Inspection on 13/09/07 for 15 Thompson Drive

This inspection was carried out on 13th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Thompson Drive 14/08/08

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 15 Thompson Drive 15 Thompson Drive Codnor Derbyshire DE5 9RU Lead Inspector Tony Barker Key Unannounced Inspection 13th September 2007 09:35 15 Thompson Drive DS0000069784.V341941.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 15 Thompson Drive DS0000069784.V341941.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. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 15 Thompson Drive Address 15 Thompson Drive Codnor Derbyshire DE5 9RU 01773 570163 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) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider 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 category: Learning Disability - Code LD The maximum number of service users who can be accommodated is 3 This is the first inspection since a change of registered provider in April 2007. 2. Date of last inspection Brief Description of the Service: 15 Thomson Drive is a detached bungalow in a residential area in Codnor, close to local facilities and shops. All bedrooms are single rooms. The Home has a large lounge, dining room, kitchen and bathroom. Service users have access to a garden and seating area. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.5 hours and was a key unannounced inspection. The Manager, one care assistant and one service user were spoken to. The other two service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Records were inspected and there was a tour of the premises. All three service users were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to all the service users and to their relatives. Short notice was given for return of these and no survey forms were returned. This inspection focussed on all the key standards. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Home’s fees were stated on the Service Users’ Guide as being £618.51 per week. What the service does well: What has improved since the last inspection? What they could do better: All avoidable risks to service users must be identified and recorded. A planned programme of activities for service users should be developed, in line with individual care plan goals. A robust and secure system of storing medication must be in place. A written protocol, on the use of ‘as and when required’ medication, must be provided in respect of any service user who is administered medication in this way. Staff must be provided with training in recognising and preventing abuse to vulnerable adults and in responding appropriately when suspected. The damaged staff room door frame must be repaired to allow the door to be secured and staff to feel safe. Staff must not be employed unless required information and documents, relating to their recruitment, are in place. All staff who handle food must be provided with Basic Food Hygiene training. First aid training for staff must also be provided. The Manager must attain an appropriate qualification in ‘Care’ at NVQ level 4 and commence a management qualification at NVQ level 4. Monthly independent audit visits to the Home must take place. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 6 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. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: The Home’s Statement of Purpose was found to be satisfactory. Service users had been provided with a copy of the Service Users Guide. This was generally satisfactory in its content though it did not include service users’ views of the Home. Also, it was not in a format suitable for the individual service users. The Registered Provider had indicated to the Commission, in a letter dated 16 April 2007, that the supply of a suitably formatted Guide would be given priority. All the service users had been admitted to the Home through the Social Services’ care management system. Individual care plans were in place based on an initial assessment of each service user’s needs. The Home had a written policy/procedure on introductory visits for a prospective service user, prior to admission, but this did not mention the requirement for a full needs assessment at that point. However, the Home’s Statement of Purpose stated that, “We will carry out a needs assessment on each service user prior to admission and demonstrate that we can meet their identified needs”. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Potential risks to service users’ safety had not been identified so leaving them vulnerable to hazards. A person centred approach was not being followed. EVIDENCE: Service users’ files were examined. The care plans had been reviewed recently by the Manager – these had been signed but not dated. However, she had signed and dated handwritten notes added to the care plans when changes had taken place in service users’ lives. Care plans had a satisfactory mix of personal needs and goals and were holistic. However, they did not contain any record of service users’ likes and dislikes and there was no evidence of a ‘person-centred’ approach being followed. This was discussed with the Manager. The Home’s documentation contained no examples of pictures or symbols appropriate to the service users’ degree of understanding. Care plan review meetings were being held periodically for each service user, with the service user, care staff, relatives and external professionals invited. Information ‘Front sheets’ were in place although there was no preferred form of address for one service user. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 10 The care assistant spoken to provided examples showing how two of the service users make decisions and choices, with one exhibiting relatively high degrees of independence in certain situations, including keeping a key to their bedroom. The third service user was said to make no choices at all and, from observations made at the inspection, this surprised the Inspector. There were no recorded risk assessments – either in relation to individual service users or to the environment - to reflect potential hazards to which the service users may be exposed. The care plan of one service user, who had epilepsy, made reference to safe practices while bathing but there was no recorded risk assessment to reflect those occasions when there was no staff member present in the bathroom when any of the service users were taking a bath. The care assistant spoken to gave some examples of service users taking ‘responsible risks’ in order to personally develop although he appeared not to fully grasp the concept. It was noted that the Home’s Statement of Purpose did state that, “We will help service users to take reasonable and fully considered risks”. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of a planned programme of activities for service users means that opportunities for their individual personal development were not being fully realised. EVIDENCE: There was no planned programme of activities for service users apart from day services and an evening class for one service user. A service user who spends two week-days at the Home enjoys car trips, it was stated, but it appeared that activities during these two days were ‘ad hoc’ and not linked to a care plan. There was a lack of evidence, at this inspection, that all service users were being given every opportunity to personally develop and maximise their potential. All the service users were attending Local Authority Day Services – two full time and one three days a week. The service user spoken to was keen to show the Inspector a folder with poems and other literacy projects undertaken on a 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 12 computer in the service user’s bedroom and at a weekly Adult Education evening class. The service user’s achievement certificates were seen. The care assistant spoken to also gave examples of service users being involved in valued and fulfilling activities. These included one service user’s and one staff member’s mutual interest in motor cycles and two service users’ interest in dogs, for example. The Manager spoke of a recent meeting with all service users to discuss a forthcoming holiday in Scotland. It was noted that account had been taken of one service user’s particular interest in animals, and in walking, in the planning of this holiday. The care assistant spoken to gave examples of service users’ participation in the local community, supported by staff. He said they make regular use of a local pub and food shops and one service user is well known by local people who chat with the person while out walking with staff. This member of staff said that service users do not attend the local barbers shop as he cuts their hair. It was noted that the Home’s Statement of Purpose states that the services of a hairdresser “will be accessed in the community”. One service user had regular contact with relatives, including face to face and on the telephone. This service user had had a close friend in the past and this friendship had continued outside day services. Another service user had infrequent contact with family members and the third had no family contact at all. The Manager spoke of prioritizing an independent advocate for this person. The care assistant spoken to said that routines in the Home promote service users’ independence. These include personal hygiene routines, housework and work in the garden. He confirmed that service users’ privacy needs are met, for example, by staff knocking on doors before entering a bedroom or bathroom. There was a privacy lock on the bathroom door and each bedroom door had a lock. One service user was more independent than the other two and held their own bedroom door key and routinely locked the bathroom door while using this facility. Food stocks in the kitchen were at a good level and included fresh fruit and vegetables. The Home’s menu showed a varied range of nutritious and appetising meals provided. Care plans did not contain a record of service users’ food likes and dislikes. The care assistant spoken to said that all the service users were involved in food shopping to some extent. One service user helps to lay the breakfast table and “dries pots”. Another “washes pots”. The third service user is not involved in these routines other than bringing dirty plates through to the kitchen. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate recording practices, and safekeeping of medicines, may compromise the health and safety of service users. EVIDENCE: The Home had flexible routines based on service users’ assessed needs and activities being undertaken. The care assistant said that one service user, who has limited verbal communication skills, knows some Makaton sign language and the Home’s Makaton folder was seen. However, this staff member had not been provided with any training in this sign language. There was no necessity for any equipment in the Home to maximise service users’ independence. All the service users were receiving regular chiropody, dental, optician and GP appointments. These were recorded in Personal Log Sheets only. The Inspector spoke to the Manager about the benefits of taking a ‘person centred approach’ to the recording and action taken with respect to service users’ health needs – through Health Action Plans. The Manager said all service users had good health, apart from one service user having regular epileptic seizures. The circumstances leading up to these seizures, the nature of them and the outcome were well recorded, and completion of a calendar provided 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 14 insight into patterns of the seizures. The Manager was unsure whether any staff member had been provided with training in understanding and managing this condition and the care assistant spoken to confirmed he had not received this training. He had worked at the Home for more than four years and was not aware of any involvement the Home had with the local learning disability team, epilepsy nurse, speech and language therapist or psychologist. The Manager