Inspection on 25/01/06 for 29 & 30 Dominion Road

This inspection was carried out on 25th January 2006.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 & 30 Dominion Road 11/07/07

29 & 30 Dominion Road 13/09/06

29 & 30 Dominion Road 27/06/05

29 & 30 Dominion Road 10/03/05

29 & 30 Dominion Road 21/06/04

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

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

CARE HOME ADULTS 18-65 29/30 Dominion Road Twerton Bath Bath & N E Somerset BA2 1DW Lead Inspector David Smith Unannounced Inspection 25th January 2006 09.45 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 29/30 Dominion Road Address Twerton Bath Bath & N E Somerset BA2 1DW 01225 332396 01225 427261 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) RNID Mr Lee Bull Care Home 3 Category(ies) of Sensory impairment (3) registration, with number of places 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 3 persons aged 18 to 64, requiring personal care. Staffing levels for initial for two service users to be as follows: Weekdays - 2 staff 7.30 am - 2.30 pm 1 staff 9 am - 4.30 pm 2 staff 2 pm - 9.30 pm 1 staff 9 pm - 7.30 am on a sleep-in basis Weekends - 2 staff 7.30 am - 2.30 pm 2 staff 2 pm - 9.30 pm 1 staff 9 pm - 7.30 am on a sleep-in basis 3. An on-call Manager to be on duty throughout the 24-hour period daily. The staffing structure as specified in condition 2 above to be reviewed by the RNID and CSCI at the time of admission of a third service user to this service. 27th June 2005 Date of last inspection Brief Description of the Service: 29 & 30 Dominion Road is registered to provide a service for 3 people who have a sensory loss. The house is in a residential setting in Twerton, which is a suburb of Bath, is on a bus route and close to all local amenities. The house has 4 single bedrooms, (one bedroom for staff sleeping-in), all with en-suite facilities, plus additional WCs. The rear garden is being developed into an area where service users can spend time relaxing, or gardening, if they so wish. Ramps and rails have been provided in order to aid service users mobility. The Statement of Purpose outlines the ethos of the home, where every opportunity is offered through staff guidance and support to ensure service users maintain or develop independent living skills. Each service user has a designated key worker. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day. The inspector gathered evidence for this report from discussions with the Registered Manager, one service user and four members of staff. Policies, Care plans and associated records were examined, along with staffing records. The inspector observed communication and interaction between staff and all three service users, at various times, during the course of the inspection. A tour of the home was also provided. What the service does well: What has improved since the last inspection? The Care Assessment for the latest service users admitted to the service is now in place. The home has confirmed to Funding Authorities that service users needs can be met. Staff training has improved. This has provided the staff team with improved skills and knowledge to enable them to support service users. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 6 Each service user now has their service reviewed regularly and their care and support plans updated. The Risk Assessments have been improved and updated. This promotes the safety and welfare of all service users. Staff have a better understanding of the Protection of Vulnerable Adults procedure. This ensures service users have greater protection from abuse. Team meetings now focus on the service users, rather than issues within the staff team. What they could do better: The remaining staff should complete training in Learning Disabilities, Medication and Basic Food Hygiene. This would ensure an appropriately trained staff team to support the service users. A team-building day should be arranged. This would help further improve morale and improve the support provided to service users. Staff supervision must be provided consistently. This would ensure all staff are supported in their role of providing support to service users. All staff personnel and training files must be updated and maintained in good order. This will help to ensure all staff supervision and training can be easily monitored. This will help to improve the support provided to service users. A copy of the contract for each service user, between the RNID and each Funding Authority, must be made available to the manager. . This remains an outstanding requirement from previous inspections but because compliance with this requirement is outside the control of the manager it is being raised with the Commission for Social Care Inspection’s Provider Relationship Manager as a national issue. The Registered Manager must complete NVQ Level 4. This would ensure he is suitably qualified to lead the care and support provided to the service users and would enable him to learn new or develop existing skills to improve the management practice and structures within the service. The Vulnerable Adults policy still needs to be amended to give reference to the Care Standards Act 2000, rather than the Registered Homes Act 1984 and the contact at CSCI must also be updated. This ensures correct information is available to each service user. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 7 A Risk Assessment must be in place if physical intervention or restraint forms part of any service users care plan. This will ensure their welfare and safety. The Commission must be informed of any incident requiring the use of a physical intervention or restraint. This will ensure a comprehensive system of reporting and monitoring to ensure the safety of service users and staff. All health and safety checks must be carried out at the specified times and a clear record maintained within the home. This will provide a safe environment for service users and staff. The carpet in the lounge area should be replaced. This would improve the environment for service users. The collation and storage of all information within the home needs to be reviewed and improved. This would help to ensure that all files are user friendly and information is easily located. This would ensure an effective management system is in place to support service users. The Quality Assurance process needs to be completed and formalised. This would ensure the home can monitor the quality of care and support provided to all service users and promote improvement. The home should review its progress and development in providing information in accessible formats to the service users. 