Inspection on 04/04/07 for 26 Stockdove Way

This inspection was carried out on 4th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 Stockdove Way 02/04/08

26 Stockdove Way 13/12/05

26 Stockdove Way 10/11/04

26 Stockdove Way 29/07/04

26 Stockdove Way 04/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 26 Stockdove Way 26 Stockdove Way Perivale Middlesex UB6 8TJ Lead Inspector Ms Jane Collisson Unannounced Inspection 4th April 2007 10:00 26 Stockdove Way DS0000027730.V334835.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 26 Stockdove Way DS0000027730.V334835.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. 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 Stockdove Way Address 26 Stockdove Way Perivale Middlesex UB6 8TJ 0208 810 6699 0208 810 8104 hm26stockdove@ealing.org.uk 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) Ealing Consortium Limited Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate LD People who may have a physical disability. One named person with a learning disability over the age of 65 can be accommodated, as agreed by the Commission For Social Care Inspection, on the 13th October 2005. The home to advise CSCI when the person no longer resides at the home. 13th December 2005 Date of last inspection Brief Description of the Service: 26 Stockdove Way is a care home providing personal care and accommodation for seven people with a learning disability. The home is situated on a housing estate close to the A40 and public transport to Ealing Town Centre. The Registered Provider for the home is Ealing Consortium and the house is owned and maintained by Notting Hill Housing Trust. It is purpose built and was opened in 1995. The home adjoins 246 Haymill Close, which is also for seven people with a learning disability. The two homes have an entry code system and are divided by the staff bathroom and sleeping in room. There are seven single bedrooms situated over two floors, and the home is wheelchair accessible on the ground floor. A passenger lift was in the process of being installed at the April 2007 inspection. There are four bath and shower rooms, a lounge, dining room and large kitchen. There is access from the lounge to the large, well-maintained garden at the rear of the property. There is parking to the front of the house. The staff team consists of a Registered Manager, three Senior Support Workers, and a team of eleven Support Workers. There is one waking night staff and a member of staff from either the Stockdove Way or the Haymill Close staff team sleeps in at night. In addition to the office within Stockdove Way, there is a shared office with the Haymill Close staff. 26 Stockdove Way DS0000027730.V334835.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 the 4th April 2007 from 10.00am to 4.30pm. The Manager Designate was present. Seven of the staff team and the home’s cook were present during the day. All of the six of the people who live in the home were met. There was one vacancy. The Inspector toured the home with the Manager Designate. A lift was in the process of being installed to give access to the first floor for wheelchair users, or people with poor mobility. Changes to the first floor bathrooms were in progress to update them and make them more accessible. During the course of the day, people were undertaking a variety of activities, including visits to the Ealing Consortium ARC day centre, which is in the same cul-de-sac. Several people had enjoyed aromatherapy sessions during the morning, returning to the home for lunch. An additional staff member was on duty to provide for extra outings, including visits to the shops and the park, while the work on the lift and bathrooms was being carried out. There have been changes to the staff team since the last inspection in December 2005. The new Manager Designate has been in post since November 2006. Two staff were in process of leaving during this inspection, but three others have been recruited. Two vacancies remain. Agency and Ealing Consortium bank staff fill the vacancies on the rota. The staff team were observed to be interacting well with the people, most of whom have non-verbal communication only. The people were seen to enjoy a freshly cooked lunch. A review for one person was taking place during the afternoon and one relative was met. The people living in the home are all in the older age group, between 59 and 82 years of age. Problems had arisen with the fire alarm system in November 2006. An Immediate Requirement was issued for the Registered Providers to arrange for the work on the system to commence, as the fire points had not been tested, and fire drills had not been held, since November 2006. An additional visit was made to the home on 18th April to examine the staff records which had not been available in the home on the first day. Although some work had taken place on the fire alarm, the telephone line has to be replaced to enable the fire station to be informed automatically of the alarm being activated. The staff had undertaken a fire drill and two fire point tests had been carried out between the two visits of the inspection. The inspection took a total of eight hours. There were no requirements at the previous inspection but twelve were made at this inspection. 