Inspection on 02/11/06 for 199 Doseley Road

This inspection was carried out on 2nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

199 Doseley Road 25/04/07

199 Doseley Road 27/07/06

199 Doseley Road 06/06/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 199 Doseley Road 199 Doseley Road Dawley Telford TF4 3BA Lead Inspector Rebecca Harrison Key Unannounced Inspection 02 November 2006 09:00 nd 199 Doseley Road DS0000066727.V313114.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 199 Doseley Road DS0000066727.V313114.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. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 199 Doseley Road Address 199 Doseley Road Dawley Telford TF4 3BA 01952 506105 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) www.dimensions-uk.org Dimensions (UK) Ltd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply. Date of last inspection 27th July 2006 Brief Description of the Service: 199 Doseley Road is purpose built detached property, which is located in a residential area of Doseley, Telford approximately two miles from Telford Town Centre. The home offers access to local amenities and transport and is in keeping with the local community. The accommodation is based over two floors providing five single bedrooms, two bathrooms, three toilets, a fully fitted kitchen, lounge, dining room and conservatory. A garden is provided to the rear of the property. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of five adults with a learning disability. Dimensions (UK) Ltd is the service provider and was registered with CSCI on 3rd March 2006. The responsible individual is Ms Susan O’Loughlin and the manager is Ms Nicola Bariana who is yet to apply for registration with CSCI. Potential service users and their representatives are able to gain information about this home from the Statement of Purpose and Service User Guide. Contracts of Terms and Conditions of residency are not yet available. CSCI reports for this service can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk At the time of this inspection the new manager was unaware of the current fees charged per person and agreed to forward this information to CSCI. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 09.00 a.m. and lasted five and a half hours. It included looking in detail at all aspects of care provided for two people, talking with three service users present at the home, the manager and three members of staff on duty, observing work practices, looking at a number of records and a full tour of the home. 16 key National Minimum Standards for Younger Adults were assessed in addition to Standards 1,3,5,33,36,38 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. This was the third ‘key’ inspection undertaken under the new registered provider since April 2006. The purpose of the inspection was to assess ‘Key’ National Minimum Standards and to review the progress made by the home since the last inspection undertaken on 27th July 2006 when twenty-three requirements and three recommendations were made. Since the last inspection the provider has received and investigated one complaint with a satisfactory outcome. No concerns or complaints have been referred to the Commission for Social Care Inspection. Multi-Agency meetings under adult protection procedures remain ongoing for three people currently living at the home and a further meeting to conclude matters is due to take place on 28.11.06. What the service does well: What has improved since the last inspection? This is the third ‘key’ inspection of this service under the current registered provider. An experienced manager has recently been appointed and commenced duties on 9th October 2006. Discussions held with staff on duty evidence that the 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 6 manager has good leadership skills and a clear sense of direction. Staff reported an improvement in morale, which has had a positive impact on service users. They were complimentary of the changes made by the manager to improve the service. Considerable improvements have been made to the environment to provide people with a homely place to live. The majority of the home has recently been redecorated, new floor coverings fitted and soft furnishings purchased. A Statement of Purpose has been developed and is currently being amended to reflect the new managerial arrangements for the home and service users have now been provided with a Service User Guide. Formal reviews have been held for two people involving significant others and reviews have been scheduled to take place shortly for the other people living at the home. The manager has recently met with an independent advocate who is currently representing the interests of service users with devising terms and conditions of residency. Information regarding support networks has also been sourced and a referral for advocacy services has recently been made on behalf of one person who does not have family representation. The key worker system has been revised and monthly meetings introduced. Staff training opportunities has improved with staff attending a number of courses appropriate to their role. It was reported that all staff have now attended training in adult protection procedures and the management of actual and potential aggression (MAPA). A new duty rota is being devised to take effect from December. Staff will work eight hour shifts rather that fourteen hour shifts and have identified breaks. Staff spoken with welcome the proposed shift changes and considered the new arrangements will be in the best interests of the people accommodated. An Environmental Health Officer visited the home during the inspection and discussions indicated that the provider is working towards meeting requirements and noted improvements made in relation to food safety since the home was last inspected by the department in June 2006. What they could do better: Support plans, although improving, still lack sufficient information for the delivery of care/support for example the levels of assistance a person requires in relation to personal care tasks. This is particularly crucial given the limited communication needs of the individuals accommodated to ensure support is provided in a consistent manner. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 7 Service users need to be provided with a contract of terms and conditions of residency and would benefit from having a person centred plan in addition to a health action plan as soon as possible. Medication procedures could be improved with the development of a medication audit system to ensure any errors can be picked up without delay, investigated and appropriate action taken to protect the service users interests. Service users are currently unable to access their bank accounts due to the appointee being on leave. This needs to be reviewed and the situation resolved as soon as possible. A staff training needs assessment needs to be carried out for the whole team and a staff training and development plan developed. 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. 199 Doseley Road DS0000066727.V313114.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 199 Doseley Road DS0000066727.V313114.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): 1,3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new person to the home however service users are currently not provided with information about their terms and conditions of residency. EVIDENCE: Four requirements were made at the previous inspection in relation to this outcome group. The manager reported that the Statement of Purpose has been developed and is currently being amended to reflect the new managerial arrangements for the home. The document was therefore not available for inspection and the manager therefore agreed to forward a copy of this to Commission For Social Care Inspection at the earliest convenience. Service User Guides are nearing completion and have been developed incorporating photographs and each service user provided with a copy. One person has recently been discharged from the home due to the service not being appropriate to his needs. The home currently has one vacancy and it was reported that the one referral has been received. The manager reported that she has met the prospective service user on three occasions at his current placement and that a Community Nurse from the local learning disability team has recently attended a staff meeting to discuss the person’s needs with the 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 10 team. Discussions held with the manager evidence that the person would only be admitted following a full assessment and a comprehensive programme of introductory visits to ensure the placement is appropriate and the person compatible with the existing people accommodated. A Statement of terms and conditions between the home and each individual remains outstanding. The manager reported that an independent advocate is representing service users best interests to ensure the contracts are individualised and appropriate to the people living at the home. 199 Doseley Road DS0000066727.V313114.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improving the care planning systems do not provide staff with sufficient information for the delivery of care and support. Service users are appropriately supported with making choices and have access to an independent advocacy service. Risk management strategies require further development to safeguard service users. EVIDENCE: The care documentation held on behalf of two service users was reviewed by the inspector. Support plans were available on both service user files however these continue to lack sufficient detail to ensure care and support is offered and delivered in a consistent manner, which was fully acknowledged my the new manager. For example one plan did not provide detail as to what level of assistance the individual required in relation to shaving. A further statement in relation to his oral care needs was contradictory. The manager reported that 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 12 she is currently working with the team to develop and implement new support plans for all individuals and stated that these would be completed within the forthcoming week. An example of a part completed plan was shared with the inspector and was found more detailed. It was reported that formal reviews have been held for two people involving significant others and that reviews have been scheduled to take place shortly for the other people living at the home. The new manager reported that she has recently met with an independent advocate who is currently representing the interests of service users with devising terms and conditions of residency. Information regarding support networks has also been sourced. A referral for advocacy services has recently been made on behalf of one person who does not have family representation. The manager has revised the key worker system and introduced monthly meetings with individual service users. Discussion held with the manager clearly evidence that she is looking to provide people with the communication support they require to assist them with decision making processes to include the development of a residents participation folder to evidence where decisions have been made and the reasons. The deputy manager is currently reviewing risk assessments as required by the two previous inspections and these were seen during the inspection. Records evidence that staff are in the process of signing assessments to state that they have read and understood assessments however further work is required in relation to action and control measures. Discussions held with the deputy manager indicate that she has received training in risk management through the previous provider. The manager committed to ensuring all identified risks are assessed as a matter of priority and that completed assessments are placed on individual files and cross-referenced to support plans. 199 Doseley Road DS0000066727.V313114.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): x EVIDENCE: The intended outcomes for Lifestyles were reviewed and met at the two previous inspections with all key standards met. Therefore these standards were not reviewed on this occasion. However it is evident through case tracking, discussions held and observations made that people continue to be provided with positive lifestyles. Social, educational and recreational activities meet individual’s expectations and family links are actively promoted. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Medication procedures need to be reviewed to fully safeguard service users. EVIDENCE: Two requirements were made as a result of the previous inspection in relation to personal and healthcare support. The requirement for service users’ preferences with regard to their personal care requires further development as the two support plans reviewed continue to lack sufficient information for the delivery of care/support. This is particularly crucial given the limited communication needs of the people accommodated and the use of agency staff. Service users present at the home during the inspection were well presented. One person has been referred to psychology following adult protection procedures. The manager reported that she intends to make a referral to wheelchair services on behalf of one individual whose chair requires attention. Evidence of health checks was available on the two files reviewed and outcomes recorded. During the inspection one person was being supported at hospital to receive treatment as a day patient. Relevant referrals and 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 15 appointments leading to his treatment were well documented and his family kept informed. Health Action Plans have yet to be developed. Since the last inspection the home has changed the supplying chemist for prescribed medication and now uses the monitored dosage (MDS) system provided by Boots Chemist. Prescribed medicines are now retained in service users own rooms in an appropriate storage facility. None of the service users are currently prescribed controlled drugs. Evidence of regular medication reviews undertaken by a Consultant Psychiatrist was available on the files of the two people case tracked. Discussions held with the manager and a staff member indicate that a number of staff have undertaken training on the administration and safe handling of medicines, however it was reported that staff have not undertaken a formal assessment. Internal competency assessments were available however these were found incomplete. Medication Administration Records (MAR) were satisfactory for two people however gaps were found on the MAR chart for a further service user dated 26.10.06 for 17.30 pm medication. It was reported that medication had been administered by the person parents however staff had failed to record such. It was also stated that the parents of a service user obtain his medication and staff are responsible for handwriting the MAR charts. While this is satisfactory, a copy of the prescription should be retained by the home, the MAR chart completed by a staff member and witnessed by a further staff member to ensure the system is not open to error. Medication audits are currently not being undertaken however the manager intends to introduce these as a matter of priority. The homes medication policy was not reviewed on this occasion. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to a complaints procedure that enables their views to be listened to and acted upon. Procedures to safeguard service users from potential harm or abuse are in place. EVIDENCE: No concerns or complaints in relation to this service have been referred to the Commission for Social Care Inspection (CSCI) since the last inspection. No complaints were recorded in the homes complaints log however a letter from the relatives of a services user was shared with the inspector which indicates that a complaint was referred to a senior manager within Dimensions since the last inspection. The letter indicated that the relatives have received a satisfactory outcome to an internal investigation undertaken by the provider with improvements to the environment and the staffing situation made. The letter concluded by stating ‘It is a credit to the staff that X is currently contented, happy and remains well adjusted’. A copy of the complaint procedure was available on the two service user files reviewed and the procedure is also available in the reception area in addition to a pictorial complaints procedure developed by the local learning disability team. Since the last inspection a level III Joint Review Meeting was held on 29.09.06 to discuss four people subject to adult protection procedures. One service user 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 17 has since left the service. A further meeting is scheduled shortly to conclude the process. A copy of the Multi-Agency Adult Protection policy and procedure was available in the office. It was reported that all staff have now attended training in adult protection although a training matrix or certificates to verify this was not available for inspection. A staff member confirmed that all staff have attended accredited training in the management of actual and potential aggression (MAPA). Discussions held with the manager indicated that she is due to attend the next available course. Service users are supported to manage their finances. The finances of the people case tracked were checked and were an accurate reflection of the records held however it is recommended that two signatures be obtained for all transactions. The manager is in the process of providing service users with more detailed financial books and finances will shortly be retained in people’s own rooms. It was reported that service users are currently unable to access their bank accounts due to the appointee being on leave and therefore service users are borrowing monies from the homes petty cash account in the interim. Discussions held with the manager evidence that she is reviewing this matter with senior managers and the finance department in an attempt to resolve the situation. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is much improved providing service users with a clean, homely and comfortable place to live. EVIDENCE: Since the last inspection considerable improvements have been made to the environment to provide people with a homely place to live. The majority of the home has recently been redecorated, new floor coverings fitted and soft furnishings purchased. A team of decorators were on site during the inspection redecorating two bedrooms. One service user was keen to show the inspector new bedding that he was supported to purchase during a recent trip to Wellington. He confirmed that he had chosen the décor of his room and his choice of bedding and it was evident that he was very happy with his redecorated room and purchases. A planned programme of maintenance and renewal for the fabric and redecoration of the premises as required by the previous inspection was not available however the manager was advised to add the replacement of dining room furniture to this once one has been developed. On the afternoon of the inspection the manager was due to attend a finance meeting to discuss the 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 19 budget for the forthcoming year and committed to developing a planned programme of maintenance and renewal for the home. During the inspection an Environmental Health Officer visited the home to review the requirements