CARE HOME ADULTS 18-65
3 Pendarves Road Camborne Cornwall TR14 7QB Lead Inspector
Lynda Kirtland Unannounced Inspection 6th May 2008 09:30 3 Pendarves Road DS0000009115.V361984.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 3 Pendarves Road DS0000009115.V361984.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. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 3 Pendarves Road Address Camborne Cornwall TR14 7QB 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) 01209 610827 alan.hegarty@dcact.eu.com Spectrum Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 4. 5/6/07 Key Inspection 22/11/07 random inspection Date of last inspection Brief Description of the Service: 3 Pendarves Road is a home providing accommodation and personal care for up to four adults with a learning disability. The registered provider is Spectrum, an organisation that provides specialist services for people with autistic spectrum disorders. Spectrum employs an acting manager and a team of staff to run the home on a day-to-day basis. External, on-call managers are available to provide specialist input, support and advice where necessary. The home is located in the town of Camborne, within easy reach of all the town’s facilities. There are shops within walking distance of the home and the home has a vehicle to provide transport for people who use the service who require access to resources in the wider community. The home is a two-storey building, set in its own grounds. All of the bedrooms are large single rooms some are en suite. One has its own lounge and bathroom. There is a shared bathroom on the first floor. The home has a lockable office on the first floor, which also provides accommodation for staff to sleep in. Downstairs there is a communal kitchen/ dining room and large lounge. The home does not provide specific facilities for people with physical disabilities, but could be adapted for this, if necessary. Fees are £1500 per week, which excludes variable charges for individuals personal items, off-site entertainment, dry cleaning, private chiropody and alcoholic beverages, 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
This was an unannounced key inspection, which took place on 6 May 2008 and lasted for approximately five hours. The purpose of the inspection was to ensure that people who use the service needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that their placements in the home result in good outcomes for them. Information received from and about the home since the previous inspection has also been taken into consideration in making judgements about the quality of outcomes for the people living there. The inspection included meeting with the people who use the service, staff were interviewed and there were opportunities to directly observe aspects of peoples daily lives in the home and staff interaction with them. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the homes manager. The principle method of inspection was “case tracking”. This involves interviews with people who use the service; staff caring for them and examination of records relating to their care. This provides a useful impression of how the home is working for people who use the service overall. Two people were case tracked in detail at this inspection. Since the previous key inspection Pendarves Road has increased the number of people it can provide care and accommodation to four people. The homes manager, Alan Hegarty has been in this post for a month, however he has been a care support worker at the home for three years and therefore knows the people who use the service and staff team well. He is applying to be the registered manager and is in the process of submitting his application to the commission. It is acknowledged that there have been five management changes in the home in the last 18 months, hence this inspection has identified positive areas of care but there are some areas of improvement needed. What the service does well:
People who use the service initial admissions are on the basis of detailed assessments; to make sure Pendarves Road would meet their needs. Their individual care needs are clearly set out in individual care plans, which are regularly reviewed with them and their representatives so that they are aware of the goals of their placements in the home. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 6 People who use the service are encouraged to make choices about things that are important to them such as what activities they do during the day, meals and what time to get up in the morning, which was observed during the inspection. Staff support them to take managed risks so that they develop their skills and independence safely. People who use the service confirmed that they enjoy a good quality of life in that staff take them out and help them to access a range of activities in and out of the home that are culturally and age appropriate. They are supported to maintain valued relationships with their families, can make telephone calls to them in private. People who use the service are given information about their rights and responsibilities as residents, including their rights to consult with advocates outside of the home, if they wish. They are provided with healthy, home prepared meals that are culturally appropriate and account for their individual tastes and preferences. Staff support the people who use the service to take care of their personal needs as independently as they can. Staff help them to access specialist healthcare services as necessary so that they maintain good physical and mental health. People who use the service said in the main they felt able to raise any concerns they have with staff and there is a key worker system in place so that they can talk to a nominated person, if they prefer. There is a formal complaints procedure, and there have not been any formal complaints made since the previous inspection. The home was clean and tidy throughout at the time of the inspection and provides people with a safe and comfortable place to live, in a convenient community setting. Safety equipment is regularly tested and checked to make sure the home is safe for them to live in. The inspector was welcomed to the home in a friendly manner by staff and People who use the service. All were aware of the reason of the inspection. What has improved since the last inspection?
