Inspection on 20/03/07 for 267 Walmersley Road

This inspection was carried out on 20th March 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 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

267 Walmersley Road 14/07/09

267 Walmersley Road 03/10/08

267 Walmersley Road 08/10/07

267 Walmersley Road 09/03/06

267 Walmersley Road 31/10/05

267 Walmersley Road 26/02/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 267 Walmersley Road 267 Walmersley Road Bury BL9 6NX Lead Inspector Julie Bodell Unannounced Inspection 20th March 2007 08:30 267 Walmersley Road DS0000062679.V297766.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 267 Walmersley Road DS0000062679.V297766.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. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 267 Walmersley Road Address 267 Walmersley Road Bury BL9 6NX 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) 0161 737 7339 0161 737 3907 Pendleton Care Ltd ** Post Vacant *** Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 6 service users to include: up to 5 service users in the category of LD (Adults with learning disabilities) and 1 identified child with a learning disability. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th March 2006 Date of last inspection Brief Description of the Service: 267 Walmersley Road provides a specialist residential facility for up to six young people who have Asperger’s Syndrome or associated communication impairments. The house is sited on a main road, has good public transport links and is accessible to community facilities. The current fees for the service range from £39,876 to £86,400 per annum. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one and a half days. The inspector spoke with the divisional manager; the acting manager, two service users’ and observed other service users’. The inspector also spoke to five staff members, looked around part of the building and at paperwork. Four survey responses were received from health and social care professionals. No issues of concern were raised in the responses. What the service does well: What has improved since the last inspection? The statement of purpose has been looked at and amended to reflect changes in the service that is provided. Parts of the building have been re-painted. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A very thorough assessment is carried out by a qualified professional within the service prior to a service user moving into the home to ensure that the service will be able to meet their specialist needs. EVIDENCE: The support records of two service users who have recently come to live at the home were examined. Both show that either the divisional manager or the service’s behavioural psychotherapist, prior to a service being offered, carried out a very thorough assessment of the service users needs. The assessments covered a wide area and included communication, social understanding and interaction, imagination and flexibility of thought, physical health, interests, dislikes, sensory processing issues, psychological well being, behavioural issues, identified risks, social care needs, education and learning and aspirations. For one service user there was also a copy of an assessment carried out by the National Autistic Society and a CPA that had been updated at the point of admission. For the second service user, who is still legally a child, LAC documentation was in place. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have very detailed care plans and risk assessments in place and are involved in the development of them. Both documents give support workers clear information as to how they are to support the service users effectively. EVIDENCE: The inspector examined two service user plans. Plans are developed throughout the assessment period and reviewed and updated as the placement progresses. Information is gathered from as many sources as possible during the assessment process such as the family, social worker and other people who have involvement in the service users life. The plan covers a wide range of areas including a detailed biographical and background information, likes and dislikes, transport, communication, social interaction, imagination and 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 10 flexibility of thought, sensory, medical details, prescribed needs and support guidelines around daily routines. Very detailed risk assessments were also in place covering areas such as deteriorating mental health, accessing the community and other areas that link to specific phobias, fears and paranoia. Any restrictions are recorded on the care plan where risks are identified. Risks are assessed prior to admission in order to determine whether an individual’s needs could be met within the established service user group. There is a behavioural profile management plan that gives support workers information that describes indicators and triggers and descriptions of the service users behaviours and how to manage them to prevent escalation, for example by minimising levels of anxiety. Service users have SMART (Specific, Measurable, Achievable, Realistic and Time-scaled) goals in place to help them manage any behavioural issues that they may have and help them move on. Service users are asked to sign the plan. The plan is reviewed on a 6 monthly basis and more if necessary. There is a key worker system in place. It was clear from discussion with staff members that they had a good knowledge and understanding of the service users behavioural needs and possible triggers to behavioural changes. Staff members said that they found written information on the working files to be very good, clear and informative. Care plans and risk assessments matched the information that the inspector gathered during discussions with both service users and staff members. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 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. Service users’ are supported to live full and active lifestyles that are based on each individual’s needs and choices. Opportunities to take part in educational, recreational, employment and training activities help to promote the service users’ independence and their personal development. EVIDENCE: All service users have a weekly plan of activities, which they are involved in setting up. If the activity that is planned does not take place then what actually happens is recorded. The activity plans are developed around each individual service users needs and change as necessary. For example one service user is affected by seasonal change and takes part in less activities’ in the winter months and much more in the summer months. A wide range of activities’ are undertaken as part of education, training and employment, again dependent on each individual service users needs. One service user is currently 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 12 undertaking a college course in IT and another service user is involved in a college course for head massage. One service user attends the organisation’s development centre for support with literacy, maths and working on a healthy eating project. One service user is now looking for work after undertaking English and Psychology to A level standard at college. The service user is being supported to look for work by Connexions and is on the waiting list for BEST a local employment service for people who have specific needs. A social worker stated in a survey response that they were, “very pleased with support provided.” Promoting independence is a key part of the underpinning practice of the home. Service users are encouraged to be involved in household tasks such as washing and ironing, and keeping their own rooms clean, as identified in their care records. One service user was observed emptying waste bins. Most service users are supported to do a personal shop every week. There is transport provided by the service available to those service users who are not able to use public transport effectively. The support workers felt that the vehicle provided was difficult to manoeuvre and concerns were raised about potential risks due to the seating arrangements. Service users are encouraged and supported to pursue their own interests. Until recently, one service user attended drama and Aspirations on a weekly basis. One service user is involved in regular exercise and uses an exercise bike daily, goes swimming, cycling and using a trampoline with support from staff members. Another service user goes to the gym three times a week, independently. Service users enjoy music, especially the digital music channel, writing, the Internet and computer games, as well as DVD’s and videos, particularly science fiction and cartoons. The Internet is very popular with service users. It has been promised for sometime that Internet access would be introduced at the house. This is yet to happen. All service users have contact with their families. Two service users go to stay with their families regularly. Dependent on the individual needs of the service user the support workers will have a handover with the family to ensure that support guidelines are followed at home to promote continuity and routines. The kitchen was checked and found to be clean and tidy and well stocked with food, including some fresh fruit and vegetables. Service users are supported wherever possible to make their own breakfast and snack lunches with extra support being provided to those involved in cooking main meals. Some service users enjoy going out for meals at specific cafes or drive in fast food places. Care needs to be taken to ensure that food purchased by service users does not become out of date and pose a health and safety risk. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 staff team are able to meet the specific needs of individual service users’ through attention to the detail in support plans and risk assessments. An awareness of changes in communication and behaviour ensure staff respond appropriately to service users behaviours. Improvements to the medication system are still needed to ensure the health and safety of service users. EVIDENCE: Service users need varying levels of support from the staff team and this is reflected in their care plans. The support needed by service users is delivered in a very precise and consistent way to ensure the emotional wellbeing of service users is maintained. Support workers are very aware and pay attention to small detail and subtle changes in the way a service user communicates or changes in behaviour that relate to fears, phobias and paranoia. Staff members have access to very good written guidance to do this and permanent longstanding staff members have good background knowledge, skill and 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 14 experience. The staff team have access to the service’s behavioural psychotherapist and the development centre. All service users are registered with a local G.P, dentist and optician and where necessary specialist healthcare professionals. Records of appointments are maintained. Lengthy discussion took place around the behavioural management issues of each service user and different approaches that the support workers use. There has been a recent deterioration in one service users mental health status and the service user concerned has returned home. CAMHS are involved with the service user who will be re-assessed to ensure that present needs can be met, before returning to the home. The behaviour of the service user had had a dramatic affect on the other service users at the home. But it also provided an opportunity to see what progress they