X 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 31/12/08 2. YA24 3. YA34 4. YA35 The current arrangements for the storage of medication are not suitable. This refers specifically to the current location potentially being too damp and/or too hot and the temperature of the room could exceed 25°C and medication could become less effective. 23(2)(c) All parts of the care home must be maintained in good working order. This refers specifically to vanity units and wash hand basin taps that are too stiff to close. 19 Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents and that all records as required by regulation are sought. 18(1)(c)(i) Staff must receive appropriate training to the work they perform. This refers specifically to those conditions associated with the needs of older people and core areas. This will ensure that staff, have the competence, confidence and ability to meet resident’s care needs. DS0000018081.V372272.R01.S.doc 01/12/08 23/09/08 01/02/09 1 Wharf Close Version 5.2 Page 28 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 YA22 YA39 Good Practice Recommendations Amend the complaints procedure to reflect that the Commission for Social Care Inspection no longer investigates complaints. The outcomes of the quality assurance surveys should be made available. 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 1 Wharf Close DS0000018081.V372272.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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