CARE HOME ADULTS 18-65
198 Rossendale Road 198 Rossendale Road Burnley Lancashire BB11 5DE Lead Inspector
Mrs Marie Dickinson Unannounced Inspection 25th July 2006 10:00 198 Rossendale Road DS0000060125.V303680.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 198 Rossendale Road DS0000060125.V303680.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. 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 198 Rossendale Road Address 198 Rossendale Road Burnley Lancashire BB11 5DE 01282 425668 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) Voyage Limited Mark James Bunce Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Physical disability (13), Sensory of places impairment (13) 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission. The staffing levels in the home must at all times consist of a minimum of 1 staff member to 2 service users during the day, on average, and 1 waking watch and 1 sleep in staff member at night. With no more than 10 people sharing a staff group. The home is registered for a maximum of 13 service users to include: Up to 13 service users in the category of MD (Mental Disorder, excluding disability or dementia) Up to 13 service users in the category of PD (Physical Disability) Up to 13 service users in the category of SI (Sensory Impairment) Date of last inspection 11th January 2006 3. Brief Description of the Service: 198 Rossendale Road is registered with the Commission for Social Care Inspection to provide personal care and accommodation for thirteen people. The home is operated specifically as a specialist provision for adults who have an acquired brain injury. Voyage Limited, which is part of Paragon Healthcare Group, owns and operates the home. Accommodation offered is in thirteen large specially adapted single occupancy bedrooms. All rooms are en suite, and some include a small kitchen and dining area. Specialist equipment required to support service users in daily living is provided in all rooms. There are several spacious lounges and dining and kitchen facilities. Specialist modern bathing facilities are also provided. The upper floor can be accessed by a passenger lift. Staff support is based on individual needs of service users living at the home. Information about the service is available from the home. Cost of stay at the home is individually assessed due to service users complex needs requirements. 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 25th July 2006. The inspection involved getting information from written information recorded at the Commission since the previous inspection, staff records, care records and policies and procedures. It also involved talking to service users, staff on duty, and the registered manager, and included a tour of the premises and grounds. Responses were returned to the Commission from eight service users giving their personal view of the services provided. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Younger Adults. What the service does well:
Care had been taken to make sure people coming to live at the home were able to say how they expected their care to be provided. The manager had completed written directives on behalf of service users themed as ‘getting to know service users’. Admission to the home is planned giving people enough time to settle in and knowing how their support will be provided. Information from assessments was linked to care plans and included specialist information such as speech, language, and physiotherapy. This enabled service users to have a full programme for care. Service users healthcare needs were monitored. The home worked with other medical professionals for the benefit of service users. Information to keep people safe was recorded such as risk assessments. Activities and daily living was according to service user choice and the home was managed in a way to avoid institutional practice. They had the opportunity to make decisions about their lives. They said staff helped them and took into account their wishes. They learned skills for independent living such as cooking. They used community facilities such as colleges, social clubs and were currently planning a holiday that Voyage had helped fund. In accordance with social needs being met in the community, service users rights were protected. Service users were helped to keep contact with relatives and friends according to their wishes. Visitors were made welcome. Catering arrangements were satisfactory. Staff worked with healthcare professionals to improve service users quality of life. Care was taken to treat people as separate individuals with different needs. Service users thought staff ‘respected’ them and were always available
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 6 when they needed them. They felt staff ‘listened to them’. Medication was managed safely. The overall provision of specialist equipment and the facilities in the home was of a high standard. Two residents using wheelchairs could access their bedrooms via automatic door openers and this helped them be independent from unnecessary staff assistance. Sufficient care staff were employed for service users to receive individualised care. The atmosphere in the home was relaxed, supportive, and friendly. Service users had confidence in staff and the manager to help them with any difficulty they may have, or to deal with any concern. Staff were given opportunities for training. Teamwork was evident and the manager supported staff by working closely with them. Staff said they enjoyed their work and were confident to ‘speak out and raise issues if needed’. They felt ‘listened to’ by the manager. The training programme had been developed according to the needs of the service users. The manager was professional in how he managed the home to provide a good service for service users, and showed commitment to the job. There was a general confidence expressed by staff and service users in the manager and the way the home was run. One service user stated ‘he asks me everyday how I am, that shows he cares’. What has improved since the last inspection? What they could do better:
All service users must be given a contract of residence. In order for them to understand about policies and procedures and ‘house rules’ this information