had made in managing their own behaviour in adverse circumstances. One service user showed that they had become more tolerant of others and was able to remove themselves independently and another although verbalising retaliation, did not do so and was easily redirected. Discussion also took place about work with other service users’ who lacked motivation or had limited understanding of social boundaries. One service user has been working with a speech and language therapist using brainstorming word techniques, balloon work and mind maps to increase the use of language. The service user was observed to be increasing in confidence and was interacting in a relaxed and friendly manner with the staff team. At the last inspection some issues were raised around recording systems and shelf life of medication. A request has been made for the CSCI pharmacist to audit the system. A visit was made, and the pharmacist made a number of requirements and recommendations. These requirements and recommendations were looked at again during this visit. The support worker could not locate an updated and reviewed medication policy and procedure or the “leave” risk assessments. There were improvements in the MAR sheet but half the MAR sheet was being completed in writing by the pharmacy, though because the information is handwritten it could be concluded that a member of staff from the home has completed the entries. The three requirements made by the pharmacist remain on the report. In respect of the recommendation there was no evidence readily available that advice from the pharmacist had been sought or if from that advice any changes had been made, or that a homely remedies policy had been implemented. Out of date homely remedies were found in the cupboard including a remedy brought from a service user’s home that was 10 years out of date. In line with good practice the issues around the storage; handling and recording of controlled drugs had been addressed. This recommendation has been removed. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 23 and 24 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Mandatory training is available to the staff team to ensure that they have the knowledge to protect service users from abuse. EVIDENCE: The Home has a complaints procedure. There has been one ongoing complaint about the service, which CSCI have been made aware of in respect of the financial arrangements of one service user. The Home has both an Adult Abuse policy and a Whistle Blowing policy. There is also a copy of No Secrets. The acting manager has delivered POVA training to the staff team, and following the recent admission of a service user who is still legally a child the divisional manager has delivered internal training to the staff team. The staff team that have received the training sign to say that they have seen copies of the local vulnerable adults procedure and the POVA guidelines following the training to ensure that clear links are made between internal policies and external local authority policies. Staff members receive physical intervention training and there have been times when techniques have had to be used. There are no physical interventions being used on an individual basis at the Home at this time. There has been an incident recently at the home that had resulted in the Police becoming involved. This incident should have been reported to CSCI. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. The property is large and spacious and provides service users with a comfortable and homely environment. Some attention is needed to improve health and safety by ensuring that window restrictors are in place where necessary and that arrangements are in place to prevent condensation developing that can be a cause of ill health. EVIDENCE: 267 Walmersley Road is a comfortable, homely, spacious detached property situated on a main road. It is tastefully furnished to a good standard reflecting the age group and the needs of those living there. Since the last inspection parts of the house have been repainted including the hall and stairs. The inspector with the permission of service users looked at three service users bedrooms. In one bedroom the chest of drawers were broken and need 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 17 to be repaired or replaced. Due to the preferred living conditions of the same service user, heavy condensation was found at the window and mould to the net curtains. The build up of mould spores in the bedroom could have an adverse affect on the service users health particularly respiratory type illnesses. Air vents to the bathrooms need to be cleaned and operable to prevent damp developing. A window restrictor need to be put in place in the bedroom for one service user, and other bedroom windows need to be checked to ensure that they are safe. The house felt warm and comfortable and observed that an acceptable standard of hygiene and cleanliness was seen throughout the building. The hall and stair carpets had recently been cleaned. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Care needs to be taken to ensure that there are sufficient numbers of permanent staff in place that have the experience, qualifications and skills to meet the needs of the service users living within the registered home and the outreach service that is being provided. The staff team needs to be strengthened to ensure that it can meet the specialist needs of the service users and withstand any further staff changes within the team. EVIDENCE: The level of need of the current service user group remains complex. As identified at previous inspections the originally high ratio of staff to service users has been reviewed and reduced over time. There remains an experienced core staff team of three, which includes the acting manager who has worked at the Home as a deputy manager and support worker for sometime and two other senior support workers. There are currently two full-time vacancies for support workers at the Home and a waking night staff, which have been vacant for the last six months. The 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 19 reason for the delay in filling the posts was discussed. The home has struggled to get suitable candidates for the posts. It was also said that it might be beneficial to advertise the jobs locally. There have been three consistent agency workers in place since October 2006 all of whom were described as very good, but other members of the staff team felt that this had been more down to good luck and was precarious because they might leave at anytime, without notice. Permanent staff members need to be employed as soon as possible to ensure continuity and consistency for service users, particularly given the nature of their needs. The inspector remains mindful that the service also continues to run an outreach service. The statement of purpose, which has recently been reviewed and revised, makes reference to the outreach service being run from the home as part of the organisations domiciliary service. The home is not registered to provide domiciliary care and the inspector requires more information on the arrangements for domiciliary service delivery from this address, which equates at present to 21 hours per week of staff time. The registered provider must ensure that there is enough suitably qualified, experienced and skilled staff in place to effectively meet the specialist needs of the service users at the Home at all times and that the outreach service does not compromise the service provided to those living at the home. An on-call system is in place. The acting manager is undertaking NVQ Level 3; one senior support worker is working towards NVQ Level 3, with the other senior support worker holding an NVQ Level 2. One night and one daytime support worker are undertaking NVQ Level 3. Two staff members hold an NVQ Level 2 and two support workers are undertaking NVQ Level 2. A minimum of 50 of the staff team needs to have achieved the qualification to NVQ Level 2 or the equivalent to meet the standard. Recruitment files for two permanent staff members were examined and generally found to be in good order. However, there was only one reference found on one of the files examined, when there should have been two. All members of the staff team undertake induction training. There is a wide range of training available to the staff team including learning disabilities and autistic spectrum disorders, introduction to challenging behaviours, values and principles of care, Asperger’s Syndrome, imagination and flexibility of thought, social understanding and interaction, sensory perception differences, physical intervention, health and safety, care of medication, communication, first aid and food hygiene. There is a training calendar in place for January to June 2007. The inspector requires an updated copy of the training matrix, to evidence that all the staff team have received mandatory training. The support workers and agency workers said that they felt very well supported by the managers’ at the home and received regular formal and informal supervision, though the formal supervision has not been recorded in 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 20 the staff files. However, some staff members said that they were very unsettled because the divisional manager and another very experienced registered manager were leaving. This made them feel uncertain about the future both for themselves and about how arrangements were going to be managed in respect of future admissions into the home, particularly during the assessment process, given the service users’ very complex needs. Reassurance and stability is needed at the home. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that the service users benefit from a well run home the organisation must submit an application for a registered manager to the CSCI. EVIDENCE: The previous registered manager was promoted to divisional manager within the organisation in September 2006, which led to the deputy manager becoming the acting manager for the service with the support of the divisional manager, who is qualified and a very experienced manager. There was some confusion at the time of the inspection about whether the person in charge was indeed the deputy or the acting manager as there had been no adjustment in payment for the post since that time. No interviews have taken place for a registered manager and no application for a registered manager has been 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 22 received by CSCI from the organisation. It is a condition of registration that, “the service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection.” It is expected that an application be received from the organisation within 3 months of a registered manager leaving the post. The acting manager is held in high regard by the staff team. But she has been well supported in the role by the divisional manager. The divisional manager is leaving at the end of March 2007. The inspector has expressed concern at previous inspections about the need to strengthen the staff team in terms of qualifications’, experience and skill to meet the specialist needs of the service users and withstand any future changes within the team. The loss of the divisional manager will further weaken the staff team and the overall management of the home and the excellent ratings in this report relate strongly to her input. The inspector is aware that other managers, who this service can access for advice, are also leaving the organisation. The divisional manager has undertaken Regulation 26 visits and copies of the reports for the last six months were