Inspection on 12/12/05 for 16 Godwyne Road

This inspection was carried out on 12th December 2005.

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

Other inspections for this house

16 Godwyne Road 22/02/07

16 Godwyne Road 20/06/05

16 Godwyne Road 30/11/04

16 Godwyne Road 24/05/04

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Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 16 Godwyne Road 16 Godwyne Road Dover Kent CT16 1SW Lead Inspector Mrs Michele Etherton Announced Inspection 12th December 2005 09:40 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 16 Godwyne Road Address 16 Godwyne Road Dover Kent CT16 1SW 01304 201714 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) Mr Peter John May Mr Peter John May Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Godwyne Road, is a large semi-detached period residence, occupying a corner plot in a residential area of Dover. The home is located on a hillside overlooking the town and has views of Dover castle. The home is within walking distance of local bus routes, leisure facilities, shops, pubs and restaurants. Some street parking is available. Although registered for 10, only nine service users are in residence. The accommodation ranges over four floors, access to all levels is via two staircases to the front and rear of the building, all service users must, therefore be ambulant and able to negotiate stairs. Seven service user bedrooms are used for single occupancy; they all have wash basins installed. A shared bedroom is located on the top floor. There are a satisfactory number of shared communal washing facilities for the existing number of service users, with two bathrooms and toilets, one shower facility, and one single toilet, staff have their own toilet and wash facilities. The home has one main lounge on the first floor and an activities/dining room on the basement/ground level. The kitchen and a separate laundry area are also provided at basement level. The home benefits from a good-sized rear garden mainly laid to lawn, which can be accessed from the laundry area. There is some garden seating and furniture for residents use. Two double gates are located to the side and end of the garden, these are kept shut. The current mixed sex user group are aged between 40 and 70 years of age. The home operates a key worker system. The present owner also undertakes the day-to-day operational management of the home. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the annual announced inspection of the premises, and aimed to assess the homes progress towards achieving requirements issued at the last unannounced inspection. This visit also enabled the inspector to check on the implementation of a number of good practice recommendations made previously, and the assessment of remaining key inspection standards. The visit lasted 6 hours commencing at 9.40 am and finishing at 3.40 pm. During the visit the inspector undertook a tour of the premises, that also included viewing all service user bedrooms (with permission) and all communal and staff areas. Eight service users were met and spoken with, three in more depth than others. In addition to the owner/manager the inspector spoke with four care staff and a member of the domestic staff team over the period of the inspection. A reduced range of documentation was reviewed during this visit, including care plans, risk assessments, complaints and accident records, the fire book, staff rosters, staff recruitment and training information, service user thoughts and ideas book, Medication administration sheets, quality assurance information, service user terms and conditions documentation. A number of inspection comment cards were received from relatives and friends, and their feedback has contributed to the compilation of this report. What the service does well: What has improved since the last inspection? The home has achieved one outstanding requirement fully and another partially, by completing required electrical works, removing building debris etc from the rear garden, making safe uneven paving, improving storage arrangements for personal hygiene items and decorating materials previously stored in the users shower area. The home has actively sought to improve the 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 6 regularity of staff fire drill and instruction. The home has improved the quality and content of some documentation, where recommendations have been issued previously, this includes:- amendments to service user terms and conditions, Improving the frequency and recording of users ‘thoughts and ideas’ sessions. Improving detail and content of Individual user risk assessments, that falls monitoring records are accurately reflected in the accident record book. Improved content of staff files, ensuring compliance with schedule 2 of the care Homes regulations 2001. The home has also developed and implemented a range of other documentation for staff use which includes the development of quality assurance policy and procedure information, the annual service development plan, and the formalisation of the laundry procedure. In addition the home has developed picture and object reference to aid service users with communication problems in independently selecting from breakfast and teatime menus. 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. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5, The home has made every effort to develop an accessible and informative statement of terms and conditions for service users placed by local authorities. EVIDENCE: The home has addressed an outstanding recommendation to amend the service user terms and conditions/contract for the home, this has been developed with written text and supporting colour picture reference prompts. The language used in the document is simple and easy to understand for those with some reading ability. This has been used for the most recent person admitted, and a copy of their’ terms and conditions document was assessed at this visit; this amended version of the terms and Conditions will now be used for future admissions. The home may wish to consider in the future other formats that could be used to explain the terms & conditions of living in the home. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 The rights and needs of service users could be placed at risk by the home not evidencing wider consultation and endorsement of care plan, risk assessment, and behaviour management guideline information by other stakeholders where users lack capacity to do so themselves. Opportunities are afforded to users to express views and ideas but the home is unable to evidence how this feedback influences change and development of the service. Service users benefit from detailed assessment of risk in their day to day routines, but, the home needs to evidence wider consultation of identified risks and their management. EVIDENCE: Three care plans were viewed at inspection, these were detailed but had not been signed by other stakeholders or authorised representatives, although the majority of users do have care management input at reviews, these are not always annual. Feedback from relatives and friends suggests that they generally feel well informed in respect of their respective relative/friend, it is essential, however, that where service users themselves lack the capacity to make informed decisions regarding their care plan, that the home actively seeks the involvement of next of Kin and funding authority representatives in agreeing its content and relevance by ensuring they have access to care plan 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 10 information. The inspector does not consider that the home have yet achieved this outstanding recommendation. The home has found that resident meetings have not worked well in the past with those more vocal service users dominating the proceedings as a consequence the home adopted a thoughts and ideas book which staff use to record feedback from service users over break fast in the mornings when users are relaxed and chatty with staff, at the last inspection the inspector noted that this record of feedback was being completed infrequently and did not routinely feature as a regular opportunity for user feedback. Discussion with staff at this inspection indicated that thoughts and ideas feedback is routinely recorded on Wednesday and Saturday mornings, at breakfast each week, a record of notes made at these sessions was noted at inspection. The inspector is satisfied that the home are trying to be proactive in seeking ways to engage with users and identify their preferences, wishes and choices, and that an outstanding recommendation has now been implemented, however, consideration will need to be given as to how the home utilises feedback and how this influences Service development(see St.39). The home has partially addressed an outstanding recommendation to further develop individual risk assessment information within care plans for service users. The inspector viewed a range of service user risk assessments on three user files, and was satisfied with the improvement to their content. Whilst they clearly showed evidence of review and updating, they have not been widely endorsed by the service users themselves or their representatives and this remains an outstanding recommendation. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,16,17 Service users are enabled to develop a community presence and to access activities and interests external to the home. Service users rights are respected and upheld by staff. Service users would benefit from further improvements to the main meal menu to make this more accessible through picture reference. EVIDENCE: Service users were observed at inspection going out to the local shops for haircuts etc, two service users spoken with at inspection spoke about contact visits with relatives/friends before and over the Christmas period. Staff spoken with confirmed visits to town with service users, access to shops etc. Service users have previously had access to a range of activities provided by Adult Education, recent restructure of adult education has precipitated the closure of some of these activities and home staff are seeking alternative activities to fill in activity programmes. Staff were observed interacting in a supportive and enabling manner with service users, encouraging their participation in household activities e.g. helping in the kitchen, laying tables, helping with their laundry etc. Service 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 12 users routines appeared relaxed and unrushed, service users were able to move between different levels of the house, any restriction in movement is linked to the level of supervision individual users require in managing the stairs, however, staffing levels are good and staff were seen to be responsive to service users, demonstrating good insight and understanding and interpreting needs appropriately. The home has made some progress in partially addressing an outstanding recommendation by making service users more aware of choices in respect of breakfast, tea time menus, and morning and afternoon teas, this has been achieved by the use of visual prompts in the form of photographs and objects of reference, this could now be extended to the main meal menu and remains a recommendation. