Inspection on 28/06/07 for 104 Highlands Road

This inspection was carried out on 28th June 2007.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

104 Highlands Road 05/02/08

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 104 Highlands Road Fareham Hampshire PO15 6JG Lead Inspector Ms Wendy Thomas Unannounced Inspection 28th June 2007 09:30 DS0000068980.V339709.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 DS0000068980.V339709.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. DS0000068980.V339709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 104 Highlands Road Address Fareham Hampshire PO15 6JG 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) 01329 849399 Disabilities Care Management Limited Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places DS0000068980.V339709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is a new home. Brief Description of the Service: 104 Highlands Road opened in December 2006. It is a purpose built residence for ten people with learning disabilities. There are four flats upstairs and accommodation for six downstairs. The flats have their own shared access or can accessed via the main home. Therefore people living in the flats can be independent, or involved in the life of the main home as appropriate to their needs and wishes. There is an enclosed garden. The home is close to local shops and a doctor’s surgery. The home expects to be providing services to people who have complex needs. The fees range from £2184.14 to 4150.58 per week. “The service user’s contract and statement of terms and conditions” state that fees include “all care, and accommodation costs, food, drink, heating and lighting, laundry done on the premises, and any other staff services.” They do not include “ costs of newspapers and periodicals, hairdressing, dry cleaning, chiropody, treatment by dentists or opticians, or the purchase of clothing and personal effects.” DS0000068980.V339709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of 104 Highlands Road which was registered on 18 December 2006. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and the Care Homes Regulations 2001. The findings of this report are based on several different sources of evidence. An unannounced visit to the home, which was carried out on the 28th June 2007 between 11.00 and 17.30, during which the inspector was able to have discussions with the person living at the home, the staff on duty and the deputy manager. The inspector was also shown around the home and viewed records and procedures relevant to the inspection. All regulatory activity since the home was registered was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. The home’s Annual Quality Assurance Assessment (AQAA) had not been returned to the Commission for Social Care Inspection as requested before the visit to the home. What the service does well: The person living at the home said that they were very happy at the home and that the staff were “fantastic.” They had been well supported during their transition to the home with staff from 104 Highlands Road visiting them in their previous home, and staff from there supporting them and the new staff team for the first two weeks after their move to 104 Highlands Road. The home keeps good records of the person’s activities and any incidents. Where any activities undertaken involve risk, the risks are analysed and plans are put in place to manage these. The person living at the home is able to decide how they spend their time. They take part in a range of activities they enjoy both within the home and the community. The home is new, it is purpose built, is freshly painted and newly furnished. The staff team are committed to the person living at the home. The person said that the staff “could not be faulted”. The relationship between the person and the staff was observed to be positive. DS0000068980.V339709.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The information about the home given to people who are considering going to live there, is not produced in a format that they would understand. It does not contain enough information for them to decide if the home is right for them. It is not clear about the range of needs other people living at the home might have, or the range of needs the staff team are able to support. This must be improved. The information obtained about the people living at 104 Highlands Road from their previous homes, should be shared with the staff team before they move in, so that they can support them effectively. Systems and routines must be set up so that the service people receive is regularly reviewed and any necessary changes are made to care plans and records. If the key-working system is to be continued, staff should have training in what they need to do to implement this. Where staff are likely to encounter aggression, clear plans must be produced explaining exactly what staff must do in each circumstance. Currently doors within the home are kept locked. This must be reviewed and a policy developed that reflects the needs and wishes of the people living there. A medication procedure must be developed outlining the steps to be followed by staff in the recording, handling, safekeeping safe administration and disposal of medicines. Otherwise there is a risk that mistakes will be made as the number of staff and people living at the home increase. There should be version of the complaints procedure that all the people who live in the home can understand and use. DS0000068980.V339709.R01.S.doc Version 5.2 Page 7 An in-house procedure about the safeguarding of adults from abuse must be developed, which reflects the practice set out in the Hampshire policy for the protection of vulnerable adults. Staff must receive training about this. There should be a written procedure explaining how money