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The information to support people who might wish to move to the home, to understand and help them to make an informed choice, was not available in an up-to-date and accessible format. The Statement of Purpose needs to demonstrate that the facilities, activities and staffing can meet the needs of people for whom the home is intended. To enable appropriate placements in the home, it needs to be demonstrated that the full assessment procedures are in place when people are referred to the service. A professional assessment, which takes account of the needs and wishes of the person referred, together with evidence of consultation, needs to be in place. Care plans and reviews, which demonstrate that the needs and wishes of the people using the service are fully documented, and easily accessible and up-todate, must be in place. Clear and current information on health and welfare needs is required to ensure that needs are being met and outcomes recorded. The record keeping needs to be streamlined to support staff to provide appropriate care. Insufficient action had been take to address the health and safety issues in the home in relation to the fire alarm system, which had resulted in regular safety checks not being undertaken. The Registered Providers must ensure that appropriate action is taken when equipment is reported as being deficient. Some of the staff were in need of updated training. Although the Manager Designate had identified this, it needs to be shown staff training is kept up-todate, both to support the people using the service and to develop team skills. The target of having 50 of the staff trained to National Vocational Qualifications Level 2 or above has not been achieved. No information was initially available on the recruitment records for permanent staff. Those for agency staff were not fully completed to show that they have 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 7 up-to-date training. Information was made available at the second visit to the home. To help to safeguard the people using the service, evidence that staff are appropriately trained, and have the required documentation, is needed to be maintained in the home. The Manager Designate is new to care home management. The information regarding the Care Home Regulations 2001 was not available and the Registered Providers need to ensure that she has the support to be fully conversant with the requirements of being a Registered Manager of a care service. 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. 26 Stockdove Way DS0000027730.V334835.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 26 Stockdove Way DS0000027730.V334835.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, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is insufficient information for people who wish to use the service to support them, or their representatives, to make an informed decision about the home. It was not demonstrated that all of the referral and admission procedures are sufficiently robust to fully assess all of the needs of a prospective resident and take their wishes into account. Adaptations being made to provide a lift and accessible bathrooms should ensure that the needs of people with limited mobility can be better met. EVIDENCE: The current documentation in the home had not been amended to include the management and staff changes. The Service Users Guide and Statement of Purpose are still in the process of being updated and changed by the Registered Providers, Ealing Consortium. When this work is completed, the information will need to be provided to the Commission for Social Care Inspection. Those provided to the people in the home, and those who wish to be admitted, should be in suitable formats to suit their communication needs. The new Statement of Purpose will need to reflect the physical changes in the home. It will also need to detail how it meets the specific needs of the people using the service, all of whom are between 59 and 82 years old. 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 10 No new residents have been admitted since the last inspection. There was one vacancy, on the first floor, and the lift was being installed so that the people with limited mobility can use the first floor facilities. Although the referrals made for the vacancy had not progressed, the Inspector was informed that no needs-led assessments had been made available to assist the process of assessment by the home. A professional assessment, to show that the health and welfare needs of the person have been considered, must be in place when new referrals are made. Evidence of the assessment, and consultation with the person, or their representatives, needs to be available to ensure that all of the appropriate action has been taken to support a successful placement. All of the people are wheelchairs users when out of the home and the wider corridors and larger rooms on the ground floor accommodate their needs. An overhead hoist is used in one room and the bathroom facilities are suitable for people with physical disabilities. The majority of the people have non-verbal communication. Although no specific signing systems are used, use is being made of symbols and visual prompts. A good level of communication was noted between the people and the staff team. Four people are supported by representatives, who are either family members or provided through advocacy services. The staff said that they hoped to find advocates to support the other people. There were no specific cultural or religious needs noted to be required to be met at this inspection. 26 Stockdove Way DS0000027730.V334835.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, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the people using the service were not recorded in sufficient detail, or current enough, to ensure that all of their requirements and wishes are known. New staff would not be supported by this information to understand fully the needs of the people using the service. Support and encouragement to make decisions, and maintain independence, were being promoted by the staff team. EVIDENCE: The Inspector examined three of the care plans in detail. Each person has two files, one for care plans and reviews, and one for appointments and correspondence. One person, who had been in the home for more than a year, had not had the care plan updated, nor had a review taken place. The information held was mainly relevant to the person’s previous placement in another home. In the other files, the care plans had not been updated following reviews, so the information was not current. The Inspector discussed this with the Manager Designate and one of the senior staff as the current 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 12 goals, which had been agreed at reviews, where not always apparent. It would not support new staff to understand the individual person’s wishes or provide the information to review the care plans. This is of particular importance given the non-verbal communication of the