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 7 should be made available to them. Rules on smoking, alcohol, and drugs should be included. To enable all service usersto utilise the facility, it is recommended the table in the dining room accommodate wheelchair users. The outdoor garden facilities must improve generally for service users. It is recommended that pathways, doorways, and window frames are kept clean. To support staff to deal with this a person should be employed for general maintenance. To keep the home clean and hygienic domestic support must be employed to deal with areas used by all service users such as toilets and the dining room. When recruiting new staff the manager must get a written reference relating to the persons last period of employment. It is also recommended care staff receive formal supervision at least six times a year, and the frequency of formal staff meetings increase. It is recommended the manager obtain a management qualification. The registered Provider must maintain a system for evaluating the quality of services provided in the home and submit a copy of this to the Commission. 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. 198 Rossendale Road DS0000060125.V303680.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 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. People are usually given up to date information about the home prior to admission. People have their needs assessed. Introductory visits, short stays and overnight stays are arranged. People living at the home are not given a contract. EVIDENCE: A revised statement of purpose and service user guide specific to 198 Rossendale Road has been completed and available for people making enquiries about the home. Service users admitted to the home had the benefit of care management assessment of needs in addition to a separate assessment carried out by the home. Information needed to provide the right care was recorded in detail. This helps everyone involved in planning care to consider what the person wants, if the home is right, the staffing levels are enough and what the other service users living at the home think. Views of service users were included as part of this assessment process and a profile then written themed as ‘getting to know the service user.’ 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 10 People living at 198 Rossendale Road have the benefit of specific specialist care for people with an acquired brain injury. All staff employed work directly with other professionals in health care. Before anyone is admitted, they can spend time in the home on visits. They can look at the facilities, meet with staff and other people who live there. If they decide to move into the home, a short stay of three months is offered. After this time everyone meets together to discuss if living at the home is satisfactory and the care given is suitable. Service users were not given a contract with the terms and conditions of residence from Voyage Ltd, and how payment of fees is met is a concern for service users. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Service users benefited from specialist assessments to ensure all their needs was considered. Assistance was available to help service users make decisions about their lives. Risk taking and risk management supported an independent lifestyle. Policies and procedures were not available to support service users take part in all aspects of life in the home. Confidentiality of service user information was observed. EVIDENCE: Information taken from the service user assessments was linked to care plans. Specialist evaluations, for example speech and language, physical disability and psychiatric, was included and helped make sure these areas of need had the correct support. All service users benefited from being involved in own care plan. This included a written directive on ‘how I would like my family and friends to be involved in my life’, and ‘how I want staff to assist me’. The care plans included all aspects of personal and health care needs. The instructions recorded for staff guidance
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 12 on service user care was very good. A personal support worker referred to as key worker was assigned to help in special programmes. Some service users were receiving guidance and support from independent advocacy services and support in money management was documented. Whilst service users said they had the benefit of one to one contact with staff, up to date information on for example policies and procedures had not yet been finalised. Since the last inspection a draft was available which included illustrated guidance on the homes policies. Risk taking and identified risk was recorded properly and detailed in how to manage identified risk. Risk analysis showed how service users were involved in decisions regarding managing risks that affected them. Records were kept confidential and agreement reached with service users about sharing of information with other professionals. The care plans seen for three service users were written with long term goal setting in place. And to help service users accomplish this short term planning was made. Setting achievable accomplishments, which benefited service users and gave them a sense of wellbeing, did this. Included for example, a programme of physiotherapy and speech. There was evidence service users right to make personal choices and recognise their diverse needs was promoted within the boundaries of their limitations. Care plans were reviewed at least every month in addition to reviews carried out by other professionals such as consultants for physical and sensory impairment. These specialist evaluations of the service users needs supported their care. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Service users had opportunities for personal development. They were supported to take part in appropriate activities within the community and enabled to keep contact with relatives and friends. Staff respected their wishes. The catering arrangements were good. EVIDENCE: Service users were given opportunities for personal development. The manager said this was individual and was discussed as part of care planning. This could be for example to attend college. Resident’s views about their opportunities to take part in activities was positive. They did what they wanted to do and what they were comfortable with regardless of varying independence skills. Staff support was available benefiting service users in using community facilities such as day centres, pubs or just going out for shopping, again recognising their diverse needs.