A random inspection occurred in November 2007 to review the progress made on the requirements set at the previous inspection in June 2007. It was noted at that time that six requirements had been complied with and have been maintained. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 7 From inspection of documentation it is evidenced that the people who use the service are now informed of their total fees payable and the method of payment. This has also meant that the recommendation that people who use the service have clearer information in their contracts about their welfare rights and how their benefits have been calculated has also been met. The manager informed me, evidenced with training records that staff have attended in house medication training. Spectrum mangers have also confirmed that as there is a 3 tier on call system that when PRN medication is needed that in theory one of the on call managers would know the individual and be confident about authorising a PRN medication. From inspection of medication records it was evident that MAR sheets are completed on a daily basis to evidence accountability for the administration of medication. The home has undergone a major refurbishment; the kitchen and dining areas are more spacious and allow people who use the service to access these areas more freely. People who use the service said they liked the new kitchen/ dining area and were observed to be using the area to prepare their own breakfasts. They also said that they were pleased with the redecoration in the home. Staff were likewise complimentary about the new arrangements in the home and felt that the kitchen/ dining area allowed people who use the service to participate more in their mealtime preparations plus have a more relaxed environment to enjoy meals in. The manager stated, confirmed by records that all staff have either attended or are booked to attend mandatory courses. From correspondence plus discussion with people who use the service it is evident that concerns expressed by individuals are listened too and appropriate actions are taken when needed. What they could do better:
The homes manager, Alan Hegarty, has been in post for a month. He must submit his registered manager application to the Commission. He should also attend the Multi agency Safeguarding course to ensure he is aware of Cornwall’s approach to Safeguarding issues. The homes Statement Of Purpose and Service Users guide should be updated to ensure that it accurately reflects the management structure of the home. Mr Hegarty stated that he would like to reintroduce residents meetings, as these have not occurred for a year. This could then include consultation with People who use the service in gaining their views in who will live or work at the home. Mr Hegarty also stated that staff meetings will be reintroduced as these have not occurred on a regular bases as will formal supervision of staff. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 8 It is required that all medicines are stored safely at all times so that only those delegated staff can access medication to maintain a safe system of storage of medication. It is recommended that the medication cabinet be fixed firmly to the wall to ensure that all medication is stored safely. In addition the medication policy needs to be updated to ensure that it reflects current practice. A copy of Safe handling of medicines in care homes should be gained for staff to access. Staffing levels must be reviewed to ensure that sufficient staff are on duty at all times. In addition there must be a further review of the risks attached to the employment of a lone worker in the home at night, plus being able to monitor safely the whole of the home as one bedroom is located at the rear of the building on the ground floor, so that people who use the service and staff are not placed at risk. Staffing levels must reflect the individuals risk assessment to ensure that People who use the service safety is maintained at al times in and out of the home. A review of gender issues in the home and staffing should be reviewed to clarify if and when female staff are able to work in the home. Fifty percent of care staff should have a minimum of NVQ at level 2 to ensure that People who use the service can be confident that staff have the necessary skills to meet their needs. Staff should have copies of the general Social care Councils Code of Practice. Supervision of staff needs to commence so that work practice and training issues can be discussed. Training by Spectrum should recommence as soon as is possible so that staff skills and knowledge are kept up to date. The reintroduction of residents meetings and staff meetings would benefit the service so that their views on the day to day running of the service is sought. Policies and procedures such as adult protection, complaints and medication should be reviewed and easily accessible to staff for their reference in their daily work. An environmental health inspection of the premises should be arranged as the manager (and previous manager) is unaware of when the last inspection occurred. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 9 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. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 10 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 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 11 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): 1,2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are given information about the services that Pendarves Road provide. People’s needs are assessed prior to moving into Pendarves Road, and are given opportunities to participate in this process EVIDENCE: Pendarves Statement Of Purpose and Service Users guide describe the facilities and services that they offer. However due to the management changes in the home this needs to be updated so that it accurately reflects these changes. From observations and talking with people who use the service it was evident that they are settled in the home, and that they get on well with each other and with the staff. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the person who will be using the service, their family or advocate, and relevant professionals. Transitional work to introduce the person to the home, other people who uses the service and staff occurs. Contracts of care were seen at the random inspection in November 2007 and were satisfactory. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 12 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): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals care plans address their personal, health and social care needs so that they are aware of the goals of their placements in the home. People who use the service are provided with opportunities to make decisions about things that are important to them and supported to take managed risks so that they develop their skills and independence. EVIDENCE: People who use the service confirmed that they are involved in the development of their individual care plans and attend their subsequent reviews to which their relatives and a social worker are invited to attend. They felt involved in the process and that their views are listened too. Care plan formats are detailed and include specific headings related to their individual personal, health and social care needs including their individual and diverse needs. Personal Care plans provide individuals with specific goals to work towards, and inform and direct staff in how to support the person to achieve this goal to encourage them to fully maximise their skills for independent living. The reviews record their views so that they are aware of the purpose of their placements in the home and are able to contribute to the ongoing care planning process. Staff confirmed they were able to understand the care plans