is looked after and recorded for people who are not able or do not wish to look after it themselves. Discussions should take place between Disabilities Care Management Ltd., the funding authority, the person and their representatives such as family or advocate, to determine how damages are paid for, as this is not currently covered by the contract of terms and conditions of residence. The practice of the person funding their own takeaway meals should be reviewed, as all meals are included in the fee’s being paid to the home. Records need to be kept of staff training and an ongoing training programme needs to be developed. Individual staff members should have one-to-one discussions with a member of the management team every two months. In some cases staff files contained only one effective reference. It is important that staff are properly checked to ensure their suitability and safety for the work. Good practice guidance recommends that at least two detailed references should be obtained for each member of staff. The acting manager should apply for registration with the Commission for Social Care Inspection. The home’s policies and procedures need to be updated. Fire precautions need to be observed and the fire alarms systems tested more often. Systems need to be in place to ensure that plant and equipment such as boilers, specialist bath and call system are serviced regularly and maintained properly. The home must develop a process for quality assurance. The person currently living there is well consulted, but there are no systems in place to ensure that everyone, and those involved in their care, will be consulted about the service as more people move in. 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. DS0000068980.V339709.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 DS0000068980.V339709.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, 2 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A carefully planned transition helps people using the service settle in. the home does not have clear information available for people considering living in the home. EVIDENCE: Information obtained when the home was first registered said that the statement of purpose and service user’s guide would be produced in formats appropriate to the needs of the people who would live in the home, including audio. This had not been done. The written version was not pitched appropriately to be understood by the people the home hoped to attract. There were no photographs or diagrams. There was insufficient information for them to make an informed decision about the appropriateness of the home for their needs and interests. There was no mention of the home providing respite care, yet the inspector was informed that the home was anticipating admitting two people for a short stay. As this will have a significant impact on the people living there it must be included in the statement of purpose. It could affect their decision on whether to move to the home. DS0000068980.V339709.R01.S.doc Version 5.2 Page 10 The statement of purpose is not clear about who the intended client group are. Some staff expressed concern that the home has too broad, so that the staff team may not have the specialist skills to meet the range of complex needs they may be expected to. It is recommended that the statement of purpose gives more specific information about the range of needs the home intends to meet. The person living at the home said that they had been given information about the home before they moved there. They had come and visited the home with staff from where they used to live, and staff from 104 Highlands Road visited them where they used to live. A member of staff said how helpful it had been that for the first fortnight staff from their previous home had come and supported them at 104 Highlands Road. This had helped the person to adapt and also provided valuable support and training for the new staff team. The file of the person contained a lot of detailed information provided by their previous home including details of strategies used to work with the person. Staff said that they had not been aware of all this information when the person first moved in and that they hadn’t been well prepared for supporting some aspects of the person’s care. The person living at the home was delighted with their choice of home that they had. They said that they had been introduced to someone who was considering moving to the home when they visited to look around. DS0000068980.V339709.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 adequate. This judgement has been made using available evidence including a visit to this service. The well-being of the person using the service and the staff were potentially at risk by not having clear guidelines as to how staff should respond in instances of aggression. More regular reviewing and updating of the person’s plans would lead to strategies being in place to support them in the most effective way at the time. The views of the person living at 104 Highlands Road were being taken into account and they were able to make decisions about their life in the home. EVIDENCE: There were files available containing information about the person living at the home and how to support them. Much of this and most of the support plans had come with them from their previous home. Records showed that most of these had not been reviewed despite the person moving and settling in to a new placement. Systems should be set up to ensure planned and regular DS0000068980.V339709.R01.S.doc Version 5.2 Page 12 reviews of care and needs of the people living in the home are carried out and recorded. These processes should then be followed as more people move in. The deputy manager talked about a person centred approach, however this was not evident in the documentation in