Inspection on 25/04/07 for 199 Doseley Road

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

199 Doseley Road 02/11/06

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 25th April 2007 09:00 199 Doseley Road DS0000066727.V335051.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.V335051.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.V335051.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 vacant post Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply. Date of last inspection 02.11.06 Brief Description of the Service: 199 Doseley Road is purpose built detached property, which is located in Doseley, Telford approximately two miles from Telford Town Centre. The home offers access to local amenities and public transport and is in keeping with the local community. The accommodation is based over two floors providing five single bedrooms, a kitchen, lounge, dining room, conservatory and gardens. 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. The home has one vacancy. Dimensions (UK) Ltd is the registered service provider and the responsible individual is Ms Susan O’Loughlin. There is no registered manager currently in place however Ms Claire Downing is the acting manager of the home. The former manager, Nicola Barina is currently acting up into Area Manager position and is providing management support to Ms Downing. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose and Service User Guide and inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk The current fees charged range from £1285.00 to £1427.06 per person per week based on assessed individual needs. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 25th April 2007 and was carried out by one inspector over 7.5 hours. It included talking with service users and two visiting relatives, the manager and staff on duty, looking in detail at all aspects of care provided for two people, examining a number of records and a tour of the home. CSCI received three surveys from relatives in preparation for the inspection and their comments have been included in the report. Staff files for two staff employed since July 2006 were examined at the organisations area office during the morning of 23rd April 2007. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review all 14 requirements made at the previous inspection undertaken on 2nd November 2006. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The people who use the service, the acting manager, visiting relatives and the staff on duty were very helpful and co-operated fully throughout the inspection. What the service does well: What has improved since the last inspection? The home has received twelve compliments since the last inspection and comments recorded include: ‘Welcomed very nicely, very helpful homely atmosphere’. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 6 ‘Nice relaxed friendly atmosphere. Clients seem very happy & welcoming’. ‘Warm welcome, fresh, clean and bright, very relaxed’. A format for Health Action Plans has been developed but not yet implemented. People are now provided with a copy of the service user guide and a contract of their terms and conditions of residency. Service user records are much more detailed and have been developed using a person centred approach, providing staff with information to enable individual needs to be met in a way that they prefer. All records examined throughout the inspection were well-presented, easily accessible, user friendly with evidence of regular review. People are encouraged to take responsible risks and risk assessments have been reviewed and new ones developed to ensure the safety of service users and staff. The organisation has recently set up a Joint Consultative Group and a Regional Advisory Forum to assist with quality assurance and future planning. A number of audits have taken place since the last inspection to monitor the service to include an internal Quality Assurance Management Audit, Financial audit and a Health and Safety Audit. The team are actively working towards the recommendations made. Training opportunities have improved and seven out of the ten permanent staff employed hold an NVQ qualification. The new management team have introduced change and structure to the service. It was reported that staff morale is very good. One member of staff stated ‘I now look forward to coming to work. Many changes have been made for the better and service users are happy’. Another member of staff stated ‘Service users are definitely a priority here’. What they could do better: Feedback received in one survey forwarded to CSCI in preparation for the inspection stated ‘From March to September last year whilst chaos reined it is a credit that staff didn’t resign. With regard to the current service provider, they have not yet fulfilled the promise that we expected…what they thought they had tendered for and what was required of them were not one of the same, and this has caused unexpected problems for them’. The service has been without a registered manager for a long time and both service users and staff have experienced numerous changes in the management of the home over the last two years, which has had a significant 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 7 impact on service delivery and outcomes for people living at the home. People now require stability within the staff team; therefore an application to register a manager needs to be submitted to CSCI as soon as possible. The acting manager should continue to keep staffing levels and the use of agency staff under review given concerns raised in surveys received by CSCI in preparation for this inspection. Discussions held with staff and training records seen evidence that staff have attended some service specific training but would welcome training in autism to support the needs of two people accommodated. The Acting Manager acknowledged that staff supervisions have lapsed but committed to making this a priority in addition to staff appraisals. This inspection evidenced that outcomes for service users have been enhanced since the last inspection therefore it is essential that the service continues to improve and develop for the people living at the home. Two requirements were made as a result of this inspection and they relate to the need to review the generic medication policy and procedure and that staff competency in handling and administering medication be measured. