CARE HOME ADULTS 18-65
3-4 Glebe Lane Distington Workington Cumbria CA14 5SQ Lead Inspector
Gordon Chivers Unannounced 09 August 2005 09:15 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 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 Stationary 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. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 3-4 Glebe Lane Address Distington Workington Cumbria CA14 5SQ 01946 831629 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) West House Leanne Marie Scott Care Home 8 Category(ies) of PD - Physical Disability registration, with number LD - Learning Disability of places 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15 March 2005 Brief Description of the Service: West House is the Registered Provider for 3 & 4 Glebe Lane which are two adjacent properties situated in a residential area close to the centre of the village of Distington on the West Coast of Cumbria. The properties provide accommodation and care for eight people who have a learning disability, some of whom may also have a physical disability. Number 3 Glebe Lane is a purpose built bungalow that has been built next door to the house, which is number 4 Glebe Lane. Each building has its own garden area and car parking is available to the front of the house and to the side and rear of the bungalow. Both properties look similar to the neighbouring houses in Glebe Lane. The home operates as two separate units. The house provides communal living space for service users together with an office / sleep – in room on the ground floor with private bedrooms and a bathroom on the first floor. The bungalow has level access into the hallway that is designed to assist service users who use wheelchairs to enter the building. All the communal rooms and private bedrooms are equipped to meet the needs of the service users. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, commencing at 09.15 and lasting six hours. The inspection took place in the presence of a Senior Support Worker, Diane Newton, who is usually based at another home but was in charge on the day of the inspection because the new manager, Fiona Dixon, was on holiday. The inspection included a tour of the premises, reference to a range of documents including a sample of service users’ case files, interviews with two members of staff and a talk to two service users. The inspection focused upon the standard which drew forth a recommendation, and the standards which were not assessed, by the last inspection. The inspector would like to thank the service users and staff of 3 and 4 Glebe Lane for their welcome and cooperation during this inspection. What the service does well: What has improved since the last inspection? What they could do better: 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 6 The long overdue replacement of kitchen units in the bungalow should have been undertaken by now. The case files could be better organised. 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. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 The home provides sufficient information for prospective service users and also undertakes a range of assessments which provide a basis for plans to meet their needs and aspirations. More evidence would be necessary to assess the appropriateness of the admissions procedures. There are no signed contracts of residency in the home. EVIDENCE: The home’s Statement of Purpose and Service User Guide have been revised and updated to take account of recent changes of staff. Further revision will be necessary if the proposed introduction of a new Senior Support Worker is implemented on September 1st. The former summarises the range of services provided by the home and a code of practice based upon the core principles of civil rights, maximising independence and social inclusion. The latter contains further information about the home’s services and facilities, and information about the admission process. It also contains a copy of the terms and conditions of residency and a reference to the complaints procedure. The case files contain a comprehensive range of risk and needs assessments about the service users upon which care plans are developed. There is also a Person-centred Plan for each service user in which their personal aspirations are recorded and plans set to address these. The home did not have a copy of Westhouse’s admissions policy and procedure on the premises. It is three years since the home admitted a new service user and the only relevant records available are an initial social worker assessment
3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 9 prior to admission and a review one month later. There was no other evidence available to assess how admissions to the home are/would be undertaken. None of the case files examined contained a copy of a contract of residency signed by the service user, or by an independent representative on their behalf, and by a representative of Westhouse. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 10 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 standard(s) 8 All the service users are supported in different ways to participate in decision making on domestic issues. EVIDENCE: The home provides for two distinct groups of service users. Those in the bungalow have very limited communication abilities and staff have to deduce and interpret their preferences and wishes by learning their individual ways of communicating through experience. Staff also actively consult with the service users’ families as part of their circle of support. Within this context the staff do all they can to involve the service users in decision making about domestic and every day issues. The service users in the house are more capable of participating fully in discussions and decisions on domestic issues. These service users confirmed this in conversation. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 Staff ensure that service users have a varied and balanced diet consistent with their individual preferences. EVIDENCE: The menus for the main meals are planned with the service users. The weekly menus are kept on record and were seen to varied and balanced. Detailed records are maintained of the food accepted and refused by service users in the bungalow so as to ensure as wide as possible a diet consistent with their observed preferences. Members of staff on duty were responsible for cooking and serving meals. Service users in the house are encouraged to help with the cooking and shopping. Both premises have a pleasant dining room (and the bungalow has a patio) where the majority of meals are taken, although individuals had the opportunity to take their meals in their room if they preferred. Assistance with meals was available for the service users who required it. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 12 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 standard(s) 21 Illness of service users is well managed by staff, often in consultation with families. The preferred funeral arrangements of some of the service users have been sensitively ascertained and recorded. EVIDENCE: Some of the service users have chronic physical illnesses/conditions which require on-going medical management. Their case files contain full records of the assessments, plans and interventions to control and alleviate the effects of these conditions, with involvement of the service user often indirectly through consultation with their family. Some, but not all, case files contain evidence that staff have attempted to ascertain the service user’s preferred funeral arrangements (again often via consultation with families). 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 13 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 standard(s) 23 There is clear and recent evidence that Westhouse ensures that its procedures for the protection of vulnerable service users will be implemented. EVIDENCE: The home has a record of the CRB check undertaken in respect of each member of staff. Allegations of unacceptable practice have been dealt with appropriately under Westhouse’s disciplinary procedures. All of the families of the service users were informed and consulted about this situation, but none have expressed concerns about any perceived danger of abuse or lack of protection. Another, unrelated, incident of aggressive behaviour has resulted in a service user transferring to the other building of the home on a temporary basis whilst alternative accommodation is sought. The need for regular training of staff in the protection of vulnerable adults has been addressed by Westhouse who have scheduled such training for the Autumn of this year. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 14 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 standard(s) 24,29 The home is well furnished and decorated, homely and contains a range of specialist equipment to support service users. EVIDENCE: 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 15 The bungalow and the house are homely and clean, well furnished and decorated. Each house has a programme for redecoration and refurbishment. All the bedrooms in number 4 Glebe Lane have been recently decorated, each service user having selected their own colour scheme, but the paintwork in the bathroom is chipped and flaking away. The communal areas in the bungalow are about to be redecorated. The carpets in the communal areas in both houses are new. However, the units in the kitchen in the bungalow are still waiting to be renewed despite having been highlighted as necessary by previous inspections dating back to 2004, and recommended by the last inspection. Westhouse has referred the matter to the landlord Impact Housing Association. Two of the bedrooms in the bungalow have adjustable beds and mattresses and one has cushioned cot sides. There is specialist bathing/showering and toileting equipment such as hoists, chairs and commodes to enable service users to be as independent as possible. The home has cushioned flooring for exercising and specialist dining aids to assist service users to eat. The Service Manager monitors the need for specialist equipment during the monthly Regulation 26 visits and makes referrals to Occupational Therapists when necessary. All staff have been trained in the correct techniques for moving and handling. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36 Staff’s roles and responsibilities are clearly defined in their job descriptions and the home is on track to achieving the required number of staff qualified to the required level. The recruitment procedures are appropriate and properly implemented to ensure the right calibre of staff are deployed. The staff receive sufficient training and are appropriately supervised. All of these management systems combine to provide a staff team which is competent to meet the needs of the service users. EVIDENCE: The support workers interviewed stated that they were in possession of a job description and that they were clear about their respective roles and responsibilities in supporting service users. Of the seventeen staff currently working at Glebe Lane, eight have qualified to at least NVQ level 2. Several others are due to complete it in the near future which will ensure the home meets the standard by the end of 2005. All new staff have undertaken the LDAF induction and foundation course and have been referred to do NVQ level 2 training. The home has copies of Westhouse’s recruitment policies and procedures, including that of Equal Opportunities and Diversity. Recruitment is undertaken by senior Westhouse managers although the manager of the home and some service users are also involved in the selection process. One member of staff recruited within the last twelve months described the process as she experienced it and through this confirmed that the procedure is adhered
3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 17 to. Sample documentation at Westhouse central office relating to the recruitment of staff to Glebe Lane has also been examined. Each member of staff has a training file with records of training undertaken. All staff undertake annual refresher training on a range of health and safety issues. Training needs are identified in individual supervision sessions and incorporated into a Personal Development Plan. The manager requests Westhouse to arrange relevant training courses to meet the identified need. Each member of staff receives formal supervision six times a year, the dates of which are recorded. One supervision session will double up as an annual appraisal. Staff receive a copy of the supervision notes and a copy is lodged in their file. Staff interviewed maintained that supervision was effective and a positive experience. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 40,41,43 After a short period of turbulence within the staff team and a change of manager, Westhouse has acted effectively to restore equilibrium and staff morale. New management arrangements have already gained the confidence and respect of the staff. The service users do not appear to have been adversely affected by these developments. The home continues to safeguard service users’ rights and interests through its policies and procedures and the storage of confidential information. EVIDENCE: Internal problems have led two members of staff transferring to other homes and a change of manager and senior support worker. The Assistant Service Manager, Alison Stephenson, is monitoring the situation during Fiona Dixon’s (the new manager) holiday absence. Westhouse senior management have implemented monthly half-day team (re)building meetings, supported by an external facilitator, in order to diffuse the underlying tensions and restore focus and morale. Staff interviewed considered these team meetings to have had a positive effect and stated that the situation has already improved. They
3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 19 also expressed respect for and confidence in Fiona Dixon’s management abilities; one member of staff has even withdrawn an application for a transfer away from Glebe Lane. The families of the service users have been kept constantly informed of developments The home has a full set of Westhouse policies and procedures (except the Admissions procedure). All confidential information relating to service users is kept in locked cabinets. Records of the administration of service users’ monies were being audited at Westhouse central office on the day of inspection and so this standard could not be assessed. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 2 2 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x 3 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x 3 x Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score 3 2 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
3-4 Glebe Lane Score x x x 2 Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 x x F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 4 5 Regulation 14 5 Requirement The home must have a copy of Westhouses Admissions procedure. The home must have contracts of residency signed by service users(or their representatives) and Westhouse. The home must ascertain the preferred funeral arrangements of service users, or record the reasons if this is not possible. The service must ensure that all staff receive training on the protection of vulnerable adults. The provider and the landlord must arrange for the kithen units in the bungalow to be replaced. (Outstanding recommendation from 15/3/05). The new manager must be registered with CSCI. Timescale for action Immediate 31/8/05 3. 21 17 30/9/05 4. 5. 23 24 13 16,23 31/12.05 31/10/05 6. 37 9 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations
F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 22 3-4 Glebe Lane 1. 2. 32 34 The manager should ensure that at least half of the homes staff are qualified to NVQ level 2 by the end of 2005. The paintwork in the bathroom of Number 4 should be renewed. 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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. Extracts may not be used or reproduced without the express permission of CSCI 3-4 Glebe Lane F58 F10 s22557 glebe lane v239856 090805 ui stage 4.doc Version 1.40 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!