confirmed that one service user can exhibit aggression. This person was being seen by a consultant psychiatrist and their medication had been reviewed with a successful outcome. Medication was being stored in a chipboard cabinet standing on top of a metal filing cabinet. The cabinet was locked but was not robust and was not secured to the wall. A serious concern letter was sent to the Registered Provider to address this matter with urgency. Following re-registration of this Home in April 2007 medication blister packs and printed Medication Administration Record (MAR) sheets had been introduced in order to improve safety. The contents of one service user’s blister pack was cross referenced against the MAR sheet and found to be correct. The seven rows of tablets within the blister packs used were not marked with the days of the week. This could lead to mistakes. Recording practices were satisfactory except that there were some handwritten MAR sheets without countersignatures and some without signatures at all. There was a record of specimen staff signatures/initials. Some medication was being administered ‘prn’ (as and when required) – for example, Chlorpromazine for agitation. There was no general written policy on the administration of ‘prn’ medication and no written protocol for the administration of this medication to this service user. Staff had recently received training in the safe use of medicines through an in-house training video. The Manager said she was pursuing additional training from a pharmacist. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff had not been provided with training to ensure the safety of service users from abuse. EVIDENCE: The content of the Home’s complaints procedure was satisfactory and was kept in the staff sleep-in room. The Service Users’ Guide refers to a copy of the complaints procedure being, “on display in the entrance area”, which was not correct. The complaints procedure did not contain any symbols or pictures appropriate to the service users’ degree of understanding. The Manager stated that there had been no formal complaints in the last 12 months and the Home’s Complaints Record confirmed this. The Home had a ‘Adult Protection Procedures and Prevention of Abuse’ written policy as well as copies of the statutory Safeguarding Adults Procedure. The Home’s policy stated that service users had a right to withhold consent to a referral being made to the Social Services Department following suspicion of abuse. It was pointed out to the Manager that this was not acceptable practice as Social Services are the lead agency regarding ‘Safeguarding Adults’ incidents. The written policy also stated that if there was an allegation of a member of staff abusing a service user, that person would not be suspended until an internal investigation had been undertaken. Again, it was pointed out to the Manager that this was not safe practice. However, throughout this discussion, the Manager did show a good personal understanding of safe practice regarding Safeguarding Adults procedures. There was a separate policy on Whistle Blowing and this made appropriate reference to staff, who 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 16 whistle blew, not being victimised. The care assistant who was spoken to was not aware of this policy but was able to describe good practice on this topic. He had not attended ‘Safeguarding adults’ training. The Manager had received this training but was unsure whether any other staff member had. She spoke of plans to approach Social Services for details of their staff training courses. She also spoke of enquiring about training staff in non-physical intervention strategies in response to challenging behaviour. Records of use of service users’ personal monies had staff signatures beside each transaction. These were examined and cross-checked against monies held in respect of one service user. The cash amount was found to be correct. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The poor condition of some parts of the Home means that service users live in a less than satisfactory environment. EVIDENCE: A tour of the Home indicated reasonable material standards inside and the Home was comfortable and homely. The Manager spoke of plans to redecorate the premises in the near future and said that one service user had chosen colour schemes. Bedrooms were well personalised and there was a personal computer in one bedroom, used most days by the service user. The frame to the door of the staff sleep-in room was broken, providing no security to staff using it. The bath seal and grouting to some of the bathroom tiles were heavily discoloured and the Manager said there were plans to provide a new suite and re-tile the room. The area at the side of the property was slabbed with a fence that was in poor repair. The area at the back of the property had cracked concrete and piles of rubble and was unsightly. The Manager spoke of plans to level this area after the winter. Garden borders to the front and side lawns were not well maintained. An annual maintenance programme for 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 18 renewal of the fabric and decoration of the premises had been produced, the Manager said, but not yet implemented. The laundry facilities were satisfactory and the Home was found to be clean and hygienic, with no unpleasant odours. The Manager stated that Infection Control training for staff was planned in the following months. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home’s recruitment practices and staff training fell short of fully safeguarding the welfare of service users. EVIDENCE: The Manager stated that one (20 ) of the staff group of five care assistants had achieved a National Vocational Qualification (NVQ) at level 2 in Care. Two other members of staff were due to undertake NVQ training at level 2 and 3 respectively. This did not meet the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The staffing rota was examined and found to be satisfactory, except that the Manager’s hours had not been recorded in recent weeks, since she became supernumerary. She had been working 40 care hours each week since the Home’s re-registration in April 2007 as three staff had left and two staff had been on long term sick leave, one just recently returning. She explained that with new staff appointed the Home was now fully staffed. She said that there was always one member of staff on duty while service users were in the Home. She spoke of her intention to now spend two thirds of her time at this Home, with the other third spent managing another local care home re-registered with 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 20 the same Registered Provider in April 2007. The Inspector agreed that this was a satisfactory arrangement. The file of a member of staff, recently appointed, was examined. The information and documents relating to her recruitment did not fully meet the Regulation requirements. There was... • no details of any criminal offence in respect of which the person had been cautioned by a police constable, • only one written reference, which did not relate to the person’s last period of employment involving work with vulnerable adults, • no written explanation of three gaps in her previous employment record. Additionally, the one written reference was of a ‘To whom it may concern’ type, with no verification of their authenticity. The recently appointed member of staff had received in-house induction training to a reasonable standard. However, it was not to the Skills for Care Common Induction Standards. The Manager stated that staff had watched inhouse training videos on Health & Safety, Fire Prevention and Safe Medication Practice but was unclear as to whether external training, prior to her arrival at the Home in April 2007, had been provided on Fire Prevention, Basic Food Hygiene or First Aid. The care assistant spoken to stated that he had received no training within the previous 12 months except for the in-house training videos already mentioned. The Manager said that Moving & Handling training for staff was planned for October 2007. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Certain management practices were not satisfactory and service users’ health and safety could be compromised. EVIDENCE: The Manager had worked in the care profession for seven years, mainly as a care assistant working with older people. She had eight months experience as Deputy Manager at a care home for older people owned by the Company to which this Home is now registered. She has acknowledged to the Commission that she has limited experience in caring for younger adults with learning disabilities. The Manager said there were no plans in place for her to be provided with training to increase her knowledge and skills in caring for people with a learning disability. There was a discussion with the Inspector about possible ways forward on this issue. The Manager had yet to attain an NVQ in 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 22 Care at level 4 and, on completion of that course, planned to start her management course at NVQ level 4. There were minutes of two service users’ meetings, in July and September, led by the Manager. These were a constructive record and included a note of action to be taken. The Manager stated that there were plans to hold a meeting with relatives and to send quality questionnaires to service users, relatives, staff and external professionals. There was no annual plan in place. There was no evidence of any monthly independent audit visits to the Home, on behalf of the Registered Provider, having been undertaken. The Manager said that a staff meeting had been held on 11 September 2007 – the first one since re-registration in April 2007, due to low staffing. She said staff meetings would be held every three months in future. All the written policies and procedures in place were developed by the previous providers. They were mentioned by name in a number of these policies. Mention has already been made in this report of policies/procedures that need improvement. The Inspector was informed that new ones were being drawn up. Fire precautions taken by the Home included weekly alarm tests, fire training and monthly fire drills. Two fire extinguishers and one fire blanket were in place though these had not been tested recently. There were annual portable appliance tests. A blank statutory staff accident record was in place but it was not clear where accidents/incidents involving service users were to be recorded. Good food hygiene practices were noted including safe food storage. There were no environmental risk assessments in place, as noted in Standard 9. The Manager stated that gas appliances were checked in August 2007 and the property’s electrical wiring had been tested in March 2007. Cleaning materials were being secured stored in a locked kitchen cupboard. Product data sheets, required by the Control Of Substances Hazardous to Health (COSHH) Regulations, were not in place. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 2 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 3 X 3 X 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 24 N/A 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 YA9 YA42 Regulation 13(4) Requirement All avoidable risks to which service users may be exposed must be identified and recorded in order to minimise these risks and maintain service users’ health and safety. A planned programme of activities for service users should be developed, in line with individual care plan goals, in order that service users personally develop. A robust and secure system of storing medication must be in place to ensure the health and safety of service users. This should take the form of a steel cabinet firmly secured to the wall. A written protocol, on the use of ‘prn’ - as and when required medication, must be provided in respect of any service user who is administered medication in this way. This protocol must be explicit in order to minimise different interpretations and ensure the safety of the service user. Staff must be provided with