3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 13 and that the detail of how to assist in a particular task allowed consistency of care. People who use the service, staff and the home’s manager were able to provide examples of how service users are enabled to make choices about things that are important to them including the activities they participate in, when they get up in the mornings and go to bed at night and menu planning. This was observed during the inspection. Individual care plans contain consideration of their abilities to make decisions for themselves. Written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities set out how staff support individuals to take managed risks in order to develop their skills and confidence. From inspecting records of two people who use the service finances it was found that all records tallied with receipts of expenditure. Spectrum Headquarters then audit the monies separately to ensure that all monies are accounted for. The Commission is aware that Spectrum is reviewing the policy and procedure of the management of monies. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff assists people who use the service to access a range of age, peer and culturally appropriate activities in and out of the home and to maintain appropriate contact with their families so that they enjoy a good quality of life. Their rights and responsibilities are set out clearly for them so that they are well informed about what is expected of them as residents of the home. They are provided with a healthy diet so that they stay well and enjoy their meals. EVIDENCE: People who use the service gave examples of activities they enjoy taking part in, during interviews held with them at the time of the inspection. Copies of their activity rotas are held on the notice board in the kitchen and their daily care records confirm that they take part in a range of activities in accordance with their individual care plans. Staff confirmed that they help people to access a range of local community facilities, which their records confirmed. People who use the service said that
3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 15 they enjoy going on trips out of the home and went out on a trip in the afternoon of the inspection. Appropriate transport is provided for them. People who use the service said they are able to contact their families by telephone in private and that visiting is encouraged, which written records also confirmed. People who use the service said that they like the food provided to them at the home and confirmed they are involved in the menu planning. People who use the service were observed accessing the kitchen and are able to prepare their own breakfasts and lunches. They help to plan the main evening meals, which are suitably varied, home prepared and appropriate to individuals cultural backgrounds and preferences. The manager explained that there has been a difficulty in open access to food due to individuals’ health needs plus concerns of infection control. This has meant that the kitchen is only accessible when staff are present. If people who use the service wish to make drinks/snacks and the kitchen is locked then they need to ask staff to open the kitchen. From observations during the day of the inspection plus in talking with people who use the service this did not appear to raise concerns. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. The recording of medication processes is satisfactory to ensure that medication errors are prevented. Medication must be stored away securely at all times. EVIDENCE: People who use the service are able to access bathrooms in private and staff guide, support and assist them as necessary, to help them maintain their independence and dignity. Staff have clear written guidance on how people need and want support, so that they provide assistance appropriately. People who use the service healthcare needs are considered as part of the care planning process and regularly reviewed. People who use the service confirmed by documentation showed that they access external healthcare providers, including specialists, when they need to. Since the previous inspection the home has purchased a suitable medication cabinet. This needs to be attached to the wall. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 17 People who use the service do not self-administer medication. From inspecting medication improvements had been made in this area. The MAR sheets were completed accurately and all medication was accounted for and tallied with documentation. From a count of PRN medication this tallied with the documentation. All staff have either attended or are booked to attend medication training. What was of concern is that on arrival to the home it was observed that medication was sitting on top of the medicine cupboard and the keys to the medicine cupboard was in the door. Staff said they had just finished administering medication but the office was unstaffed and the blister packets were on display and the medication cabinet was accessible. Medication must be locked away safely at all times. The manager agreed to address this immediately. The medication policy was dated 2003 and needs to be updated. The current policy outlines how staff are to dispense medication, yet their medication comes in the Monitored Dose System and is therefore already to administer. In addition the policy should include for example the procedure for disposal of medication, reporting of drug errors and use of homely remedies. The safe handling of medicines guide buy the Royal Pharmaceutical Society should also be gained for reference for staff. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. People who use the service are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. EVIDENCE: People who use the service confirmed they could make their views known to staff. There is a key worker system in place so that they can discuss any concerns with a nominated individual if they prefer. They are invited to contribute to their care plan reviews and can access the home’s formal complaints procedure if they feel they need to. (This needs to be updated) There have not been any formal complaints since the previous inspection. The homes adult protection policy could not be found. However the manager was aware of what process he should follow if there was a suspicion of abuse. The home’s manager was aware from his staff-training programme that a number of staff needs to attend adult protection training and he should attend the local multi-agency training. People who use the service are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Spectrum has a whistle blowing policy. Staff records show they are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and the required checks are made before they commence work in the home.
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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, 30, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and safe to provide People who use the service with independence, a good quality of life and adequate protection from infection. EVIDENCE: People who use the service commented that they are pleased with the furnishings and décor of the home. They were particularly pleased with their bedrooms which they said they had personalised (not inspected) and the communal lounge area, which was attractively furnished. This was also apparent during an inspection of the premises. An environmental audit of the home occurred in November 2007 and no issues were identified for urgent attention. People who use the service and staff were pleased with the redesign of the kitchen/ dining area, which is now more spacious and allows people who use the service better access to prepare meals etc. The room is more open and encourages people who use the service and staff to spend more time in this area. The home was clean and tidy throughout at the time of the inspection and staff have written guidance on maintaining good hygiene in the home.