people concerned. It is planned that a new care planning system is to be introduced. In the interim period, care plans must be shown to be current and shown to be produced with the person concerned, or their representative, wherever possible. A number of people had not had their annual review meetings and this had not assisted in keeping their care plans up to date. Staff were aware that some reviews were overdue and arrangements were being made to hold them. One was taking place on the day of the inspection. To meet the National Minimum Standards, and keep the information current, care plans should be reviewed at least six monthly. It was strongly recommended by the Inspector that the files are streamlined to provide clear and concise information regarding the each person’s support needs and personal goals. Although all but one of the persons living in the home are non-verbal, they were seen to be able to make their decisions known and staff responded well to these. More visual prompts are being introduced to support them to make decisions. This included the use of photographs of the staff, and “objects of reference” to support them to understand or choose an activity. These were accessible, in the hallway, so that they could be used as reminders. Among these were leaves to represent a visit to the park and a container of scent for the aromatherapy session. Good use had been made a digital camera to illustrate the documentation for the review taking place on the day of the inspection. People were seen to be encouraged to participate in the daily living tasks in the home, with staff assistance. These included making a drink and folding laundry. Although the kitchen is locked, for health and safety considerations, one person was seen to use it to make a drink, with staff support. None of the people are able to go out the home independently but within the home they are able to choose where to spend their time. One person has been able to show their preference for eating alone and this has been respected. Those who are able to act independently may choose to go to their rooms and all have their own facilities for listening to music or watching television. The records, such as care plans, are stored on open shelves, but within a locked office. One senior staff member discussed with the Inspector the issue of sensitive information being kept on the generally accessible files. The staff member was seeking clarification about data protection to ensure that this information is being stored appropriately. 26 Stockdove Way DS0000027730.V334835.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): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the opportunity to enjoy a range of activities at the nearby day centre, as well as individual outings and activities with staff. The meals observed were well balanced and prepared from fresh ingredients. EVIDENCE: Although all of the people are within an older age group, and some are limited by their physical disabilities, there appears to be the opportunity to enjoy a range of activities and to retain their skills. However, due to the lack of up-todate information, it could not always be seen how the current wishes, or the goals for their personal development, were being met. The updating of the care plans, as discussed elsewhere in this report, needs to include the ways in which people are supported with their personal development. All of the people spend some time at the Ealing Consortium day service facility, which is located next door to the home. The activities available include drama, 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 14 music and art. Four of the people had aromatherapy sessions on the first day of the inspection. One person attends a local evening club for people with learning disabilities. Although one care plan made a mention of a regular outing to church for one person, staff said that this was no longer a regular arrangement as the person did not always enjoy it. Photographs of trips to the London Eye and the Notting Hill Carnival were seen. Staff said that they try to arrange an annual holiday for all of the people living in the home. Where there are family, friends and advocates involved, contact is encouraged. They also visit the home and take people out. In one instance, support is given for a person to see a family member. Friends and relatives are able to use the dining room to meet the people they visit and the review meeting on the first visit of the inspection was held there. Attendance by the Inspector at the staff handover meeting demonstrated that people had been enabled to have choices about their daily routines. This included the wish of one person to return to bed for a “lie in” that day. While most of the people seem to prefer being around the lounge area, enjoying company, the choice of one person to spend time alone was respected. A cook is employed in the home for five hours a day, Monday to Friday. The meals seen on the day of the inspection were freshly prepared and there was evidence of ample fresh fruit and vegetables. A meal of stuffed peppers, potato wedges and salad was being enjoyed on the first day of the inspection, with a vegetable curry for the evening. The cook also prepares the meals for the weekend, in advance, and was assisting with the meals for the adjoining home as they were without a cook. The weekly menu is based on the meals that the people enjoy but alternatives are available if the any person indicates that they do not wish to have what is available. Meals taken are recorded in the daily logs. One person was having a food supplement because of weight loss. No specific cultural needs were required to be met at the present time. 26 Stockdove Way DS0000027730.V334835.