made by the department following an inspection undertaken in June 2006. Discussions held with him indicate improvements have been made and that the provider is working towards meeting the outstanding minor requirements. It was reported that the Fire Officer has not visited the home since the last inspection however the manager agreed to make contact with the department to ensure there are no outstanding requirements and to discuss the fire arrangements for the home. The home was found bright, clean and airy during this unannounced inspection and cleaning schedules are now maintained on a daily basis. Products hazardous to health were found appropriately stored and data assessments have recently been revised. The laundry was appropriately maintained and the policy for infection control available and personal protective equipment seen. It was reported that some staff have attended training in infection control. An infection control audit was undertaken by an infection control nurse as reported at the last inspection. Observations made evidence that clinical waste is currently not being securely stored, which was also raised by the Environmental Health Officer and the manager committed to address the issue. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 20 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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a trained and committed staff team who are meet the needs of each individual in a sensitive and professional manner. The homes recruitment procedures safeguard service users. EVIDENCE: During the inspection the staff on duty were accessible and discussions held with them demonstrated they had a good understanding of the needs of the people they support. Staff reported an improvement in morale, which has had a positive impact on service users. They were complimentary of the changes made by the new manager to improve the service. It was reported that the home employs nine permanent staff of which four hold an NVQ qualification and one staff member is nearing completion of the award. A requirement was made at the previous inspection that there must be sufficient numbers of staff on duty to support service users’ assessed needs at all times. The manager reported that staff deployment has since been reviewed with there being a minimum of three staff on duty throughout the day and a new duty rota is being devised to take effect from December. Staff will work eight hour shifts rather that fourteen hour shifts and have identified 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 21 breaks. Staff spoken with welcome the proposed shift changes and considered the new arrangements will be in the best interests of the people accommodated. At the time of the inspection there were sufficient numbers of staff on duty to support the service user receiving treatment in hospital and the service users present. The home currently has one waking night staff vacancy. Recruitment procedures were found satisfactory when reviewed by separate appointment at the organisations area office on 21.07.06. The personnel file reviewed was well presented and contained the relevant documentation required. The personnel file of the newly recruited manager was not reviewed during this inspection due to the file being held at the area office. This in addition to the files of any new staff recruited will be assessed at subsequent inspections. Requirements were made at the previous inspection that a team training needs assessment be developed in addition to individual staff training and development assessments. The recently appointment manager has not yet had opportunity to develop a team training plan however reported that she will develop this in addition to a training matrix of courses attended following scheduled supervisions, performance and development reviews and through obtaining training information and certificates. Staff spoken with reported that training opportunities are much improved. One person stated that she has attended training in ‘Our Approach’ induction, health and safety, first aid, food hygiene, the management of actual and potential aggression (MAPA), and manual handling. Another staff member stated that she has recently attended training in record keeping and report writing however has yet to undertake training in food hygiene. The deputy manager reported that she very recently attended a course in leadership skills and that all her mandatory training is valid. The manger reported that all staff have been booked to attend the induction training through the organisation. As previously stated training records and certificates were not available for inspection with the exception of two certificates seen for induction training. Staff would welcome training in makaton and autism as reported at the previous inspection. The manager reported that staff supervisions have been scheduled. She reported that she has recently received training in the organisations Performance Framework and Development Plan and a copy of such was shared with the inspector. She stated that the appraisal system would be discussed at the next team meeting and dates then scheduled with individuals. The minutes of a staff meeting held on 20.10.06 were seen and items discussed include supervisions, teamwork, policies and procedures, dignity and respect, health and safety, medication and CSCI and environmental health requirements. As previously stated a Community Nurse was a guest speaker to discuss a recent referral to the service. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 22 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): 37,38,39,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a clear vision for the home and is approachable and supportive, having a positive impact on staff and service users. Quality assurance systems require further development to ensure all aspects of performance are reviewed. The homes record keeping systems although improving requires further development. The health, safety and welfare of service users and staff is promoted. EVIDENCE: The recently appointed manager of the home is Ms Nicola Bariana who commenced duties on 9th October 2006 and is yet to submit an application for registration with Commission For Social Care Inspection. Discussions held with the manager indicate that she has extensive experience with a variety of client groups in both day and residential settings. She stated that she has attained 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 23 her NVQ level 4 in Care and the Registered Mangers