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 14 Service users had weekly planners of personal activities they followed. For example a planner read colledge, help make own lunch, physiotherapy in own bedroom, beauty session, maths and english, go out for walk, food shopping, menu planning and painting. Service users had different interests such as for example creative writing, gymn routines, keeping a diary and a work programme. These interests referred to ‘Goals I am going to work towards’. The service user guide states the aim of the home is to make sure service users are given maximum choice on matters relating to their daily lives including opportunities to take reasonable risks. Also included is a recognition of individual ethnic, religious and social needs that are characteristic of service users and care to be provided appropriate to these. As part of the basic contract price, service users had the option of a minimum seven-day holiday outside the home they help to choose. Some service users were planning a holiday in Scarborough Flamingo Land. The resort offers facilities for disabled people, and the length of stay will cover four nights. The home was managed in a manner which avoids any institutional routines. Letters were delivered unopened and observations made of staff working in the home showed they treated residents with respect. Residents had their preferred name stated on their plan. Residents did not have ‘house rules’ they had agreed to follow. All bedrooms had locks on their doors and service users managed their own keys. To support service users be more independent some wheelchair users had automatic door openers fitted. These enabled them to be less reliant from staff support and had made a difference to managing their own personal care needs. Service users said they spent time in their bedroom when they wanted, and had agreed flexible times for going to bed and getting up. Relatives and friends were made welcome to the home. Household tasks were managed by service users with staff support, for example keeping their room clean and laundering clothes. Menus showed service users were offered variety and choice. The manager said menus were changed every four weeks. Part of learning life skills for individuals involved nutritional needs. Records showed how budgeting skills, shopping, preparation, and cooking food were managed. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users healthcare was promoted. Personal care was given according to service users needs and wishes. Medication was managed safely. EVIDENCE: Comments received at the Commission from service users indicated staff treat them well. Service users routines were recorded and special to them. Personal care was given according to individual wishes. Personal care plan shows how this was to be managed by staff for example service users asked staff ‘Don’t patronise me’. ‘I don’t want to be treated any different to anyone else’. I want to be respected’. Every person in the home had technical aids they needed to assist in personal care such as overhead tracking from bedroom to en suite facilities. This provision now included automatic bedroom door openers for people confined to wheelchairs. Two service users who benefited these said they were able to attend to personal needs instead of waiting for staff assistance for example using the en suite toilet. Staff were trained in operating equipment provided.