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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by the staff team to have their health and medical needs through the use of community services. Better recording is required, however, to show that all of these needs are being met, with updated information incorporated into the individual care plans. The medication administration was satisfactory. EVIDENCE: Most of the people need full support with their personal care and one requires the assistance of two staff. The staff team reflects the mainly female person group and there is information on preferences for personal care noted in the care plans. However, male staff confirmed they do give support with personal care to the females. Because of the limitations people using the service have to express their personal preferences, it is recommended that this subject is discussed regularly at reviews, with the person and their advocate or representatives, to ensure that there is ongoing agreement about the assistance being provided. 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 16 Peoples’ health and medical needs are maintained by the use of community services, which includes visits to local general practitioners. “OK Health Checks”, a format to review, annually, the person’s health needs, were seen to have been carried out by the community nurse. However, because the files are in need of streamlining, and care plans need updating, it was not always possible to see the frequency of appointments, the outcome of visits and whether ongoing treatment is required. A more orderly system is required to evidence that peoples’ health needs are being met fully. None of the people would be able to self-medicate and all are supported by staff, who use a 28-day blister pack system to administer the medication. A number of medication errors had been reported by the home since the last inspection. Although staff have been carrying out daily checks to try and ensure that none occur, some errors of non-signing have happened since. Staff need to ensure more thorough monitoring to ensure these are noticed when medication is administered. The PRN (as and when) medication is kept separately for each person and a sample of these medication items were examined. All of the stock sampled was found to be correct. 26 Stockdove Way DS0000027730.V334835.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate action has been taken to try and ensure that people are protected from abuse or harm. Methods to support people to make their concerns known, with formats suited to those with non-verbal communication, could be explored to increase awareness and involvement. EVIDENCE: There had been one concern raised since the previous inspection but this had not been made formally into a complaint. Staff showed an awareness of the way in which the people show their concerns and said that these would be noted. One representative felt able to advocate on behalf of the person using the service and to make any concerns known to the staff team. However, no complaints procedure to suit the communication needs of the people in this home was available. It is recommended that work is carried out to see if people can be further involved in this procedure. There had been one incident reported under the Safeguarding Adults procedures to the Commission for Social Care Inspection. This had resulted from inappropriate handling. Manual handling raining for the staff member was organised following the incident. A key trainer in manual handling also attended a team meeting to ensure that staff were undertaking the correct procedures. Staff are provided with training on the safeguarding of adults during their induction period. One staff member was in the process of becoming a trainer with Ealing Consortium in order to facilitate courses. The 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 18 London Borough of Ealing’s safeguarding adults policies and procedures were seen to be in the home. 26 Stockdove Way DS0000027730.V334835.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, 25, 26, 27, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although major work was being undertaken, the communal and private areas were being maintained in good order. The house and garden provide a pleasant environment for the people living there. The health and safety needs of those living and working in the home had not been fully considered by the failure to have regular tests of the equipment or fire drills. EVIDENCE: The home is purpose built and provides a spacious environment. It is pleasantly furnished with personalised items around, such as photographs of the people living there and their activities. The lounge overlooks the wellmaintained garden, which had tubs of spring flowers. It is planned that some redecoration will be taking place of the kitchen. All of the bedrooms were seen on this inspection and seen to be pleasantly furnished and personalised with pictures and photographs. However, some of the carpets were noted to be stained but the Inspector was informed that new 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 20 carpets were on order. Televisions and music equipment were available and staff said that some people enjoy spending time in their rooms. Comfortable chairs have not been provided in the bedrooms. All of the rooms have the space available for at least one easy chair and this would support the people to use their rooms to listen to music or watch television in more comfort. The items details in the National Minimum Standards should be offered to the people and support given to ensure that their needs are met. The home has domestic assistance, from Monday to Friday, and was found to be clean. An incontinence laundry service is used. The area where the lift was being installed had been enclosed for safety, and to try and minimise the effects of the building work. Work was being carried out in the first floor bathrooms to make them more accessible, including the installation of walk-in showers. This work was due to be completed within the next month. There are four bathrooms, with assisted baths and shower equipment, to provide a variety of equipment to meet differing needs. All of the people have some mobility problems, ranging from using wheelchairs out of the home to the provision of an overhead hoist in one bedroom. The equipment was seen to have been serviced within the last six months. Staff have full manual handling training every three years, but the annual refresher courses for six of the staff were overdue. Because of the disabilities of the people, and their reliance on staff support, this training needs to be a priority. 