Inspection on 08/10/07 for 267 Walmersley Road

This inspection was carried out on 8th October 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 20/03/07

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 8 & 15 October 2007 09:30 th th 267 Walmersley Road DS0000062679.V334530.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.V334530.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.V334530.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 761 2484 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.V334530.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. 20th March 2007 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 and “high functioning autism.” 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.V334530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection which the home did not know was going to happen took place over one day, as well as two short visits. Two inspectors and a pharmacist, who looked at the safety of the medication system, carried out the inspection. We spoke with the acting manager, two support workers and three people who use the service and briefly observed a fourth person. We also looked around the building and at paperwork. Information requested before the visit was received and four surveys were returned, one from a person who lives at the home, two from relatives and another from a social worker. What the service does well: What has improved since the last inspection? Ways of improving the involvement for people who live at the home in decision-making and participating in the day-to-day running of the home and the organisation are being considered. 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 6 Training has been undertaken in promoting independence and developing daily living skills and new documents have been introduced to help support workers to monitor progress. This will help to ensure that people living at the home are supported to keep their bedrooms clean and tidy, which has been a cause for concern. To ensure that people’s concerns and views are acted upon in an effective and fair way the complaints policy and procedure is being reviewed. A number of improvements have been made to the medication system to ensure the health and safety of people receiving medication, with only one item outstanding. Parts of the building have been re-painted and new bedroom furniture has been purchased for some people. To improve health and safety within the home window restrictors are now in place to first floor bedroom windows where necessary, and arrangements are in place to prevent condensation developing in some areas of the house that can be a cause of ill health. The monitoring arrangements by the person responsible for the home have been clarified and regular visits by an external manager are being made to the home. What they could do better: People who are considering using the service need to have more information about the home available to them to ensure that they can make an informed decision about whether the home is appropriate to meet their needs. The statement of purpose for the home needs to be reviewed, revised and amended to reflect recent changes in the service. People using the service need to have an individual written contract that gives clear information about what facilities and support they can expect from the home during their stay, including specialist services. This needs to be signed by the registered manager and the person using the service and by a third party if necessary. People’s support plans need to be kept under review to ensure that they reflect the changing needs of the person concerned. When serious incidents happen we need to be formally notified about them and where appropriate what the outcome was in respect of the incident. 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 7 Some members of the staff team need to undertake safeguarding training to ensure that they know what action to take to protect people living at the home from abuse. 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 complex needs of the people living at the home. All members of the staff team need to be provided with necessary induction and basic training to ensure that it can meet the specialist needs of people using the service effectively. To evidence that the organisation undertakes a rigorous approach to recruitment to protect people using the service, records that stand up to scrutiny must be maintained. To ensure that people benefit from a well run home the organisation must submit an application for a registered manager to the CSCI. A review of the quality of care of the service needs to be undertaken to ensure that the service is being run in the best interests of the service users. Bathroom water temperatures continue to be too low and do not ensure people living at the home can have a hot bath. This is compounded by poor water pressure. To ensure the health and safety of both people living and working at the home copies of certificates confirming the safety of the homes portable electrical appliances and electrical fittings and fitments are safe are required.. 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.V334530.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 267 Walmersley Road DS0000062679.V334530.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 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A qualified professional from within the service, prior to a person moving into the home, carries out an assessment to ensure that the service will be able to meet their specialist needs. More information that accurately reflects the service provided is needed so that people know what to expect. EVIDENCE: 267 Walmersley Road provides a specialist residential facility for up to six people who have Asperger’s Syndrome or “high functioning” autism. The current condition of registration for one identified child is to be removed, as that person is no longer residing at the home. Since the last inspection in March 2007 there have been a number of changes to personnel within the organisation, including a new divisional manager and a new behavioural psychotherapist. An updated statement of purpose is requested that also amends the facilities and services section and reference to the “outreach” provision of the service, which the home is not registered to provide. In response to the last inspection the person responsible for the organisation agreed that the “outreach” service would cease to be provided at 267 Walmersley Road following a