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 16 Staff were involved with other professional people involved in service users care. A physiotherapist was employed on a regular basis for sessions with individuals. Staff worked with service users on planned programmes. Going to bed and getting up was also a personal choice depending on any planned activity. The individual records outlining this including likes and dislikes and were of a high standard. Daily notes showed how these instructions according to service users wishes were followed through. Medical care was promoted such as dental visits and routine medical checkups. Care plans showed guidance given and any action needed for wellbeing. All service users were in contact routinely with their own General Practitioner. Staff role included helping service users attend medical appointments. Records of service users medication was kept that included information about service users medication, and what staff should be aware of if someone was not well. Residents could self medicate following an assessment to make sure this would be safe. Medication storage was secure and tidy. Medication administration records were being kept. Medication was managed correctly. Staff were trained in safe administration of medication. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users felt their views were listened to and acted on. The Adult Protection policies and procedures helped staff in their responsibility in protecting vulnerable adults and of their responsibility in care. EVIDENCE: The complaints procedure had been updated and is accessible, accurate, and available. Service users spoken to said they had no complaints as such. Written comments from service users indicated they knew whom they could approach if they were not happy and whom they would make a complaint to if needed. During discussions, service users voiced their opinion about this as they had confidence in the staff and in particular the manager. One service user said he ‘asks us every day if we are alright’. The cards available for use to send direct to Voyage in the event of service users being unhappy have envelopes provided to ensure confidentiality. The information available regarding advocacy services was not included in information provided although service users sourced these services from a variety of places for example ‘headway’. There had been no complaints received at the home. Staff on duty said they had been trained in protection of vulnerable adults and knew their responsibilities in dealing with these issues. Policies and procedures were available for reference.
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 18 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The living environment was generally satisfactory; some outdoor areas however were in need of attention to provide a more pleasant environment for service users and staff. EVIDENCE: The grounds of the home were in need of improvement. The rear garden area requires upgrading for the benefit of service users. To create a more pleasant outdoor environment, pathways must be maintained to keep them even and free from weeds. Windows and doorways must also be kept free from a build up of debris for example, leaves, cobwebs, and entrances clear of discarded cigarette ends. The home has been tastefully furnished. The main dining room table however does not allow wheelchair users to sit comfortably there. The provision of a breakfast bar was appreciated however this was not sufficient for one service user. There was an option to use another dining room with a suitable table although everyone did not favour this.
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 20 The overall provision of specialist equipment for physical disability was to a high standard. Bedrooms were equipped with individual aids and wheelchair users could access their bedroom without the assistance of staff. This impacted on them very much as one service user said ‘I don’t need to ask staff to use the toilet anymore as I can go to my room.’ There was an improvement in the overall standard of hygiene in the home, however communal areas still require domestic input to support care staff. This is because service users needs regarding spillages of food and drink are relatively high. The problematic drain outside the kitchen has not yet been dealt with, although the manager said he has managed to keep this clear and will do so until it is permanently sorted. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Recruitment procedures were mainly good. Service users benefited from one to one care by trained staff. Insufficient staff were employed for residents to benefit satisfactory standards of hygiene and grounds maintenance. EVIDENCE: The current level of staffing was linked to the needs of the service users. Staffing needs are assessed prior to people being admitted to the home and therefore benefited service users requiring one to one care. At the time of inspection nine staff were employed to work in the home. The manager had maintained a written staff rota, showing how staffing levels were maintained to a satisfactory level. Comments received at the Commission show most people felt there was enough staff on duty. A number of staff files showed recruitment procedures to be satisfactory. Three new care staff records showed checks required for protection of residents had been carried out prior to employment. One application form however failed to give past employers as referees and interview notes did not show this was considered. The manager said to help service users be involved in the interview process; part of selection of staff is for interviewees to spend time in the home with them. The manager and seniors observe this. Staff are given