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. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. The home has a Statement of Purpose, which provides comprehensive information on the service available. This has been adapted into an accessible format for one service user. The home now has evidence of thorough pre-admission assessment of each person contained within their care plans. There are no contracts in place between the RNID and Funding Authorities, as there need to be. This remains an outstanding requirement from previous inspections but because compliance with this requirement is outside the control of the manager it is being raised with the Commission for Social Care Inspection’s Provider Relationship Manager as a national issue. EVIDENCE: There have been no new admissions since the last inspection. The care records were therefore examined for the most recently admitted service user. This now contains the initial Care Management Assessment and confirmation to the Funding Authority that the home can meet assessed needs. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 10 The care planning documents were comprehensive and the review process clearly recorded and outcomes acted upon. The home has also drafted a statement of terms and conditions for this service user. The inspector spoke with this service user who confirmed she did receive information regarding the home and offered the opportunity to visit prior to agreeing to move home. She is involved in her reviews and feels happy to talk at these meetings. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Care plans are now subject to regular review and updated. All service users are supported to participate in this process. The home should review how service users could access this information. Service users are supported to make decisions about their lives and are regularly consulted with about life in the home. All service users are supported to take risks. This is reflected in the home’s Risk Assessment process. Each Risk Assessment must be signed by the manager and have a review date added. EVIDENCE: Care plans for all three service users have been developed. The home also provides monthly summaries of each service users daily records. This enables a clear link to be developed between each daily record and the review process. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 12 Two service users care plans were examined in detail by the inspector. These care plans are now reviewed at six-month intervals. Each service user is supported to be as involved as they can in this process. The outcomes of each review meeting are recorded and acted upon by being incorporated within the revised care plan. One service user told the inspector she was involved in her review meetings. She had also written a list of things that she liked, to take to her last review meeting. Service users are able to make decisions, and are assisted to do so by being offered support by staff that are able to use sign language to communicate choices and opportunities. There is also some written information provided in symbol format and objects of reference are also used. The inspector observed interaction between staff and all three service users during the course of the inspection. This demonstrated that the staff team were knowledgeable and confident in communicating with the service users and did provide choices but let the service users make decisions. Individual risk assessments have been developed, which were examined in detail. These contained all relevant information relating to each risk, control measures to reduce risk levels and were up to date. However, each one still requires the manager’s signature and the date of their next review added. The home is working toward the development of care plans in a format, which each service user can understand. The progress of this work should be reviewed by the home. This would enable each service user to be more involved in decision-making and have greater autonomy. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13 and 14. Service users have opportunities for social and educational development and appropriate leisure activities. Service users are supported to use facilities on the main the Poolemead site and in the wider community. EVIDENCE: All three service users attend Educational Development Studies at the main Poolemead site. Practical life skills are taught together with a range of other activities chosen by each service user. Each of the service users accesses facilities in the wider community, and during the inspection various trips out of the home were made. The records examined showed that each service users was being supported to take part in various activities such as sewing, music sessions, ten pin bowling, 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 14 going out for meals, swimming, walks, going to the theatre and visits to museums. One service user spoken with explained that she was attending a massage session that afternoon. She really enjoyed this session. She said she also went to a music session, workshop, sewing, goes for walks and has visits form her family who live in Salisbury. She is also learning how to lip read and said that the staff support her to do all these things. All three service users were supported on holiday at Centre Parcs at Longleat. There are several pictures in the home of service users holidays and day trips. Staff spoken with all the service users went away for a week and the holiday was very successful. Staff would support each service user to plan and attend a holiday again this year. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users receive personal support which is flexible and responsive to their changing needs. A monitored dosage system of medication is in place for the service users. Some staff still require training in this area and the management of this system should be improved. EVIDENCE: Each service user is registered with a local GP, Dentist and other relevant professionals. Each care plan explains the support needs for each service user in this area. These are reviewed regularly. There are varying levels of support from other health care professionals such as Occupational Therapist, Speech and Language Therapist and Community Physiotherapist. Contact with these professionals was clearly recorded in each service users file and the outcomes acted upon. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 16 The inspector observed staff interacting and communicating with service users within the home. Staff spoken with displayed a good knowledge of the personal care they need to provide to service users and this was in accordance with the care plans examined. The home has a gender sensitive policy, which is adhered to. At present all the service users are female and the male members of staff therefore do not support any personal care. The home uses the Boots Monitored Dosage System of medicine administration. The medication records contained a recent photograph of two service users, details of their medication, times of administration, a list of staff signatures and manufacturers notes on some of the prescribed medications administered within the home. This system should be improved to include a recent photograph of all three service users, manufacturers details of all medication prescribed, and profiles of each service user. Clear records of the medication entering the home and being returned to the pharmacy are maintained. Several staff have had medication training recently provided by Aset. This should be provided to all remaining staff as soon as possible. Discussions with the manager confirmed that one service user is currently being supported to reduce her medication. This process involves the staff team, the service users family, GP and Funding Authority. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Although no complaints have been made by service users, the information and processes in place would be supportive in such an event. Staff now demonstrate a better understanding of the Protection of Vulnerable Adults procedures. Risk Assessments must be put in place for any service user who requires physical intervention or restraint. This will promote the safety of both service users and staff. EVIDENCE: The home’s complaints policy and procedure is comprehensive in detail, and the service users handbook also fully explains in symbol format how complaints are dealt with, along with the action can be taken if they remain dissatisfied with the way their complaint has been investigated. No complaints have been made by service users, or their relatives, since the last inspection. One service user spoken with confirmed she would speak to staff members if she was unhappy or had a problem. She could also speak to the manager as well as the staff team. She said they would be able to help her. Training has been provided in the Protection of Vulnerable Adults. Staff spoken with were now able to describe the action they would take if a service user said 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 18 they had been abused or if this was suspected. This was in accordance with the home’s policy. The home has clear guidelines in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. Staff receive regular training in responding to these using the NAPPI (Non Abusive Psychological and Physical Intervention) system, which is accredited by the British Institute of Learning Disabilities. It was not clear from either the records of staff training, or discussions with the manager, how often this training should be provided to staff. The manager must clarify this issue with the relevant trainer and act upon these discussions. The inspector could find no evidence of Risk Assessments relating to physical intervention or restraint of service users, despite the manager confirming these had been completed. These must be implemented to form part of a safe behavioural support plan for service users and staff. The records examined for one service user describes physical intervention being used by staff on two separate occasions. These records are not explicit, as they do not describe the technique staff had used and the inspector could therefore not ascertain if this was an approved and trained method. These incidents were not reported to the Commission as required by the regulations. This process must be improved. All staff must accurately record all incidents of challenging behaviour, including their responses. The home should consider the use of a separate physical intervention report form when these interventions are used. This should record the staff involved, the technique used, the length of time used and the outcome for the service user. The Commission must be informed each time physical intervention is used within the home and the manager must ensure all staff are aware of this procedure. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The house provides a homely environment for the service users. The home would benefit from a new lounge carpet and the development of a utility room. This would improve the environment for the service users. The house was clean and tidy on the day of inspection. EVIDENCE: The home is reasonably well maintained and provides a homely environment for the service users. The open plan kitchen/lounge/dining area promotes the service users independence. The inspector observed service users using these areas at various times during the day. The carpet within the lounge area is badly stained. At present the kitchen contains the home’s washing machine and tumble drier. The manager confirmed there are plans to create a utility room within the 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 20 home. The inspector agrees that the current facilities are not ideally located and a utility room should be developed to improve the home. Each service user is expected to contribute to ensuring the home is clean and tidy. The staff team supports this. There are several pictures displayed of recent service user holidays, day trips and events which have occurred within the home. This promotes the homely feel and enables the service users to personalise their home. There is a large garden to the rear of the house. This has a patio area, clear pathways and handrails fitted to support all three service users to use this area. There is a vegetable patch in the garden, where the home grows its own vegetables in the summer. The manager explained he would like to develop part of the patio area and provide a conservatory. This could be used as a games/arts and crafts room. This would provide useful additional space for all service users. The inspector awaits the outcome of discussions regarding this development. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. The staff team has become more cohesive and effective in supporting the service users. Team meetings now focus on the support needs of the service users, not issues within the staff team. Records of these meetings need to be improved. Staff are provided with training both by the organisation and external agencies. Staff training requires completion/updating in some areas and staff training records need to be updated regularly to accurately reflect the training they have received to enable them to support service users. There needs to be a clear action plan in relation to supporting staff to obtain a National Vocational Qualification. All staff must be supervised on a regular basis and a clear record maintained in their personnel files. All staff files need to contain all relevant information to ensure a robust recruitment process, which protects service users. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 22 EVIDENCE: The last inspection report indicated that a small number of staff were experience difficulty in maintaining cordial working relationships with their colleagues, and that the key values of Dominion Road were being affected by this. Two members of staff have left the service recently and these changes appear to have assisted in the improvement of both the dynamics and morale within the team. The inspector spoke with four members of staff who confirmed there had indeed been a significant improvement in these areas. The team was once again working together and communication had improved. This has led to a more consistent approach in supporting each service user and made it possible to discuss issues openly at team meetings and supervisions. The Team Meetings now focus on the needs of service users, rather than the issues which existed within the staff team. The minutes examined by the inspector were not always explicit. The records of some meetings were not clear and outcomes not recorded. These need to be improved to provide an accurate record of each meting and also describe the outcomes in detail. The manager confirmed that a Team Day was still essential to build upon the progress made within the staff team. The inspector concurs with this opinion and this should be organised as soon as possible. There has been progress in providing additional training to the staff team. Several staff members have now received training in Learning Disabilities, Medication and updated their Food Hygiene Certificates. This must be provided to all remaining staff to ensure the team are sufficiently skilled and able to provide consistent support to each service user. It is also essential that staff receive all mandatory training. This should include First Aid, Manual Handling, Fire Procedures and Protection of Vulnerable Adults. It was not clear from some staff files whether they had attended all mandatory training. This could not be checked using the staff-training matrix, as this had not been updated. The training matrix in use in the home must be regularly updated. This will ensure all staff are provided with training to maintain or update their knowledge and skills to enable them to provide support to the service users. It could also provide the manager with a useful tool in tracking all staff training requirements, if it were to be kept up to date. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 23 The home does not currently not have any member of its staff team trained to NVQ Level 2/3/4. The standards expect at least 50 of the team to be trained or working towards these qualifications. A clear plan must be developed describing how staff are to be supported to gain these qualifications, including the anticipated timescales and a copy supplied to the Commission. The records of staff supervision examined showed that not all staff were being formally supervised every 6 to 8 weeks as described in their supervision contact. The records of supervision did not always provide a clear record of these discussions and the outcomes which had been agreed upon. The inspector noted a confidentiality issue had been raised by a senior staff member with the manager. The senior staff member had sought advice from the manager on how to deal with this issue. The manager confirmed this had been addressed by this senior with the staff member in question during their supervision meeting, however the inspector could find no record of any such discussion within the relevant supervision notes. The supervision process must be improved to ensure all staff have consistent support to enable them to provide the support to the service users. Each record of supervision meeting must also be improved, to ensure that an accurate record is maintained and outcomes are agreed and acted upon. All staff personnel files kept in the home must include all relevant information as part of a robust recruitment process. This should include proof of identity, a recent photograph, a copy of the staff members application form, two written references and proof of any relevant qualifications. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 and 43. Service users benefit from the ongoing development and improvement of the management systems in place. The records maintained as part of this process must be improved to ensure accuracy, consistency and that outcomes are recorded and acted upon. The manager ensures the service users remain the focus of the service, however the home should review how service users are supported to express their views and access information. The home has procedures in place, which are designed to provide a safe environment for service users. The management of these procedures needs improvement to ensure all service users’ welfare and safety. The service users would benefit from the Manager completing his NVQ Level 4. This would enable more effective management systems to be implemented within the home. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 25 EVIDENCE: The content and filing of the management documents within the home has been the subject of review and improvement since the last inspection. The home has an Operational Plan 2005/2006. This is being used as part of a Quality Assurance process to measure the home against its stated aims and objectives. This process needs to be improved and formalised. The manager confirms he also uses Review Meetings, monthly Audits, Service Users Meetings, Questionnaires and Team Meetings as part of the Quality process. This needs to be incorporated into a formal system, as it was difficult for the inspector to gauge how all this information is collated and then used as part of an annual quality review. This would help ensure the home uses reliable methods of measuring the quality of the service provided and identify areas where improvement is needed. Service users views are sought during house meetings, reviews and meeting with Keyworkers. Staff also have skills and training to enable them to communicate effectively with each service user. One service user spoken with confirmed that she was able to talk about the home, support form the staff team, any problems she has, what changes she would like to see. She did feel that she was spoken to about her service and confirmed to the inspector that she was happy to live in the home and that she liked the staff and the manager. The home should review its progress in how it supports each service users to express their views and also how they access information. There are both generic and person centred Risk Assessments in place. These had all been updated in December 2005 but they need to be signed by the manager and have the next review dates added to each one. The COSHH products were stored securely and comprehensive details of all the products used within the home were evident. The home uses a monthly Health and Safety checklist, which is designed to ensure that all checks are carried out at the appropriate times. This form confirms that some checks are being omitted, but this has not been acted upon. This system must be improved to ensure the health and safety of service users and staff. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 26 The annual PAT testing, electrical wiring certificate, fridge/freezer temperatures and water temperature checks were in order. There was no evidence that the home had a gas safety check carried out in the last year. The last certificate located was dated 2004. The manager was unable to confirm if this had been completed since this date. Several weekly fire checks had not been carried out and there was no evidence of the fire alarm system being serviced in the last year. The vehicle checks are not being carried out on a weekly basis. The health and safety records are currently stored in a number of different files. The inspector found it difficult to locate information and to ascertain if this was up to date. All Health and Safety checks must be completed regularly to ensure the welfare and safety of all service users. The recording and filing of these checks must be improved to ensure that this is easy for the manager to monitor. The registered manager has completed various training courses, which complement his role and responsibilities, however he has yet to complete NVQ Level 4. He is continuing to work towards this award, but it remains unclear when he anticipates completing this. There needs to be a clear plan developed to support the manager gaining this qualification. This would benefit the manager, as it would improve his knowledge base and skills and help to lead and motivate the team as well as developing or improving the systems and structures to enable him to effectively manage the home. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 2 2 X 2 2 2 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 28 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 YA3 Regulation 12 Requirement Training for staff on the management of service users with learning disabilities to be completed. All staff to update food hygiene certificates where necessary. Existing Risk Assessments must be signed by the manager and dates of review added. All staff who administer medication to receive accredited training. Risk Assessments must be put in place for each service user who requires physical intervention or restraint. The Commission must be notified of any use of physical intervention or restraint. The Protection of Vulnerable Adults Policy to be amended to reflect the Care Standards Act 2000,rather than Registered Homes Act and update CSCI contact. The carpet in the lounge area should be replaced. Develop a clear plan to support staff to gain a National Vocational Qualification and DS0000008186.V276512.R01.S.doc Timescale for action 25/04/06 25/04/06 25/02/06 25/04/06 25/02/06 2. 3. 4. 5. YA17 YA42 YA20 YA23 18 13(4) 13 13(7) 6. 7. YA23 YA23 37 13 25/01/06 25/02/06 25/04/06 25/03/06 8. 9. YA24 YA35 23(2) 13(6) 29/30 Dominion Road Version 5.1 Page 29 10. 11. 12. 13. YA35 YA36 YA37 YA39 17 18 9 24 14. 15. YA42 YA34 12 ? supply a copy to the Commission. Staff training matrix to be updated, and maintained in good order. All staff must receive regular supervision and a clear record be maintained. The Registered Manager must complete NVQ Level 4. Quality assurance methods to be improved in order to track the homes success in achieving the aims, objectives, and Statement of Purpose. All health and safety procedures must be adhered to as required by the regulations. All staff personnel files must contain all relevant information as required by the regulations 25/01/06 25/01/06 25/04/06 25/04/06 25/01/06 25/03/06 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 YA32 Good Practice Recommendations The home should review its progress in adapting information into accessible formats for each service user. Team building exercise to be organised. 29/30 Dominion Road DS0000008186.V276512.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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