planned recruitment programme at Pendleton 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 10 Care domiciliary care agency. There have been two referrals for the use of the “outreach” service since the last visit. We were informed that it is the organisation’s intention to move the development centre from Salford to the Bury area, in the near future and provision of the “outreach” service will be based from there. A date for when this service will cease to operate from 267 Walmersley Road is now required. A relative commented that although the staff team working at the home were very helpful in answering enquiries, “written information about the care home is poor.” The organisation have recognised that this is an area for improvement and there is currently a consultant working with the organisation to look at ways to improve the profile and quality monitoring of the organisation and this forms part of that work. Since the last inspection there have been no changes to the people using the service. Assessments have been looked at previously and found to be very thorough. We were informed that the assessment process for people wanting to access the service is currently under review. As this is yet to be agreed and used we were unable to form a judgement about the effectiveness of the new process. We were informed that the divisional manager and the behavioural psychotherapist are to be responsible for undertaking the new assessments. The registered manager will need to be kept involved when reaching an agreement for a person moving into the home as they will become legally responsible for meeting the assessed needs of the individual and those of the established group. As part of the former assessment process people visit the home to check out that they like it. One relative on a returned survey stated, “We visited 267 Walmersley Road together. We were shown round including the bedroom that would be allocated.” At the time of this inspection three people were in the process of leaving the home, all had Asperger’s Syndrome and associated needs. One person was living at home and making occasional visits, a second person was moving back to their home town to supported living accommodation and the third person was waiting to access another service. Both people currently living at the service said that they were happy to be moving on. A relative commented in a returned survey, “The staff are approachable and friendly but I do not feel it meets my son’s needs entirely and nor does he. At times it is more like living in a ‘hostel’, somewhere to reside, but he isn’t taught in the autism specific way both he and I hoped for.” However responses from a relative of a person diagnosed with Autism were more positive stating, “they have developed good coping mechanisms to prevent ’behaviour reactions’. This has greatly improved my son’s quality of life. We returned to the home to look at individual contracts and terms of conditions that are held at the head office to assess whether people were getting the service they should do. This information was not forthcoming. 267 Walmersley Road DS0000062679.V334530.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have 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 people effectively. EVIDENCE: We briefly examined two peoples care and support 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 person’s 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 flexibility of thought, sensory, medical details, prescribed needs and support guidelines around daily routines. One plan had not been reviewed and updated 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 12 for over six months. Plans are normally reviewed every six months but in this case it was important to have been done earlier because there are a number of ongoing complex issues. The activity plans and discussions with the staff members and the person concerned, confirmed that the person was no longer engaging with the service. People are asked to sign the plan. As with assessments and policies and procedures, care and support plan documentation is currently under review. We were informed that this was being carried out to reduce the duplication of work. As new arrangements are yet to be agreed and used we were unable to form a judgement about the effectiveness of the new process. 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 behavioural needs of people using the service 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 inspectors gathered during discussions with staff members. In line with best practice the organisation has recognised that more work needs to be undertaken to include people using the service to become involved in decision making both within the homes and the overall organisation. A number of ideas are being considered including developing a service user forum. The home would also like to have control of the household budget so that people can be more involved in choosing and purchasing items for the house. People have very detailed risk assessments 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 people’s behaviours and how to manage them to prevent escalation, for example by minimising levels of anxiety. People 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. 267 Walmersley Road DS0000062679.V334530.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 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 are supported to lead 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 people’s independence and their personal development. EVIDENCE: People living at the home 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’s needs and change as necessary. For example one person is affected by seasonal change and takes part in less activities’ in the winter 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 14 months and much more in the summer months. One person attends the organisation’s development centre. Promoting independence is a key part of the underpinning practice of the home. Most people are supported to do a personal shop every week. People are encouraged to be involved in household tasks such as washing and ironing, and keeping their own rooms clean. However, one person’s bedroom was again seen to be in a very poor condition, to the point where it could be hazardous to health. A relative of another person stated in a returned survey, “I have been upset a few times about my son’s living conditions. Often his room is untidy, disorganised and not clean.” Training was undertaken last week in