26 Stockdove Way DS0000027730.V334835.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training needs have not all been fully met, possibly because of the staff and management changes. The target of having 50 of the staff team trained to National Vocational Qualifications Level 2 or above is unlikely to be achieved within a reasonable timeframe. It was not shown that people using the service were being safeguarded by confirmation of the full recruitment checks. EVIDENCE: There have been a number of staff changes since the last inspection, including the employment of a new manager in November 2006. This followed a year without a Registered Manager being in the home. The staff team had five support worker vacancies, but had been successful in recruiting three staff. Further recruitment is due in May. In the meantime, agency and bank staff are being used. A shift leader, who is generally one of the three senior support staff, takes responsibility for each shift. Duties include responsibility for medication administration and financial checks. The Manager Designate is employed from Monday to Friday, with one weekend day on duty each month. One member of 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 22 staff, from either the Stockdove Way or 246 Haymill Close team, sleeps in each night and there is a waking night staff in each home. The Manager Designate informed the Inspector that, if the seventh bedroom becomes occupied, there will be an increase from the current three staff on the early shift to four, and an increase from two to three staff on the late shift. Additional staff have been on duty, during the disruption caused by the work on the lift and bathrooms, to ensure that people have additional time out of the home. The staff recruitment files, or the information to show that the required information had been obtained, was not available for inspection at the first visit to the home. It is required that, to support the safeguarding of the people living in the home, staff are seen to have been the Criminal Records Bureau disclosure, references, health checks and other relevant documentation. The home had obtained a “profile” for the agency staff employed but these did not all have consistent information, such as showing whether staff had up-to-date moving and handling training. The Manager Designate undertook to get these by the second visit. As the recruitment records are held at Ealing Consortium’s central office, forms were obtained which recorded information about the records, and these were examined. They were generally in order but one appeared to show that a Criminal Records Bureau disclosure has been obtained after the employment had commenced. The Responsible Individual at Ealing Consortium had not signed the forms and this should be rectified. The Manager Designate had prepared information to show which of the staff needed updated training courses. These included moving and handling refreshers, choking and resuscitation, food hygiene and first aid. A new programme of training had arrived from Ealing Consortium and the Manager Designate was putting forward names for the courses. A full training programme is provided for new staff who undertake a two week induction when they commence with Ealing Consortium. In additional, all staff now undertaken the Learning Disability Framework Award induction, for the first six months, to develop their skills in working with people with learning disabilities. Three of the current staff team have a National Vocational Qualification at Level 2. Because of the staff changes, and the need to complete the Learning Disability Framework Award before commencing, there have been difficulties in meeting the target of having 50 of the staff trained to NVQ Level 2 or above. None of the newly recruited staff have a National Vocational Qualification. Two senior members of staff are training to be NVQ Assessors, one just completing the course. This should assist the home to meet the target of having 50 of the staff trained. 26 Stockdove Way DS0000027730.V334835.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changes in management and care staff have not supported the general maintenance of records and management tasks, but the recent appointments should help to provide more consistency for the people living in the home. The Registered Providers have taken insufficient action regarding health and safety issues in the home. They also need to provide the Manager Designate with the support to be fully conversant role of a Registered Manager. EVIDENCE: The home has undergone a number of changes in the last year and is relying on agency and bank staff to complete the rota. Although staff were more positive about the future now that there is a permanent manager in post, there remain a number of staff vacancies and priority should be given to fulfil these to provide consistency to the people living in the home. 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 24 The current Manager Designate was in the process of applying to the Commission for Social Care Inspection for registration. She has a degree in occupational therapy and is intending to undertake the Registered Managers Award. She has not had previous management experience as a manager of a registered care home. Information on the Care Home Regulations 2001 and National Minimum Standards was not available in the home and the Manager Designate will need to make herself aware of the requirements for a Registered Manager and the management of a care home. She had taken action to obtain the documentation by the Inspector’s second visit to the home. The Registered Providers need to ensure that new managers are supported to fulfil their role as a Registered Manager. While the non-verbal communication of the people using the service does limit the ways in which they can make their wishes and aspirations known, the staff showed an awareness of their likes and dislikes. Each person has a key worker and it is planned that the quality assurance system, which is now in place, will provide questionnaires which key workers will