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 199 Doseley Road DS0000066727.V335051.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.V335051.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people and their representatives have the information needed to choose a home. They have their needs assessed and a contract which tells them about the service they will receive. EVIDENCE: Following the last inspection the homes Statement of Purpose has been updated to reflect managerial arrangements and the document was seen displayed in the home. Individual Service User Guides have been developed which are user- friendly and each person has been provided with a copy. The acting manager was advised to update documents to reflect current managerial changes and to ensure the Service User Guide complies with the changes in the Care Home Regulations as amended in September 2006. Following a referral from the local team and upon receipt of a Community Care Assessment and planned trial visits one person was admitted to the home in December 2006. Although initially the placement was considered appropriate the person has since left the home and reasons for this were shared during the inspection. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 10 Terms and Conditions of residency between the registered provider and each individual have been developed and approved by an independent advocate. People have recently been issued with their contract, which are comprehensive and produced in a format appropriate to the needs of the individuals living at the home. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with detailed information to ensure the individual assessed needs of people receiving a service are met. People are appropriately supported to make decisions and are enabled to take responsible risks within a risk-assessed framework, which is regularly reviewed. EVIDENCE: Care documentation held on behalf of two people was examined during the inspection and significant improvements were noted to the layout and the content of the files incorporating a person centred approach. ‘My Plan’ was available on the files examined and provides staff with detailed information for the delivery of support. Both people case tracked have received a formal review with the local team and significant others since the last inspection however the home have not yet received the minutes of the meetings. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 12 Key workers are responsible for compiling monthly reports to review individual health needs, finance, life skills, self-care, social/recreational and educational skills/needs and short-term goals. It was evident through discussions held with key workers and staff on duty that they had a clear understanding of the individual needs of the people they support. Throughout the inspection staff were observed to engage with service users in a positive manner and people were offered choices and were actively involved in decision-making processes in relation to their daily routines and activities. Each individual has an allocated key worker to represent their best interests and people also have access to an independent advocacy service. It was reported that one person was recently supported to attend an Advocacy conference. People living at the home are enabled to take responsible risks based on assessment. Since the last inspection risk assessments have been reviewed and new ones developed for in-house and community based activities as required. Assessments seen on the two files examined had been developed by the key workers and countersigned by the acting manager who stated that she has received relevant training to support this process. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their life style, and to develop their life and social skills and maintain family contact. Rights and responsibilities are promoted and people are provided with a varied diet in accordance with their personal preferences. EVIDENCE: Discussions held, records examined and observations made evidence that people are provided with opportunities to develop their skills, including social, emotional, communication, and independent living skills. One of the people case tracked attends college and a work placement during the week and clearly leads an active lifestyle. The other person reviewed attends a day service managed by the local authority five days per week and it was reported that he continues to enjoy attending the service. During the inspection a 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 14 further person was supported to attend a college course and people were seen going into the local community for a walk and to use the local recycling facility. Records seen on one file evidenced that a referral was made to the Communication and Swallowing Team and a communication assessment was undertaken with recommendations made however these have yet to be actioned. The acting manager committed to address this shortfall at the earliest opportunity. Objects of reference have been developed for a further person, and a staff member stated that this is proving very successful for the individual concerned. All staff spoken with reported that activities have improved and that people lead positive and active lifestyles. It was reported that individuals access public transport in addition to their own vehicles or the vehicle provided by the home. Activity records examined were detailed