promoting independence and developing daily living skills and new documents have been introduced to help support workers to monitor progress. There is transport provided by the service available to those people who are not able to use public transport effectively. Support workers have said previously that the vehicle provided was difficult to manoeuvre and concerns were raised about potential risks due to the seating arrangements. People are encouraged and supported to pursue their own interests. One person is involved in regular exercise and uses an exercise bike daily, goes swimming, cycling and uses a trampoline with support from staff members. People enjoy music, especially the digital music channel, writing, the Internet and computer games, as well as DVD’s and videos, particularly factual documentary programmes and science fiction. The Internet that has been promised for sometime had been connected during the inspection. There was still a need to sort out the system for firewall and to enable staff to monitor and check what is being viewed. There have been two meetings for people living at the home, one discussed the Internet and the second was about the installation of a payphone, which is now in place. Minutes are recorded. People are also involved in developing activities planners. Most people who live at the home have contact with their families. Two people go to stay with their families regularly. Dependent on the individual needs of the person support workers will have a handover with the family to ensure that support guidelines are followed at home to promote continuity and routines. Weekly courtesy calls to families have recently started and a record of the conversation is maintained. The kitchen was checked and found to be clean and tidy and well stocked with food, including some fresh fruit and vegetables. People 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 people enjoy going out for meals at specific cafes or drive in fast food places. 267 Walmersley Road DS0000062679.V334530.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 adequate. This judgement has been made using available evidence including a visit to this service. The staff team have access to a behavioural psychotherapist who can offer strategies and guidance to support the emotional needs of people living at the home. Training is needed in some areas to ensure that the staff team are able to support people with associated mental health conditions effectively. A number of improvements have been made to the medication system to ensure the health and safety of people receiving medicines. EVIDENCE: People living at the home have varying levels of support from the staff team. The support needed by people is delivered in a very precise and consistent way to ensure the emotional wellbeing is maintained. The staff team have access to the service’s behavioural psychotherapist and the development centre to support them in their role. Support workers are very aware and pay attention to small detail and subtle changes in the way people communicate or changes in behaviour that relate to fears, phobias and paranoia. Support workers have access to good written guidance to do this and permanent longstanding staff 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 16 members have good background knowledge, skill and experience. However, one person has other associated needs around mental health and obsessivecompulsive disorders and the staff team would benefit in training in these areas. A Regulation 37 notification is needed in respect of a person who was recently admitted to hospital voluntarily. We were informed that people living at the home are registered with a local G.P, dentist and optician and where necessary specialist healthcare professionals. Records of appointments are maintained. The medication policy had been reviewed and was available for reference by staff handling medication. Changes had been made to the way medicines were supplied. Staff had received training in the use of the new blister packs and paperwork for recording the handling of medication. The acting manager said she planned to complete a competency assessment provided by the pharmacy and to carry out regular audits. This will help to ensure medicines are well managed and that any areas for improvement are identified. An audit of records and blistered medication showed that medication was administered as prescribed. Arrangements were in place for people with minor ailments such as a cold to have treatment without delay (home remedies). People wishing to manage some of their own medication were supported do so. Arrangements were agreed with people using the service and their families, when medicines were taken away for administration away from the home, to help ensure they were supplied in the best and safest way. The medication records were mostly up-to-date but there were gaps in recording the administration of a home remedy and, an infrequently used prescribed medicine was not recorded on one person’s list of current medication. Most of the medication records were pre-printed by the pharmacy, but where staff made handwritten entries these were not signed, checked and signed by a second person. This is recommended to reduce the risk of making mistakes. Changes made to medication following visits to the GP were clearly recorded to help ensure they were correctly made. 267 Walmersley Road DS0000062679.V334530.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way that complaints are handled is currently under review to ensure that the process is both effective and fair. Mandatory training needs to be undertaken by some members of the staff team to ensure that they know what action to take to safeguard people living at the home from abuse. EVIDENCE: The home has a complaints policy and a procedure. This document is currently under review. There has been one ongoing complaint about the service, which CSCI have been made aware of in respect of the financial arrangements of one person living at the home. Relatives and the person concerned are not happy with the outcome because in their view it was not handled fairly. A survey from another relative stated that their written correspondence about the lack of Internet access, which was sent to the managing director, was not responded too. This matter has been recognised by the organisation and the complaints policy and procedure are currently under review. A copy of the agreed complaint policy and procedure must be sent to CSCI. As with a number of key policies the internal safeguarding policy is under review. The staff team have access to mandatory training on adult protection. However the staff training matrix updated on 1st October 2007 shows that only three of the seven permanent staff members of the team have received this training. The acting manager needs to ensure that the home obtains a copy of the new local authority safeguarding policy and procedure from the safeguarding co-ordinator. 