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 22 contracts and sign a training agreement. Staff on duty said they enjoyed their work and the training provided. One staff member said ‘Voyage are good employers’. They worked to a key worker system and this entailed helping service users with personalised goals such as independent living skills. Induction given to new staff includes training in ABI (Acquired Brain Injury). Staff were given supervision and felt they could ‘have their say’ as the manager worked alongside them. Formal supervision needed to be regular. Staff thought the opportunities for training with Voyage were very good and specific for the type of rehabilitation work they did with. Other professionals gave training such as the physiotherapist and speech therapist to keep special programmes for individuals maintained. Given the need for an improvement in the environment both in the grounds and hygiene in the home, a domestic assistant should be employed for this purpose and a general maintenance person for heavier work. The manager said that the night staff have been given some domestic duties, however it was discussed with the manager that care staff need support in this area, as their prime role is personal care support. Whilst service users do learn life skills in keeping their environment clean, this should not be expected to extend to communal areas such as the dining rooms and toilets. 198 Rossendale Road DS0000060125.V303680.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The management and leadership approach was satisfactory, however the manager does not hold relevant qualifications for this position. Service users views were taken into account and responded to by the manager. Health and safety was being dealt with and training for staff organised. Quality assurance processes in place required formalising. EVIDENCE: The registered manager is currently training for the Registered Managers Award. He said he had a target date for completion in September/October as Voyage has set this timescale. Staff and service users expressed confidence in his leadership and in his management style. Service users said they spoke to him individually and he was involved in their care. Staff said they had formal meetings, and had the opportunity to discuss work issues at these, however these meetings were not
198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 24 as regular as they should be. Relevant training was provided and the staff felt the manager was supportive in this area. Topics included mandatory training for example moving and handling, acquired brain injury, abuse, National Vocational Qualification in care, and other work related topics. One new staff member said she enjoyed learning about Acquired Brain Injury and felt it helped her understand how unique each person is and how needs should be met. Since the last inspection the combined managers supervision and inspection carried out by a senior representative of Voyage has ceased. The manager said his supervision is arranged and separate from the required unannounced senior management visit by Voyage. Confidential records were locked away. Each service users files has written permission for sharing of information with people directly linked to service users welfare. The policies and procedures for service users were still being finalised. Samples seen showed care was being taken to illustrate these for people with limited capacity for understanding written information. The views of the service users were considered important. Service users felt they were included in decision-making. One new resident said ‘I’m new here and wish to be more involved’. The health, safety, and welfare of service users are a shared responsibility between Voyage and the manager. Insurance cover was in place and the manager said sufficient funding was available for maintenance. This was discussed, as areas in need of a continuing maintenance programme needs to be organised such as regular grounds maintenance. Weekly checks on the environment safety were carried out for example water temperature checks and fire alarms. Voyage had arrangements with contractors for maintenance beyond everyday management such as electrical appliances, legionnaires disease control and fire safety appliances. To make sure the views of service users and other interested parties are considered and influence quality services and facilities, a quality assurance audit should be carried out at regular intervals and the results published. 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 25 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 3 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 2 2 X 3 X 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation Requirement Timescale for action 31/08/06 2 3 YA24 YA33 4. YA34 5 YA39 6 YA40 5(1)(b)(c)Sch4 All service users must be given a contract. Previous timescale 31/07/05 and 28/04/06 not met. 23(2)(b) The outdoor garden facilities must improve for service users. 18(1)(a) The registered providers Voyage Limited must employ sufficient staff to keep the home clean. Previous timescale of 28/04/06 not met. 19(5) The manager must get a Schedule 2 written reference relating to the persons last period of employment. 24(1)(5) The registered Provider must maintain a system for evaluating the quality of services provided in the home and submit a copy to the Commission. 24(1)(5) The registered provider must make sure service users are consulted about the services and facilities offered as part of quality assurance. 30/09/06 31/08/06 17/08/06 30/09/06 30/09/06 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 27 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 YA8 Good Practice Recommendations It is recommended service users receive up to date information they can understand about policies and procedures for everyday living such as ‘house rules’, special to the home, they have discussed and agreed with each other. This recommendation was made in the previous inspection. It is recommended rules on smoking, alcohol and drugs be included in agreed ‘house rules This recommendation was made in the previous inspection. It is recommended the table in the dining room accommodate wheelchair users. It is recommended that the outdoor areas, pathways, doorways, and window frames are kept clean. It is recommended Voyage employ a person responsible for general maintenance. It is recommended care staff receive formal supervision at least six times a year. It is recommended the manager obtain a management qualification. It is recommended staff have increased formal staff meetings with records kept. 2. 3 4 5 6 7 8 YA16 YA24 YA30 YA33 YA36 YA37 YA38 198 Rossendale Road DS0000060125.V303680.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. Extracts may not be used or reproduced without the express permission of CSCI 198 Rossendale Road DS0000060125.V303680.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!