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Service users benefit from a well informed staff team who utilise detailed care plan information effectively to provided personal support that accurately reflects their needs and preferences. Shortfalls in the administration and recording of medication could compromise the welfare of service users. EVIDENCE: Personal care routines noted on user files were detailed. Staff spoken with appeared knowledgeable and understanding of the needs and routines of individual users, citing specific preferences etc . The home is still to develop a cross gender care policy, however, and this remains an outstanding recommendation. One user bedroom was noted where curtains were tied up, in response to the service users behaviour and own preference, as a consequence there is a risk that the service users privacy and dignity may be compromised, the inspector was satisfied from discussion with staff that steps are taken within the individuals daily routines to ensure that this does not occur. Consents to medication administration by staff are still not available for all service users although the home were able to provide evidence of signed care 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 14 management care plans that clearly indicate medication is to be administered by staff. It is a requirement that medication consents are in place for all service users, where these currently do not exist. The inspector noted some handwritten changes to MAR sheets that had not been signed or dated by the person changing them. The home was unable to evidence from user log information why these changes had been made. Codes used to denote some reason for non-administration of medication need to be clearly detailed at the bottom of the MAR sheet. The home has actively sought to reduce the number of recording omissions on the MAR sheets, and from those viewed at inspection there has been a significant improvement in this area. None of the present service user group are self administering of any medications including topical medications, a previous recommendation for a risk assessment in respect of one service user who was previously applying their own cream is now not required, following a re-assessment of their competency to do so. It was recommended that it should be clearly stated within the care plan, or on the MAR sheet, where topical medications are to be applied. Although the home does not have use of liquid medications other than Lactulose at present, they should as good practice be developing a system for the auditing use of liquid medications; the home has addressed a previous recommendation to date liquid medicines upon opening. The inspector has also recommended the development of PRN guidelines for staff to ensure administration by staff is undertaken consistently. The provider advised that Stasolid training is being arranged for staff, the inspector reminded the owner/manager to ensure that the training takes account of the specific needs of those service users who may require the administration of stasolid, and this should be stated on any documentation supplied by the nurse/trainer, and is a recommendation. The inspector expressed a concern that the only service user requiring stasolid on an infrequent basis is located one floor down from the staff sleep in room. A risk assessment is needed to look at the risks of a significant night-time seizure going unnoticed by the staff member on duty; there is currently a over reliance on another service user on the same floor to alert staff. Consideration should be given as to whether warning systems could be introduced to alert staff to the onset of a seizure for this user. The provider will discuss the likelihood of a seizure requiring stasolid etc, and options for management of it. The risk assessment for this issue should be discussed at review and agreed by all parties, and this is also a recommendation. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 A satisfactory complaints system is in place and systems to enable service users to express their views and opinions. The routine recording of personal possession inventories, adherence to existing financial procedures and the wider agreement of behaviour guidelines and risk assessments by other stakeholders for all service users would improve systems in place within the home for their protection. EVIDENCE: The complaints record was viewed at inspection, one new complaint since the last inspection, the record provided evidence of investigation and outcome and that the complaint was handled appropriately. Opportunities for service users to express views, concerns or opinions are provided by the routine establishment of twice weekly ‘thoughts & ideas’ sessions. Individual service user financial records and monies were not closely assessed on this occasion, however, the inspector discussed with the provider the current system for management of user finances. The home provider has developed a good system for the management, recording and auditing of user finances, unfortunately, these procedures have slipped recently with the provider expressing concerns that accounts were out of date; the provider was confident that service users would not, however, experience any disadvantage from this. The home are required to ensure service user monies are routinely paid into their accounts and up to date records maintained, the provider/manager was recommended to review the present system which can be labour intensive of the providers time, and at risk therefore of being given a lower priority at times of work or personal pressure. Discussion with staff indicated that some records of possessions have been developed this has not 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 16 been routinely implemented for every service user yet and remains an outstanding recommendation. Discussion with staff indicated a general satisfaction that behaviour guidelines currently in place were adequate, where these were no longer effective staff expressed confidence in their ability to discuss within the staff team changes needed, staff felt listened to and able to influence change. Behavioural guidelines although discussed at review are not routinely endorsed by service users or their representatives where they lack capacity to do so themselves. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Service users are benefiting from an ongoing programme of maintenance to upgrade the premises, to provide a comfortable and more homely appearance with appropriate aids and adaptations to support the needs of users. The home is maintained to a good standard of cleanliness. EVIDENCE: An ongoing programme of maintenance is underway, as is the decorative upgrade of the premises. Improvements in hallways, the lounge and dining area have been redecorated providing a more homely appearance. The dining area has been soundproofed on the adjoining house wall, and is awaiting the installation of a built in unit. Bedrooms viewed were clean, and personalised to reflect the individual tastes and interests of the respective service users, one bedroom on the top floor is in need of remedial work to some of the plaster and general redecoration of the current paintwork and wallpaper, which is tired and worn, the owner is aware of this but is prevented from undertaking this work by the current occupant who is unwilling for this work to be done, and this was confirmed with the service user by the inspector It is unclear however, whether the service user would accept the redecoration of their bedroom whilst they were away on holiday, and the home need to check the feasibility of this. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 18 Another bedroom on the top floor has had the wash basin removed as a result of its inappropriate usage by the present service users of that room, the home will keep this under review, the absence of the wash basin should be recorded in user files and reviewed on a regular basis. A communal bathroom on the second floor is in need of upgrade and is included in the development plan for the home, the provider was hopeful that this work would commence in the near future. A shower facility on the first floor has in response to a previous recommendation had building materials removed and shower gels and shampoos are no longer stored on the over sink light. Discussion with staff indicated that this room can become very steamy, making the floor and walls slippery, this is due to inadequate venting and this will need to be reviewed and addressed within the current development plan. There have been improvements to the plasterwork in a second floor user bedroom where there is an en-suite wash basin, further work is still needed to finish the work off to a good standard, a slide bolt lock on the outside of this en-suite area is no longer used following the change of room occupant and it is recommended that this is removed. Previously the majority of the service user group have enjoyed a good standard of health and mobility, recently one service user has become affected by a deterioration in their health and mobility and has been unable to use the bath, although the service user concerned is currently having showers an electric bath seat has been purchased for use once the OT has trained staff in its use. Although generally the home was maintained to a good standard of cleanliness, there was an absence of liquid hand-wash in communal bathrooms used by service users and it is a recommendation that this is provided. The home has considered the use of paper hand towels but have decided against their use in user washing facilities because of the likelihood of them being used to block toilets etc, the inspector was advised that hand towels are changed daily. Hand towels viewed at inspection although clean, looked as though they had been in circulation for a long time and consideration should be given to replacing over a period of time the current stock of older towels. The inspector viewed the laundry area, an industrial washing machine is currently out of use and awaiting repair, the home is using a back up washing machine at present. The inspector was satisfied from discussion with staff that good systems are in place for the separation of soiled and non soiled laundry. Service users are encouraged to sluice any of their badly soiled laundry themselves. Staff’ have access to gloves and aprons for handling soiled laundry. Alginate ‘red’ soluble bags should be considered for use to collect soiled laundry, thus preventing the need for the manual transference of soiled laundry into the washing machine from the laundry bag. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Service users benefit from a satisfactory level of staffing that provides continuity of care and support, they are protected from abuse by the implementation of robust recruitment practices and the presence of an ongoing staff training programme. EVIDENCE: The staff roster was viewed over a number of weeks, staffing levels tend to average at 4 care staff on early shift and 3 on afternoon shifts with one sleep in person and an on call facility. Discussion with staff indicated that this level of staffing is adequate to address the needs of service users and support activities, occasional drops in staffing on afternoon shifts to 2 although not desirable or routine occurrences, did place pressure on staff particularly with the ongoing deterioration in the health of one user and the need for additional staff support. Seven staff files were viewed, these provided evidence that the home is operating a robust recruitment procedure, with the home being proactive and seeking additional references, where the standard two were less informative than needed. Staff induction training was discussed, the provider feels confident that the homes own induction programme is equal to that provided by the sector skills council which includes LDAF, the provider was aware of recent changes to the induction process and the introduction of the common induction standards, and will be reviewing the homes induction package to take account of these 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 20 changes, the provision of LDAF training for staff new