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The property is large and spacious and provides people living at the home with a comfortable and homely environment. 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. Parts of the home have been re-painted since the last inspection. There is a new vegetable patch in the garden area to the side of the house. The house felt warm and comfortable and observed that an acceptable standard of hygiene and cleanliness was seen throughout the building with the exception of the bedroom identified earlier. The hall and stair carpets had recently been cleaned. 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 19 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 people living at the home. The staff team needs to be provided with necessary basic training to ensure that it can meet the specialist needs of people using the service effectively. To evidence that the organisation undertakes a rigorous approach to recruitment to protect people using the service, records that stand up to scrutiny must be maintained. 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 people using the service has been reviewed and reduced over time. In a recent letter we were informed by the responsible individual that he plans to reduce staffing levels further. Since the last inspection a senior support worker and a support worker have left. It was unclear as to whether the post’s are to be filled. It was 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 20 not clear what the actual hours the acting manager had to produce a rota and the lack of contracts available at the home made it difficult to make an assessment about whether the staffing was sufficient to meet the needs of people living at the home. Further information was requested but not received. Feedback from the staff team was that at this time they were able to meet the needs of those people living at the home but this was in part due to the hours still being in place for the person who was no longer living at the home. There was still a view that people, were having to fit into allocated hours to them, which impacts on the way the home is run. On a more positive note, we were informed that there had been a significant reduction in the use of agency staffing, which helps to ensure continuity and consistency for people, particularly given the nature of their needs. Where agency staff is being used the same workers are being requested and this has been mainly to cover waking nights. An on-call system is in place. The acting manager is undertaking NVQ Level 3 and the senior support worker is working towards NVQ Level 3. One night worker holds an NVQ Level 3. Four staff members hold an NVQ Level 2 and two support workers are undertaking NVQ Level 2. The supplied staff team, training matrix, does not include the three vacancies at the home. 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 requested for examination at the return visit. The responsible individual however did not make the recruitment files available at the home and sent instead, to evidence safe recruitment processes copies of a CSCI (Annex 4) pro-forma. Unfortunately the documentation sent was incomplete, with no information about whether they had a CRB as there was no reference number or the date obtained on one document and on both documents no reference numbers for identification documents supplied. Neither document had been signed by the responsible individual to confirm that they had been verified. We were informed that all members of the staff team undertake in-house induction training. Unfortunately there was no evidence on site to confirm this as it is held at head office. The training matrix shows that there is a wide range of basic 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, but there are some gaps in training identified on the sheet. By enlarge health and safety training, has been undertaken by all the staff team, and where there were gaps, evidence of planned training was seen. Evidence of regular supervision was evident on support workers files that are held in house. A staff meeting was taking place on the first day of the inspection. 267 Walmersley Road DS0000062679.V334530.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: We have expressed concerns at previous inspections about the need to strengthen the staff team in terms of qualifications’, experience and skill to meet the specialist and complex needs of people using the service. The role of registered manager is vital to ensure leadership and direction of the home. The registration certificate confirms that the home has been without a registered manager since 21st September 2006. It is a condition of registration 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 22 that, “the service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection.” It is generally expected that an application be received from the organisation within 3 months of a registered manager leaving the post. The person responsible has now appointed a manager who is due to commence employment in the near future. To date we have received an application from the proposed manager but this has been returned due to insufficient information. The person responsible for the home did provide evidence that on the day after the inspection commenced that he had written to the prospective manager to request that the forms were completed. Given the importance of this role, we were surprised to learn that a visit to the home was not included as part of the recruitment and selection process. The acting manager will stay as deputy manager. The new divisional manager has undertaken Regulation 26 visits and copies of the reports have been sent to CSCI to evidence that the home is being closely monitored by the organisation. The staff members spoken with spoke highly about the divisional manager who was described as “very supportive and getting things moving.” To ensure that the service is being run in the best interests of the people who use the service, a quality review of the service is being