the person’s file. The policy file also detailed an “individual planning and review procedure/policy.” Documentation showed, and the deputy manager agreed, that this was not happening. The home should be following its own stated procedures. It was explained that the person using the service had had a key worker but they had left. There was no documentation about the role of the key worker or what staff were expected to do. Staff described the key worker as having a good relationship with the person, yet the updating of files and records that would usually be associated with the key workers role had not been carried out. Staff asked were not aware of any training being offered about key working. If the home is to use a key worker system this should be undertaken so that staff can fulfil the role as more people move in. Daily records and records of incidents were good. There was also recording in place to track the activities and opportunities that the person participated in. The person living at the home said they very happy living at the home and were especially pleased with the freedoms they had there. Within a structured framework, described by staff and demonstrated in the records, the person was able to choose the activities they took part in. Discussions about this were observed between staff and the person they were supporting during the visit to the home. As well as risks identified and management strategies developed at the person’s previous service, the staff at the home had identified risks specific to the activities the person was now doing. These were well documented with detailed management strategies. Despite the potential for staff to need to employ physical intervention techniques there was no detailed documentation about exactly what staff were to do in what circumstances. The risks associated with this were not clearly identified and analysed. The home’s policies file contained a general policy statement and only generalised guidelines about the prevention and management of aggression. Staff reflected that the techniques they had been taught since working at the home were not appropriate for the needs of the person currently living there. DS0000068980.V339709.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Consultation with the person living in the home ensures that they are involved in activities that interest them and the routines of daily living. Appropriate levels of support mean they can benefit form contact with their family and the use of local facilities and amenities EVIDENCE: During the visit to the home the person living there went with staff to use a local gym. They showed the inspector the books they had borrowed from the library recently, and talked about a swimming lesson they had enjoyed the day before. A member of staff described how they are encouraged to take photographs of the activities they take part in to keep in a file. They were particularly pleased to have access to the house vehicle and liked being able to DS0000068980.V339709.R01.S.doc Version 5.2 Page 14 go out everyday. They also showed the inspector an area of the garden they had prepared and were now growing plants in. Staff explained, and records confirmed, that the day was divided into sections and the person was supported to decide upon and carry out an activity in each section. One of these a day was outside the house and the others were at home and included playing board type games that the person enjoyed. They were observed in discussion with staff about their activities for the day. The person who uses the service and the staff described how they use local shops to buy provisions for the house. The person told the inspector about visiting, and being visited by, members of their family. They indicated that this was something that was important to them. The records reflected this and there were details of the support needed for this. Staff also were clear about this. Staff were observed to engage with the person living at the home in a respectful manner, the routines of the home were centred around them and their wishes, and a member of staff was observed to knock on the door before entering the flat and checking that it was okay to go in. Doors throughout the home were kept locked. There was no rationale, policy guidelines or risk assessments indicating that this was necessary. Consideration should also be given to people who may come to live there in the future who may find it difficult to keep and operate the key system for accessing their own rooms. Those living in the main body of the house would also be denied free access to their kitchen and the quiet lounge. Although people living in the flats would have free access to all rooms within their flat. The system of locking doors should be reviewed and a policy developed in line with the needs of the people living at the home. The person living at the home and staff described how they have support to plan their menu and shop for food on a weekly basis. They, and staff, explained that they are able to prepare their meals more or less independently. The menus kept on file showed that they had a balanced and nutritious diet. There was also documentation in evidence to show that consideration was being given to maintaining a healthy diet. DS0000068980.V339709.