DS0000069784.V341941.R01.S.doc Timescale for action 01/11/07 2. YA11 16(2)(n) 01/11/07 3. YA20 13(2) 28/09/07 4. YA20 13(2) 01/11/07 5. YA23 13(6) 01/01/08 Page 25 15 Thompson Drive Version 5.2 6. YA24 23(2)(b) (3)(b) 19(1)(b) Schedule 2 7. YA34 8. YA35 13(3) 9. YA35 13(4) 10. YA37 9(1) 9(2)(b)(i) 11. YA39 26 training in recognising and preventing abuse to vulnerable adults and in responding appropriately when suspected. The damaged staff room door frame must be repaired to allow the door to be secured and staff to feel safe. Staff must not be employed unless required information and documents, relating to their recruitment, are in place. This is necessary to ensure the safety of service users. All staff who handle food must be provided with Basic Food Hygiene training to ensure the health and safety of service users is not compromised. There must be one first aid trained person in the Home at all times, to make sure that service users receive appropriate treatment in an accident. The Manager must have the necessary competencies to meet the needs of the service users at the Home, in order that the objectives set out within the Statement of Purpose can be achieved. This must be through the attainment of an appropriate qualification in ‘Care’ at NVQ level 4 and commencement of a management qualification at NVQ level 4. Monthly independent audit visits to the Home must take place, to ensure the Registered Provider is kept aware of the Home’s conduct. 01/11/07 01/11/07 01/01/08 01/01/08 01/04/08 01/11/07 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 26 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 YA1 YA2 Good Practice Recommendations The Home’s Service Users Guide should include service users’ views of the Home and be in a format suitable for the individual service users. The Home should review its policy/procedure on the admission of a new service user, making explicit the need for a full assessment of need to be available before admission. All records kept in the Home should be dated. A ‘person-centred’ approach should be followed with service users, and health and care planning documentation should reflect this. Pictures or symbols, appropriate to individual service users’ degree of understanding, should be included as well as recorded personal likes and dislikes. A review should be made of individual service users’ ability to make choices and decisions in their life – no matter how simple. Service users should be supported to take responsible risks as part of an independent lifestyle. Staff should be aware of opportunities for ‘positive risk taking’. Service users should be using community facilities, such as the barbers, unless care plans clearly show this is inappropriate or not possible. The use of an independent advocate should be seriously considered for the service user with no family contact. Staff should be provided with Makaton sign language training. Health Action Plans should be developed. Staff should be provided with training in understanding and managing epilepsy. The Manager should make contact with the local learning disability team to give her an overview of the services they offer and assess whether they could be providing any services to the Home. The day of the week should be recorded beside each of the seven rows of tablets within blister packs. Handwritten entries on medicine records should be accompanied by two staff signatures and the date, to ensure a clear audit trail. There should be a written procedure covering the safe use DS0000069784.V341941.R01.S.doc Version 5.2 Page 27 3. 4. YA6 YA6 YA17 YA19 5. 6. 7. 8. 9. 10. 11. 12. YA7 YA9 YA13 YA15 YA18 YA19 YA19 YA19 13. 14. 15. YA20 YA20 YA20 15 Thompson Drive 16. 17. YA22 YA22 18. 19. 20. 21. 22. 23. 24. YA23 YA23 YA23 YA24 YA32 YA33 YA34 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. YA35 YA35 YA35 YA37 YA39 YA39 YA40 YA42 YA42 YA42 of ‘as and when required’ medicines. The complaints procedure should be more prominently displayed. The Home should be working towards providing all documents, to which service users should have access, in an ‘easy read’ format. This should include the complaints procedure. The Home’s ‘Adult Protection Procedures and Prevention of Abuse’ should be amended to fully reflect safe practices. Staff should be reminded of the policy on Whistle Blowing. Staff should be provided with training in non-physical intervention strategies in response to challenging behaviour. Environmental defects found at this inspection should be included in the Home’s annual maintenance programme and be rectified. 50 of care staff should achieve a National Vocational Qualification (NVQ) at level 2 in Care. The staffing rota should include the Manager’s hours. Written references of a ‘To whom it may concern’ type should not be accepted without verification as to their authenticity. Requests for written references should be made by the Home to the people named by applicants. Staff should receive induction training to the Skills for Care Common Induction Standards. Plans to provide staff with training in Moving & Handling should be carried out. All staff should receive suitable training in Fire Prevention. The frequency should be annually and twice yearly for night staff. The Manager should be undertaking training to increase her knowledge and skills in caring for people with a learning disability. Quality questionnaires should be sent periodically to relatives, staff and external professionals, as well as service users. An annual plan should be developed, covering all aspects of the running of the Home. New written policies and procedures should be developed. The Home’s two fire extinguishers and one fire blanket should be tested periodically. All accidents, injuries and incidents of illness involving service users should be recorded. Product data sheets, required by the Control Of Substances Hazardous to Health (COSHH) Regulations, should be in place. 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 15 Thompson Drive DS0000069784.V341941.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!