support residents to complete. A number of the files examined were in need of streamlining to make them more accessible and provide relevant information to support the people using the service. Some of the maintenance files also had information that needed to be brought up-to-date or archived. There has been a failure by the Registered Providers to address the problem of the fire alarm. Fire drills and weekly testing of the fire points had ceased as it was erroneously believed that the alarm could not be isolated and would alert the fire station when tested. An Immediate Requirement was issued to ensure that the Registered Providers took action to start the work to repair or replace the system. Although this work had not been completed by the second visit on the 20th April, it was underway, and a fire drill had been held and fire tests had recommenced. The telephone line was due to be replaced so that the alarm would go directly to the fire station. These concerns with the fire alarm system had been noted on a Regulation 26 Registered Providers’ visit to the home in December 2006 but insufficient action appeared to have been taken to have the system repaired or replaced. The concerns with the fire alarm system had not been reported under Regulation 37 as required. A senior member of staff had completed a fire risk assessment but insufficient information was included to demonstrate that all of the needs of the people in the home, who all have limited mobility, were fully considered. Further information was supplied following the inspection to show that the home was considering all of the potential risks and specifying what was being done to minimise them. During the inspection, the door of one person’s bedroom was seen to be propped open. The prop was removed but, as the person prefers to 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 25 the door to remain open, suitable equipment must be fitted to meet the fire regulations. The home did keep the Commission for Social Care Inspection informed regarding the Legionella testing and its outcome which was satisfactory. The home was also informed of a burst gas pipe in March 2007, which was repaired. 26 Stockdove Way DS0000027730.V334835.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 2 2 2 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X 2 2 X 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 4 (1) Requirement The Registered Providers must ensure that the Statement of Purpose is updated to provide information and details of how the specific needs of people admitted are to be met by the facilities and services in the home. The Registered Providers must ensure that the Service Users Guide is updated to provide information and details of the current facilities and services available. The Registered Providers must have the systems in place to provide evidence that any persons wishing to be considered for residence in the home have had all of their needs assessed, by a suitably qualified or trained person. The Manager Designate must ensure that care plans are updated, and reviewed on a regular basis, to ensure that the health and welfare needs of persons using the service can be fully supported, with their wishes seen to be taken into DS0000027730.V334835.R01.S.doc Timescale for action 30/06/07 2 YA1 5 (1) 30/06/07 3 YA2 14 (1) 31/05/07 4 YA6 12 (2) 15 (2)(b) 30/06/07 26 Stockdove Way Version 5.2 Page 28 account. 5 YA19 12(1)(a)(b) The Manager Designate must ensure that the information to support health needs is maintained in good order, updated regularly, and shows clearly how the needs of the individual person are being met. 19 (1) (b) The Manager Designate must ensure that the staff recruitment records of both agency, bank and permanent staff, or sufficient information to demonstrate that the information has been obtained, is available for inspection. 18 (1) (c) The Registered Providers must (i) provide an Action Plan for National Vocational Qualification training, to ensure that the target of having 50 of the staff team trained to National Vocational Qualifications level 2 or above, will be met within a reasonable timeframe. 10 (1) The Registered Providers must support the Manager Designate to ensure that they are fully conversant with the requirements of being the registered manager of a care home. 17 (1)(2) The Manager Designate must (3) ensure that the record keeping, including care plans and maintenance records, are updated and maintained in good order. 13 (4) The Manager Designate must ensure that where people using the service have a preference for leaving their bedroom door open, appropriate equipment is provided to minimise any risk to their safety in the event of a fire. 13 (4) Work on the fire alarm system must be commenced by 6pm on DS0000027730.V334835.R01.S.doc 31/05/07 6 YA34 31/05/07 7 YA35 30/06/07 8 YA37 30/06/07 9 YA41 30/06/07 10 YA42 31/05/07 11 YA42 06/04/07 Page 29 26 Stockdove Way Version 5.2 12 YA42 13 (4) 6th April 2007 to repair or replace the system to ensure it is in full working order. IMMEDIATE REQUIREMENT ISSUED The Registered Providers must ensure that the required health and safety checks, including fire equipment and fire drills, are carried out regularly and in accordance with their fire risk assessment, to minimise any risk to the people visiting, living and working in the home. 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA19 Good Practice Recommendations That the care planning files are streamlined for ease of use and to support reviews, which would assist staff to better support the people living in the home. That. because of the limitations people using the service have to express their personal preferences, it is recommended that the provision of personal care is discussed regularly as reviews, with the person and their advocate or representatives, to ensure that there is ongoing agreement about the assistance being provided. That ways of communicating the complaints procedure more appropriately to the people in the home are considered. 3 YA22 26 Stockdove Way DS0000027730.V334835.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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