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. By supporting those living in the home to access the healthcare professionals retained by the home and NHS services, the home promotes the health and wellbeing of those living there. Improvements are needed to the medication procedure so as not to put people at risk of medication errors as the number of staff and people living in the home increases. EVIDENCE: The person using the service, staff and records confirmed that the person is able to manage their personal care without support. All concerned expressed their satisfaction with this arrangement. The home retains the services of a consultant psychiatrist whom, staff said, visits the home weekly, a psychologist and a speech therapist. For other health care services, it was explained that the people living in the home would be supported to use the NHS. The person living at the home described a recent visit to the dentist and explained that when they needed a doctor they DS0000068980.V339709.R01.S.doc Version 5.2 Page 16 went to the local surgery. The deputy manager described how she was setting up a health care file to keep track of appointments and follow up. This was in its early stages and did not yet included feedback from GP visits and the person’s regular meetings with a physiatrist. The medication policy was seen. There was no in-house procedure detailing how the general principles of the policy were put into practice. It is important that there are clear instructions for staff to refer to back to so that the risk of errors being made is minimised. The person using the service and a member of staff showed and explained the medication process to the inspector. The person said they were happy with the procedure. The deputy manager agreed to obtain a copy of the Pharmaceutical Society of Great Britain’s guidance on managing medication in care homes and to follow this guidance in developing the home’s procedure. DS0000068980.V339709.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. The lack of a complaints procedure in a format suitable for those living at the home means that they will not be clear about how to express their views if they are unhappy with the service. Without thorough staff training in safeguarding adults from abuse, the people living in the home could be put at risk. EVIDENCE: A thorough complaints procedure with timescales was submitted with the original application. This provided good guidance for staff but was not suitable for service users. Reference is made to a “leaflet detailing the Home’s procedure.” This had not been developed at the time of the site visit. This should happen so that the procedure can be useful to the people moving into the home. There was a system in place for the person living in the home to have support to keep their money safely. Records were being kept. Possible improvements were discussed and the deputy manager agreed to implement these. The procedure must be documented so that all staff and the people who come to live at the home and their representatives are clear about what support is given and how records are kept. DS0000068980.V339709.R01.S.doc Version 5.2 Page 18 The contract outlining the terms and conditions of residence does not include any clauses about the people living in the home being responsible for paying for damages. However people living in the home were being expected to pay for damages. This could have a huge impact on their finances. Any such agreement must be included in the contract and be arrived at through consultation with all interested parties such as representatives from the funding authority and the home, the person and their representative or advocate. The person was funding from their personal monies a take away meal once a week. The home’s fees include all meals, therefore this practice must be reviewed. The policies file contained a leaflet produced by the authorities in Hampshire explaining the agencies in the county’s approach to protecting vulnerable adults. There was no copy of the county’s procedural guidelines or a detailed in-house policy that dovetailed with this. In-house policies and procedures must be produced and it is recommended that a copy of the Hampshire Procedure for the Protection of Vulnerable Adults be obtained. Staff spoken with were aware of issues relating to safeguarding vulnerable people from abuse. One said that they had not had training on this at 104 Highlands Road but that they had undertaken their own reading about the subject. Another said that they had had training about this in their previous employment and it had been covered briefly during their induction at 104 Highlands Road. They did however think the organisation was arranging more in-depth training, which they hoped to be able to do. DS0000068980.V339709.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. The people who use the service benefit from a new building which is clean and newly decorated and furnished. EVIDENCE: The home has been purpose build and consists of six bedrooms downstairs, all of which have en suite wet rooms, a communal lounge/dining room, an additional quiet lounge and another small room that may be developed as a sensory room. In addition to the showers in each en suite there is one assisted bath for those who prefer or need this. There is an office, staff sleeping in room, toilet, sluice room, laundry and kitchen. Patio doors from the lounge/dining room open onto the garden. At the time of the visit the grass needed cutting. It was explained that the home was planning to purchase a lawn mower. The person living at the home had had support from DS0000068980.V339709.R01.S.doc Version 5.2 Page 20 a member of staff to develop some areas to grow flowers and vegetables. They took pride in showing the inspector what they had done. Upstairs there are two one-bedroom and two two-bedroom flats. Each has a small kitchen, lounge, bathroom with bath and overhead shower, and one or two bedrooms. One staircase leads into the main body of the house and another direct to an external door. Each flat has an intercom system connected to doorbells by the external door. This way the flats can be visited without having to go through the main building. The person living in the flat showed the inspector around the communal areas of the home and their flat. They were pleased with their flat and the facilities they had. They explained that they currently had to use a different bathroom whilst a leak in their shower was remedied. The home was clean. The care staff are currently responsible for cleaning the home. They said that they had sufficient time to do this. The person living in the home was encouraged to help with the communal areas they used, and was responsible for their own flat. The home was clean and hygienic at the time of the visit. It was explained that eventually, as the number of people living in the home increased, it was planned to employ cleaning and catering staff. DS0000068980.V339709.