given to the inspector. The responsible individual needs to submit the name of the person who will now take responsibility for this task. The divisional manager had also undertaken a quality assurance audit on 12/03/07. A quality review of the service needs to be undertaken to ensure that the service is being run in the best interests of the service users. A lengthy discussion took place about the future of inspection and the quality ratings. Information about Inspecting for Better Lives can be accessed on the Internet but as already stated the home does not have Internet access. Health and safety records and recording were checked. Portable electrical equipment was being checked during this inspection. A gas safety check was undertaken on 22.01.07. The fire alarm system, emergency lights and fire extinguishers were checked on 05.01.02. Health and safety checks are undertaken in relation to freezer temperatures, food temperatures and water temperatures. The inspector had some concerns about the water temperatures records. During discussion it was said that there had been difficulties maintaining steady water temperatures and baths for service users were also sometimes too cold. In line with good practice showerheads are cleaned weekly. The acting manager was advised to contact Environmental Health for further information on water temperatures. Weekly fire system checks are carried out to heat and smoke detectors. The NICEIC valid for 5 years from 15.04.02 is due for renewal. The home has insurance cover until 23.06.07. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 2 X X 2 X 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES – Pharmacist 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 The registered person must review and implement the medication policies and procedures. (Outstanding 14/08/06.) The registered person must ensure that complete, clear and accurate records of medication administration are maintained. (Outstanding 14/08/06.) The registered person must ensure that arrangements for ‘leave’ medication are risk assessed and documented in individual files. (Outstanding 14/08/06.) To ensure the protection and safety of the young person CSCI must be formally informed about the significant incident that took place during which it became necessary to involve the Police. To ensure the safety of service users window restrictors must be put in place to first floor bedroom windows were necessary or where appropriate a risk assessment produced to confirm that the service user occupying the room does not DS0000062679.V297766.R01.S.doc Timescale for action 30/04/07 2. YA20 13(2) 30/04/07 3. YA20 13(2) 30/04/07 4. YA23 35 30/04/07 5. YA24 23 30/04/07 267 Walmersley Road Version 5.2 Page 25 6. YA26 23 7. YA26 16 8. YA32 18 9. YA33 18 10. YA34 19 11. YA35 18 12. YA36 18 want or require a window restrictor. That arrangements are in place to prevent condensation developing that could be a cause of ill health to service users. That the identified chest of drawers in a service users bedroom are repaired or replaced. To ensure that service users needs are met by competent and qualified staff, a minimum of 50 of the staff team (including agency) need to achieve a qualification to NVQ Level 2 or the equivalent To ensure that the service users are supported by an effective staff team the registered provider must ensure that there is enough suitably qualified, experienced and skilled staff in place to meet the specialist needs of the service users at the Home at all times. The registered provider must inform CSCI of what action is to be taken to recruit permanent staff and write to explain the current legal position in relation to arrangements for those service users being provided with and outreach service from the registered home. To ensure that service users are protected by the home’s recruitment practices the registered person must obtain two written references for all employees. That an up-to-date skills matrix is completed and a copy sent to CSCI that evidences that service users are supported by appropriately trained staff including agency workers. That supervision records are DS0000062679.V297766.R01.S.doc 30/04/07 30/04/07 30/04/07 30/04/07 30/04/07 31/05/07 30/04/07 Page 26 267 Walmersley Road Version 5.2 13. YA37 38 14. YA39 26 15. YA39 24 16. YA42 13 maintained to evidence that service users benefit from wellsupported and supervised staff. The registered provider must provide CSCI with the name of the person managing the home and make an application to CSCI to start the fitness process. With the departure of the divisional manager the responsible individual must inform CSCI who will now undertake Regulation 26 visits for the organisation. A copy of the reports for these visits must be forwarded to CSCI. To ensure that the service is run in the best interests of the service users a quality review must now be undertaken and a copy of the report produced sent to CSCI. To ensure the comfort of service users water temperatures to the baths via thermostatic mixer valves reach a water temperature that is high enough to ensure the service users are able to have a pleasant bath, safely. 30/04/07 30/04/07 30/06/07 30/04/07 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. Refer to Standard YA20 Good Practice Recommendations The advice of the supplying pharmacist should be sought about: record keeping, controlled drugs and homely remedies. Handwritten MAR entries should be signed, checked and countersigned. 2. YA20 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 27 3. YA20 Consideration should be given to the implementation of a homely remedies policy. 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 267 Walmersley Road DS0000062679.V297766.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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