and it was reported that holidays have been arranged in consultation with service users and their relatives. People have the opportunity to develop and maintain personal and family relationships. During the inspection the relatives of a service user visited the home to join in their son’s birthday celebrations and discussions held with them suggest that they are made welcome at the home and that they have seen improvements under the new management team since the last inspection. Family contact details were available on the files examined and visits are also recorded in people’s daily records. Staff on duty had a clear understanding of service user rights and how these are promoted in addition to upholding privacy and dignity. Bedrooms are lockable and one of the people case tracked holds a key and chooses to lock his room when unoccupied, which staff clearly support. Staff were observed to knock on bedroom doors during a tour of home. Observations made indicated that people who use the service are treated with respect and are supported to assist with domestic routines as much as possible. People have unrestrictive access to the home and can choose when to be alone or in the company of others as observed throughout the inspection. Menus seen appeared balanced and nutritional and cater for the varying dietary needs of the people living at the home. It was reported that one person is following a healthy eating plan and was seen to prepare himself a snack and a drink. Observations made and discussions held suggest that the team could monitor the persons dietary needs more closely to assist with maintaining his weight. It was reported that people are involved in meal planning and shopping. During the inspection people were supported to go out for a meal to celebrate a service users birthday. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. 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 however the medication policy and procedures require review to fully safeguard service users. EVIDENCE: Since the last inspection staff have started to develop Health Action Plans for the people they support and these were seen on the two files examined but have yet to be completed. Preferences in relation to personal support needs were found more detailed than at previous inspections and developed using a person centred approach. Surveys received in preparation for the inspection indicated that the home could improve the laundering of personal clothing and ensure people only wear their personal clothing. One person stated ‘Not always pleased with clothing and personal hygiene, especially shaving’. People were found well presented during this unannounced inspection. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 16 Records reviewed and discussions held with key workers evidence that the health needs of the people living at the home are taken seriously and individuals are appropriately referred to health and social care professionals as appropriate. Appointments and outcomes were recorded on the one file examined but not on the other file. It was reported that the person is accompanied to all appointments by his parents however there is still a need to record outcomes of appointments for the purpose of monitoring the individuals health. Information relating to specific medical conditions was seen on the files reviewed. The CSCI’s Pharmacist Inspector has recently undertaken medication audits at two local homes managed by the organisation and the generic policy and procedures for the safe handling of medicines was found to be lacking in detail and did not provide the staff with a detailed account of how medicines should be handled. With the exception of this and the lack of staff competency monitoring records, procedures adopted by Doseley Road staff appeared satisfactory at the time of this inspection. The home has liaised with CSCI’s Pharmacist Inspector and obtained advice on the management of one person’s medication. The training matrix identified that all but four staff have received medication training. Medication is stored securely in service users own rooms and records evidence that medication reviews are regularly held. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to a robust, effective complaints procedure. People living at the home are protected from abuse, and have their rights protected. EVIDENCE: People who use the service and their representatives have access to a complaints procedure in an appropriate format. A Complaints & Compliments log is held next to the visitors book in the reception area of the home. No complaints were found recorded in the book and the acting manager confirmed that no complaints have been received since the last inspection. No complaints or concerns have been referred to CSCI. The home has received twelve compliments since the last inspection and comments include: ‘Welcomed very nicely, very helpful homely atmosphere’. ‘Nice relaxed friendly atmosphere. Clients seem very happy & welcoming’. ‘Warm welcome, fresh, clean and bright, very relaxed’. Staff have access to the local Multi-Agency Adult Protection policy and procedure and this was seen readily accessible in the office. No referrals under these procedures have been made and a review of the training matrix 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 18 indicates that eight staff have received training in adult protection since the last inspection and all but four staff have received accredited training in the Management of Actual and Potential Aggression (MAPA). It was reported no person has been subject to physical intervention or restraint since the last inspection. An external financial audit was undertaken 7.3.07 and the acting manager stated that she is awaiting the full report but that the few recommendations made have since been met. It was reported that people who use the service hold their own bank accounts and appointeeship is currently under review. The acting manager and staff spoken with reported that they are happy with financial procedures in place and considered these safeguard people. Records examined evidence that the acting manager regularly audits people finances. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with a comfortable, clean, safe and well-maintained environment to live. EVIDENCE: A brief tour of the home was undertaken. The accommodation provided is over two floors consisting of comfortable, bright and spacious rooms. Peoples own bedrooms were found personalised and reflect their individuality. A new dining room suite has recently been purchased alongside numerous photographs, pictures and ornaments presenting a relaxed and more homely atmosphere. It was reported that the lounge suite is due to be replaced with one more suited to the needs of the people accommodated. The hob in the kitchen has been replaced and a new garden fountain purchased and people have been supported with planting out tubs. Plans to improve the garden were shared with the inspector however the front and rear 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 20 gardens are currently overgrown. The acting manager stated that quotations to manage the gardens are currently being obtained from contractors. The acting manager committed to developing a programme of renewal and maintenance as required. The home was found clean at the time of this unannounced inspection and cleaning schedules are maintained. The staff-training matrix indicates all but five staff have undertaken training in infection control procedures. Substances hazardous to health are appropriately stored and assessments and data sheets readily available in addition to personal protective equipment. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are safeguarded by the homes recruitment procedures and are supported by a trained, enthusiastic and committed staff team who have a clear understanding of their individual needs. EVIDENCE: Discussions held with three support staff during the inspection evidenced that they had a clear understanding of the individual needs of the people they support. They spoke positively about their role and responsibilities and reported that significant improvements have been made since the last inspection in relation to the management of the home. It was reported that staff morale is very good. One staff member stated ‘I now look forward to coming to work. Many changes have been made for the better and service users are happy’. Staff spoke about increased training opportunities. Another member of staff stated ‘Service users are definitely a priority here’. Another person stated ‘The home is much improved’. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 22 Due to concerns raised via feedback from surveys regarding staffing levels and high use of agency staff at the home, the rota was examined and evidenced three shift patterns with a minimum of two staff on shift and a third staff member working between the hours of 9am – 9pm. Staff spoken with confirmed staffing is appropriate to meet the individual needs of the people they support. Surveys were distributed to relatives and health and social care professionals in preparation for the inspection and concerns were raised in relation to staffing levels. One person stated ‘There always seems to be a staffing issue at bank holiday times and no-one appreciates that it is the residents bank holiday too, and they should be suitably staffed to enable them to have some fun, not for meaningful activity/occupation to cease at 5.00 pm, this situation regularly occurs and places staff interests before residents welfare’. Another person stated ‘Am pleased with the care of regular staff, but do get very concerned over the use of agency staff’. Another person stated ‘A staffing level of two is not safe or satisfactory when all residents are in the house…More thought should be given to ensuring that there is a mix of experienced and less experienced staff on duty at one time. There is a marked difference in atmosphere in the house when it is not properly and suitably staffed’. Monitoring forms have been developed since the last inspection to monitor the use of agency staff used within the home. Monitoring forms for February and March were examined during the inspection. One shift was recorded in February and ten shifts in March, which was mostly waking night cover due to 1x30 hr waking night vacancy. It was reported that the home uses staff from one agency that are familiar with needs of service users. Concerns were stated in feedback received in preparation for the inspection in relation to the agency staff used last year where English was not their first language. It was stated ‘We felt that this was completely inappropriate given that residents already have severe communication difficulties’. The acting manager must continue to keep staffing levels and the use of agency staff under review given concerns raised in surveys received by CSCI in preparation for this inspection. Personnel files are currently held at the organisations area office and records for two staff recruited since 21.07.06 were examined during the morning of 23rd April 2007. No shortfalls in documentation required by Regulations were identified. Dimensions have requested to centralise their Human Resources records, which CSCI policy now allows following approval. This allows the provider to keep the originals of their records centrally and keep a proforma in the care service, which the acting area manager committed to undertake. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 23 An overall staff training and development plan and individual training and development assessments have not yet been undertaken as required by the previous inspection however the acting manager stated that a Team Away Day, scheduled for 26.4.07, would help identify training needs to assist with this process. A Training matrix has been developed since last inspection and it was reported that managers are currently in the process of collating photocopies of staff training certificates. Staff have attended some service specific training but would welcome training in autism. It was reported that all staff are booked to receive training on the Mental Capacity Act shortly. The acting manager stated that seven out of the ten permanent staff employed hold an NVQ qualification. Staff have recently received some service specific training delivered by a healthcare professional and a compliment was seen recorded in the complaints/compliments book which stated ‘Carried out training for staff – very well received. Staff were co-operative and joined in well with experiences and questions’. The Acting Manager acknowledged that staff supervisions have lapsed but committed to making this a priority. A supervision and appraisal tracking document has been developed which indicates forthcoming supervisions have been scheduled. Staff have yet to receive an appraisal. Regular team meetings are held and a team away day scheduled. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team are approachable and supportive, having a positive impact on staff and service users. Aspects of performance are reviewed and the health, safety and welfare of service users and staff are promoted. EVIDENCE: Nicola Barina was employed to manage the service from 9.10.06 and was in the process of applying for registration however she is currently acting up into Area Manager position therefore the deputy manager, Claire Downing has taken on the position of acting manager from 18.4.07. Ms Downing stated that she has increased her hours accordingly and changed her shift pattern to enable her to effectively manage the service. She stated she has 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 25 obtained NVQ level 4 and reported that many improvements have made to the service since the last inspection to include record keeping systems, staff morale and improved activities and opportunities for people using the service She described Ms Barina as ‘Fair but firm’ and stated that staff are working well as a team. Comments in surveys received in preparation for this inspection include ‘Management doesn’t seem as constant as the support workers, making it difficult as parents to feel confident as to why Doseley Road never seems to have a permanent manager’. An internal Quality Assurance Management Audit was undertaken on 23.1.07 by the organisation and the report identifies strengths and weaknesses and identified actions. It was reported that quality assurance surveys have yet to be distributed to service users/ their representatives, families and stakeholders however a Family event was held on 5.12.06 and feedback sought from relatives about preferred forms of communication in relation to future events. Visits and reports as required as required by Regulation 26 are undertaken and copies forwarded to CSCI. It was reported that the team would develop a service ‘PATH’ for the forthcoming year at the Team Away Day to inform planning and review. The organisation has recently set up a Joint Consultative Group and a Regional Advisory Forum to assist with quality assurance and future planning. Record keeping systems are much improved. Those examined were wellpresented, easily accessible, user friendly with evidence of regular review. Records examined evidence that health and safety checks are carried out at the required frequency and all equipment serviced within required timescales. Staff receive training in safe working practices and risk assessments have been reviewed since the last inspection. It was reported that both the Environmental Health Officer and Fire Officer have visited the home since the last inspection and the only outstanding requirement is for a detailed fire risk assessment to be completed. The home is nearing completion of this as evidenced during inspection. The temperature of the water tested in one of bathrooms on the first floor exceeded the recommended safe limit, however the acting manager committed to reporting this as a matter of priority. Records evidence that staff test water temperatures prior to individuals taking a bath. A health and safety audit is undertaken monthly by the staff team and a comprehensive health and safety inspection was recently undertaken by the organisation and a report submitted to CSCI. 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 3 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 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x 3 3 x 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 27 No 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 Timescale for action 30/06/07 2. YA20 13(2) A comprehensive policy and procedures document must be developed for the handling of medication within the home, which depicts all of the procedures that are, and need to be, carried out by the care staff to ensure people are safeguarded. An effective programme must be 01/06/07 developed to assess and monitor care staff competency in handling and administering medication to ensure staff are competent in the management of medication in order to fully safeguard people. 199 Doseley Road DS0000066727.V335051.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 YA17 YA36 YA37 Good Practice Recommendations It is recommended that the nutritional needs of service user identified at inspection be assessed and kept under review. It is recommended that staff receive formal supervision at the required frequency and an appraisal of their performance as soon as possible. It is recommended that an application to register a manager be submitted to CSCI as soon as possible. 199 Doseley Road DS0000066727.V335051.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 199 Doseley Road DS0000066727.V335051.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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