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, 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. The person living at the home benefits from a staff team committed to meeting their needs. Improvements to staff training and supervision would increase their confidence and competence in doing this, thus supporting the people who use the services better. The practice of having just one reference, or references with too little detail, may put people at risk, as staff’s suitability for the work cannot be verified. EVIDENCE: There are currently seven staff including the manager. Support workers spoke of finding their colleagues very supportive and helpful. The daytime shifts are 7.5 hours and the night shift from 21.15 to 07.15. Shifts are timetabled to overlap so that there is time for information to be handed over from one shift to the next. Because of staff vacancies, the current team are currently covering the vacant posts leading to longer shifts and fewer days off. This benefits the person living in the home who, it was explained, would find the DS0000068980.V339709.R01.S.doc Version 5.2 Page 22 use of different agency staff difficult, but puts the staff under additional pressure. Most staff already had NVQ qualifications at levels 2 or 3 before joining the team at 104 Highlands Road. A member of staff who had been there since the home opened in December 2006 said that before the first person moved into the home the staff team had a two week induction period which included; Health and Safety, first aid, risk assessment, assertiveness, care planning, active listening, food hygiene, the system the home uses for managing aggressive behaviour, use of the call system and manual handling. A member of staff who started later on said that their induction was not as comprehensive. The deputy manager said she had a list that she used for the first day of new bank staff, which included systems such as health and safety, fire exits, medication and confidentiality. One of the staff spoken with confirmed that they had an induction pack to work through, and the deputy manager explained that there was a test that staff had to pass at the end of the three-month induction period. The deputy manager explained that there was no training programme as yet as this was still being prepared. There were no records of the training staff had had. It was explained that these were also being prepared and a verbal undertaking was given that this would be done. The documentation submitted with the application for registration said that there would be a staff training element within the fortnightly staff meetings. Staff, the deputy manager and staff meeting minutes showed that there had been a staff meeting in April and one in June. Staff training did not feature. The deputy manager reported that the aim was to have a staff meeting at least once a month, but that this was not happening. Most of the staff had received a one-to-one supervision session with the manager since she started in April 2007. It was reported that two had been unable to take place and these would be rescheduled. Staff should have such a one-to-one meeting with their line manager at least every two months Two staff described their recruitment process which included completing an application form, receiving an interview, providing references and undertaking Criminal Records Bureau cheeks. They also said that they had a three-month probationary period. Three sets of staff records were sampled. Two had only one reference, and one of the references for the third did not give sufficient information on which to make an informed decision as to the person’s appropriateness for the job. In order to make sure the people who use the service are supported by competent staff and that their well-being is safeguarded the recruitment process must be improved. It is recommended that the home obtain a copy of the Commission for Social Care Inspection’s publication, In Focus : Safe and Sound? – Checking the suitability of new care staff in regulated social care services. DS0000068980.V339709.R01.S.doc Version 5.2 Page 23 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, 39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and processes are not in place to prompt regular maintenance, servicing of equipment, review of care plans, monitoring of staff performance and overall performance of the home etc. If these are neglected the health and safety and well-being of the people living and working in the home could be put at risk. EVIDENCE: One member of staff said that the management of the home has improved and “there is a vast improvement from three months ago.” Another person said they felt well supported, but others did not feel so well supported, with several citing the lack of an on call system in which they had confidence as being a DS0000068980.V339709.R01.S.doc Version 5.2 Page 24 major concern. Both staff, during the visit, and the acting manager, in the AQAA, referred to low staff morale. The acting manager acknowledged this and planned to address the matter. The home does not currently have a registered manager. The person currently acting as manager started in April 2007 and is the home’s third manager. The deputy manager