to learning disability services remains a recommendation, until the provider can evidence that their own package has been accredited by the sector skills council as equivalent. Individual training profiles were noted on staff files, a programme of mandatory training is in place. The staff team are still to all achieve infection control training, in view of the delay in obtaining places for staff with an affordable training programme from KCTA, the provider is going to be providing a days training session to all staff within which infection control issues will be discussed, the provider will be making reference to the infection control book and the standards therein Previously the home had made very good progress in the majority of staff achieiving NVQ 2 qualificiation training, recent staff turnover has reduced this figure, but the level of trained staff is still approximately 67 and exceeds the 50 target set for homes to achieve by 2005. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 The home is still to evidence how feedback from service users and their representative’s influences service development. The health & safety of service users is promoted but this could be compromised if shortfalls in some key standard areas EVIDENCE: The home has addressed an outstanding recommendation to develop a quality assurance policy, procedure and service development plan. The home has actively sought to engage with other stakeholders to obtain views and feedback about the service, but is still to analyse and publish this information or to evidence how this influences change and service development, it is a recommendation that the home can evidence how feedback is acted upon to effect change, if, at all. Falls monitoring of one service user is ongoing, an audit of accident records by the provider has indicated that recorded falls are reflected accurately in accident recording documentation for the home. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 22 The home has addressed an outstanding requirement to evidence completion of required electrical installation works. A mandatory staff’ training programme is in place, and with recent staff turnover some staff are still to achieve all mandatory core training, and delays in obtaining affordable training places in sufficient numbers have made this difficult for the home to address. The home is hoping to supplement this shortfall in core training, with a days training in several outstanding areas including Moving and Handling, and infection control training, provided by qualified trainers from the home as an interim measure. Staff spoken with at inspection confirmed regular fire drills and instruction are happening, satisfactory records of this are being maintained. A staff member responsible for health & safety in the home confirmed that fire point testing is happening along with monthly checks of emergency lighting and fire extinguishers, records of these tests and checks were viewed at inspection. 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 16 Godwyne Road Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000023285.V258604.R01.S.doc Version 5.0 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement 1)Consents to medication administration by staff are to be provided for all users. 2) 3)Handwritten changes to MAR sheets must be signed. 4) Codes used to denote nonadministration of medication need to be clearly detailed at the bottom of the MAR sheet. The home to ensure service user monies are routinely paid into their accounts and up to date records maintained. All staff to have achieved infection control training. Timescale for action 31/01/06 2 YA23 17(2)Sch 4 13(3)(4) 31/01/06 3 YA42 31/01/06 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 6 Good Practice Recommendations All care plans are to be signed by the service user or their representative a minimum of annually(not achieved previously) DS0000023285.V258604.R01.S.doc Version 5.0 Page 25 16 Godwyne Road 2 9 3 4 5 17 18 20 Users should be involved in the risk assessment process where possible and either they or their representative should sign agreement to risk assessment.(partially addressed) Home to extend development of picture reference/visual menu prompts for service users to the main meal selections for the week.(partially addressed) Home to develop cross gender care policy (not achieved previously) 1)It should be clearly stated within the care plan, or MAR sheet, where topical medications are to be applied by staff. 2)The home to develop a system for auditing use of liquid meds. Home to develop PRN guidelines for staff to ensure administration is undertaken consistently.3) Stasolid training is to be arranged for staff that is specific to the needs of the service user concerned. 4) A risk assessment is needed to look at the risks of a significant night-time seizure going unnoticed by the staff member on sleep in duty; Consideration should be given as to whether warning systems could be introduced to alert staff to the onset of a seizure for this user. The risk assessment for this issue should be discussed at review and agreed by all parties. Home to develop personal possessions inventories for ser vice users (not achieved previously). Provider/manager to review the present system for the management of user monies. Slide bolt lock to be removed from door of Service user ensuite wash area Liquid hand-wash to be provided in service user communal bathrooms New staff without experience of learning disability should be registered to undertake LDAF training (not achieved previously) Home to evidence analysis of service users & their representatives feedback, to publish an annual report and indicate how feedback influences service development 6 23 7 8 9 10 26 30 35 39 16 Godwyne Road DS0000023285.V258604.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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