Award and attended numerous courses appropriate to her role and has over two years managerial experience. Discussions held with staff on duty evidence that the manager has good leadership skills and a clear sense of direction. Staff were complimentary regarding the changes she has made since her appointment. Visits as required under Regulation 26, continue to be undertaken by the organisation and a report forwarded to CSCI. The new manager has not had the opportunity to develop and distribute questionnaires to service users, family, stakeholders etc to seek the views on how the service meets the needs of people accommodated or develop an annual development plan as required by previous inspections. A Regional ‘PATH’ with aims for the forthcoming months has been developed and this was seen displayed in the office. Discussions held with the manager evidence that she is working towards meeting the requirement for all records required by regulation to be wellmaintained, up to date, accurate and accessible. Policies are procedures are now available and daily records held on behalf of service users are now much more detailed. As previously stated support plans require additional detail and the information contained in service users files made more accessible. Health and safety procedures appeared satisfactory at the time of this inspection. Risk assessments are currently being revised. The inspector reviewed accident records, temperature monitoring charts, cleaning schedules, the maintenance book, COSHH data sheets and service certificates. The last landlord gas safety certificate available was dated 17.03.05. A fire plan and risk assessment was not available and the manager agreed to contact the fire department to discuss this and any outstanding recommendations concerning fire safety. As previously stated the Environmental Health Officer visited the home during the inspection and discussions indicated that the provider is working towards the meeting the outstanding requirements and noted improvements made in relation to food safety. Discussions held with staff on duty indicate that since the last inspection a number of staff have attended training in safe working practices to include infection control, food hygiene, manual handling, health and safety and first aid. Certificates were not available for inspection however the manager stated that she has requested a list of training and access to certificates in order to develop a training matrix, which will assist with the future planning of mandatory training. A health and safety policy is in place and a staff member confirmed that she has read the document. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 24 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 x 3 3 4 x 5 2 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 3 2 x 2 2 x 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 25 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 5(c) Requirement Timescale for action 01/12/06 2. YA6 15(2) 3. YA9 13(4)(b) The registered person must develop and agree with each service user and their representative a written contract/statement of terms and conditions between the home and the each individual to include all items specified in NMS 5.2 and each service user be provided with a signed copy. (Previous timescale of 17/07/06 and 19/09/06 not met). Detailed support plans 01/12/06 must be drawn up with service users and significant others and be reviewed at least every six months and updated to reflect any changing needs. Service users must be 01/12/06 enabled to take responsible risks within a risk assessed framework, which is a comprehensively recorded and regularly reviewed and updated. Action must DS0000066727.V313114.R01.S.doc Version 5.2 Page 26 199 Doseley Road 4. YA18 12(1)(b) 5. YA19 1213(1)(b) 6. 7. YA20 YA35 13(2) 18(1)(c) 8. YA35 18(1) (c) 9. YA37 8,9 10. YA39 24 be taken to minimise risks and hazards. (Previous timescale of 07/07/06 and 31/08/06 not fully met). The registered person must ensure that service users’ preferences with regard to their care are identified and respected and any aids and adaptations required are maintained in safe working order. (Previous timescale of 07/07/06 and 18/09/06 not fully met). Service users health must be monitored through annual health checks and outcomes recorded in a Health Action Plan (previous timescale of 07/07/06 and 18/09/06 not fully met). Medication procedures must be reviewed. A training needs assessment must be carried out for the whole team and a staff training and development plan developed. (Previous timescale of 01/08/06 and 18/09/06 not met). Each staff member must have an individual training and development assessment. (Previous timescale of 01/08/06 not met). An application to register an experienced and skilled manager must be submitted to CSCI. An effective quality assurance system must be developed in addition to seeking the views of service users/relatives and DS0000066727.V313114.R01.S.doc 01/12/06 11/12/06 03/11/06 18/12/06 18/12/06 04/12/06 18/12/06 199 Doseley Road Version 5.2 Page 27 11. YA39 24 12. YA41 17 13. YA42 13 (6) 23 (4) (d) 14. YA42 12,13 significant others and results published. (Previous timescale of 01/09/06 not met). An annual development plan for the home must be developed. (Previous timescale of 01/09/06 not met). The registered person must ensure that all records required by regulation are well maintained, up to date, accurate, accessible to staff and available for inspection. (Previous timescale of 07/07/06 and 31/08/06 not fully met). All staff must receive mandatory training relating to safe working practices and these be updated at the required frequency. (Previous timescale of 01/08/06 and 18/09/06 not fully met). Risk assessments must be carried out for all safe working practices and staff made familiar with these. (Previous timescale of 07/07/06 and 31/08/06 not fully met). 18/12/06 01/12/06 04/12/06 01/12/06 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA7 YA9 YA23 Good Practice Recommendations The use of a gate on a service users bedroom should be risk assessed and discussed as part of a multidisciplinary review as it restricts the person’s freedom of movement. It is recommended that risk assessments for service users be retained on their own file and cross-referenced to support plans. It is recommended that financial procedures be reviewed to improve accessibility of funds. 199 Doseley Road DS0000066727.V313114.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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