undertaken by the divisional manager. A copy of the findings will be sent to us once completed. A copy of a business plan and objectives was provided but this was out of date. The organisation is aware that there is a need to promote and improve the profile of the service. A consultant has been employed to undertake this task. Once the homes Internet access is operational staff at the home will have access to information and guidance about Inspecting for Better Lives, AQAA, Klora and quality ratings, which will help them understand the new inspection process. As at the last inspection water temperatures continue to be running low. We were informed that the housing association has written to the person responsible for the home recommending a change in the boiler system. Bathroom water temperatures continue to be too low to ensure people living at the home can have a hot bath and this is compounded by poor water pressure. Health and safety records and recording were checked. A gas safety check was undertaken on 22.01.07. The fire alarm system, emergency lights and fire extinguishers were checked on 05.01.07. Health and safety checks are undertaken in relation to freezer temperatures, food temperatures and water temperatures. Weekly fire system checks are carried out to heat and smoke detectors. Portable electrical equipment were being checked during the last inspection but no certificate was available to confirm that the work had been satifactorily completed. A check has also been undertaken to ensure that the homes electrical fittings and fitments are safe, but again a certificate to confirm that the findings were satisfactory could not be produced. We asked for the photocopier to be removed from the office that is used by staff to sleep in to ensure that their health was not compromised by toxic fumes. 267 Walmersley Road DS0000062679.V334530.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 2 2 4 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 4 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 2 X X 2 X 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 5 Requirement That people using the service have a copy of a service user guide to the home that covers all the information required in this regulation, the national minimum standard and other information to ensure that they can make an informed decision about whether the home is appropriate to meet their needs. People using the service need to have an individual written contract that gives clear information about what facilities and support they can expect from the home during their stay, including specialist services. This needs to be signed by the registered manager and the person using the service and by a third party if necessary. People’s support plans need to be kept under review to ensure that they reflect the changing needs of the person concerned. A Regulation 37 notification is needed in respect of a person who was recently admitted to hospital voluntarily. Training is needed to ensure that DS0000062679.V334530.R01.S.doc Timescale for action 31/12/07 2. YA5 5 31/12/07 3. YA6 15 30/11/07 4. YA19 37 30/11/07 5. YA19 18 31/12/07 Page 25 267 Walmersley Road Version 5.2 6. YA22 7. YA23 8. 9. YA23 YA33 10. YA34 11. YA35 12. YA37 the staff team are able to support people with associated mental health conditions for example obsessive effectively. 22 When agreed and finalised a copy of the home’s complaints policy and procedure needs to be sent to CSCI. 13 When agreed and finalised, a copy of the home’s safeguarding policy and procedure needs to be sent to CSCI. 13 That all members of the staff team undertake adult protection training. 18 To ensure that people 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 people living at the home at all times. The registered provider must inform CSCI of the date service users will cease to be provided with and outreach service from the registered home. (Outstanding 30/04/07) 19 To ensure that people living at the home are protected by the home’s recruitment practices the responsible must maintain accurate records in respect of recruitment processes. Updated copies of Annex 4 documentation, is therefore required. 18 All members of the staff team need to be provided with necessary induction and basic training to ensure that it can meet the specialist needs of people using the service effectively. Section 11 To meet the home’s conditions of of Care registration, the manager of the Standards home must submit an application DS0000062679.V334530.R01.S.doc 30/11/07 30/11/07 31/12/07 30/11/07 30/11/07 31/12/07 30/11/07 267 Walmersley Road Version 5.2 Page 26 Act 2000 13. YA39 24 to us for registration. To ensure that the service is run in the best interests of people using the service, a quality review must now be undertaken and a copy of the report produced sent to CSCI. (Outstanding 30/06/07) 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. (Outstanding 30/04/07) To ensure the health and safety of people using the service a copy of a valid certificate in respect of the homes electrical fittings and fitments is required. To ensure the health and safety of people using the service a copy of a valid certificate in respect of the homes portable electrical appliances is required. 30/11/07 14. YA42 13 30/11/07 15. YA42 13 30/11/07 16. YA42 13 30/11/07 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 YA1 YA8 Good Practice Recommendations The statement of purpose needs to be reviewed and revised and amended to reflect recent changes in the service. That ways of improving the involvement in people who live at the home in decision-making and participating in the day-to-day running of the home and the organisation are considered then acted upon. In line with recent training, it is strongly recommended that people living at the home are supported to keep their bedrooms clean and tidy to prevent hazards to health DS0000062679.V334530.R01.S.doc Version 5.2 Page 27 3. YA11 267 Walmersley Road 4. 5. 6. YA20 YA23 YA32 developing. Handwritten MAR entries should be signed, checked and countersigned. That the home obtains a copy of the new local safeguarding procedures from the local safeguarding coordinator. To ensure that peoples 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 267 Walmersley Road DS0000062679.V334530.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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.V334530.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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