started shortly before her. The staff team have found this unsettling. They are very committed to the person living at the home but are frustrated by the lack of continuity and say that although the current acting manager came in with some positive ideas they are taking time to implement. The organisation’s directors are very involved in influencing the running of the home. There are therefore a number of issues that need to be resolved between the directors, management team and staff. These include: Providing sufficient staffing levels to support the person using the service, whilst allowing systems, processes and procedures to be developed so that home will function effectively as more people move in. Planning for service development in an orderly way. Supporting staff training. Staff are currently expected to undertake any nonmandatory training in their own time. Resolving difficulties with the rota and the high number of additional shifts staff are expected to do to cover staff vacancies. The home had been asked to return its Annual Quality Assurance Assessment (AQAA) to the Commission for Social Care Inspection by 31 May 2007. This had not happened and despite a telephone call and letters of reminder, this was not returned until after the visit to the home. Now that the home is operational the policies and procedures need developing. Those submitted with the home’s application for registration need updating in the light of the needs of the people being admitted to the home. All staff have experience and expertise in the field of social care and should be contributing to the development of the home’s policies and procedures, along with the people living there, if this is appropriate. Several fire doors were being propped open. The advice of Hampshire Fire and Rescue Service must be sought to ensure that appropriate closures are fitted if doors are to be left open. No quality assessment procedure was available and the deputy manager was not aware of a quality assurance process. As there is currently one person living in the home, the home is run to suit their needs and they are informally consulted about many issues. However an annual quality assurance process must be developed including consultation with all parties interested in the running of the home or who support the people living there in aspects of their lives. DS0000068980.V339709.R01.S.doc Version 5.2 Page 25 The home is new and well equipped, but there was no evidence that equipment was being serviced as per the manufacturers recommendations. Systems must be set up to ensure that equipment such as the fire detection and fire fighting equipment, gas appliances and the specialist bath receive regular servicing and maintenance and that this is recorded. The in-house tests to the fire alarm system were not taking place with the regularity expected by the Hampshire Fire and Rescue Service. The home must ensure they comply with this. In-house tests and checks for other fire and health and safety issues were being carried out and recorded as expected. DS0000068980.V339709.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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 X 2 X DS0000068980.V339709.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 4 Requirement The statement of purpose must include sufficient detail so that a person can make an informed decision as to whether they want to consider moving there i.e. all the information on Schedule 1 of the Care Homes Regulations 2001. This must be in a format meaningful to those living at or considering living at the home. The management of aggression must be documented in detail in the person’s service user plan. It must be clear to staff exactly how they should respond in particular circumstances. A medication procedure must be developed outlining the steps to be followed by staff in the recording, handling, safekeeping safe administration and disposal of medicines. A complaints procedure that is accessible to the people living in the home must be produced and support given so that they are aware of, and understand, the DS0000068980.V339709.R01.S.doc Timescale for action 20/09/07 2 YA6 13 (7) 20/09/07 3 YA20 13 (2) 20/09/07 4 YA22 22 (2) 20/09/07 Version 5.2 Page 28 process. 5 YA23 13 (6) The practice of the person paying for damages and for takeaway meals from their personal finances must be reviewed. The home must develop procedures and training to ensure that the people living there are safeguarded from abuse. The home must ensure that staff are thoroughly checked and their suitability for the work confirmed. At least two references with sufficient information to form a judgement must be obtained. The advice of Hampshire Fire and Rescue Service must be followed and fire doors only held open by appropriate devices. The fire detection/alarm system must be tested at the frequency stipulated by the manufacturers/ Hampshire Fire and Rescue Service. 26/07/07 6 YA23 13 (6) 20/09/07 7 YA34 19 (5) 26/07/07 8 YA42 23 (4) 26/07/07 9 YA42 23 (4) 26/07/07 10 YA42 23 (2) (c) Equipment such as boilers, 20/09/07 specialist bath, call-bell/alarm system and gas appliances must be serviced as per manufacturers instructions. DS0000068980.V339709.R01.S.doc Version 5.2 Page 29 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 YA16 Good Practice Recommendations The system of locking doors should be reviewed in line with the needs of the people living in the home and a policy appropriate to their needs and wishes developed. The home’s policies and procedures should be reviewed and developed to ensure they are relevant to the needs of the people living there. 2 YA40 DS0000068980.V339709.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000068980.V339709.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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