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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): 32,33,34,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A review of staffing levels must occur to ensure that at all times sufficient numbers of qualified staff are on duty to meet the needs of people who use the service. Staff access to training needs to recommence so that staff skills are constantly updated. The home’s recruitment policies and practices are fair, safe and effective so that people who use the service can be assured that staff are suitable to work in a care setting but they lack regular, formal supervision EVIDENCE: In discussions with people who use the service, staff and manager it was apparent that there are times when there has been insufficient staff on duty. For example the previous day there was only two members of staff on duty, and the minimum staffing states three. People who use the service said they were in the main satisfied with the care that they receive from staff but they felt that at times they was insufficient staff on duty and gave the example that certain planned activities have not taken place as there is not enough staff on duty. One commented that it is ‘unfair’ and felt that certain people who use the service were given more staff attention i.e. activities to occupy them and others were left. When this was discussed with the manager he agreed with this comment.
3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 21 In discussions with staff it was apparent that the current ratio of three staff to four people who use the service and one night member of staff, was at times insufficient. It was also observed during the inspection that a member of staff escorted two people who use the service out in a vehicle. However in looking at the individuals risk assessments it clearly stated that the People who use the service required one to one support in the community each to take them out safely. This was discussed with the manager who agreed that the risk assessments do not reflect current practice regarding staffing levels. Therefore it is required that staffing levels are reviewed to ensure sufficient staff are on duty at all times plus a review of individual and group risk assessments take place to ensure sufficient staffing are present on activities in the community. The manager showed risk assessments in respect of lone working with individual people. Gender issues still need to be taken into account in these risk assessments, as currently no females work at the home. However People who use the service commented that they would like some female support and therefore this needs to be reviewed as to how and if this can occur. Staff cover at nighttimes has just been reduced to one member of staff. One bedroom is located on the ground floor and some distance from, the sleeping in /office area. A risk assessment as to if this is sufficient also needs to occur as staff acknowledged that if the person left their room they would not be able to hear this due to the distance between the rooms. The homes manager confirmed there is a currently two and a half support care workers vacancies. Therefore he has been on shift more and away from management duties and staff have been working long hours to cover the vacancies. According to the manager and records held in the home, less than the recommended 50 of care staff are qualified to NVQ level 2, although this situation should improve as more staff are due to complete it in the near future. Staff recruitment records inspected evidenced that staff have undergone the necessary clearances before they commenced employment at the home. An induction programme for new staff is implemented. Care staff have individual training records and those interviewed during the inspection confirmed that the training has been beneficial to their work. Spectrum has currently stopped all training courses for the next two months due to staffing levels within the spectrum homes. Whilst staffing of the homes needs to be a priority it is of concern that no training is available for the next two months. The manager acknowledges that formal staff supervision needs to commence and will address this.
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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): 37,39,40,41,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The homes manager must apply to the Commission to be registered so that an assessment of his fitness to provide this role is assessed. The home is mainly well managed for the benefit of People who use the service. There are formal informal systems in place to ensure that individual views are accounted for in the day-to-day running and ongoing development of the home. There are systems in place to protect People who use the service from avoidable harm and injury. EVIDENCE: Alan Hegarty, the current manager has been in post for a month but has worked at eh home for three years and therefore knows the People who use the service and staff group well. Spectrum have liaised with the Commission as to the reasons for the change of management in the home. Mr Hegarty must
3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 23 apply to the Commission for registration to ensure that his fitness in this role is assessed. He has not completed his NVQ level 2 as he stated that Spectrum have now enrolled him to commence his NVQ 4. People who use the service were complimentary about Mr Hegarty. The manager has not undertaken a Quality assurance process yet due to his recent arrival. A quality assurance questionnaire was seen on one person’s file that was case tracked which was completed by a relative, this was positive about the care and support they received from the staff at the home. Regulation 26 visits also show a level of quality assurance process in the home Mr Hegarty is aware that residents meetings have not occurred for a year and wishes to resume these. He also stated that he wishes to resume staff meetings on a regular bases. The home’s fire safety records were completed and up-to-date. There are records of regular tests and checks of safety equipment and procedures in the home to ensure People who use the service safety. The homes fire risk assessment has been reviewed in line with the new legislation. The homes manager was unaware, and unable to find documentation as to when the last environmental heath inspection occurred. It is recommended that this be arranged. Records are stored confidentially, staff need to be conscious of their recordings to ensure that it adheres to the data protection act i.e. communications book. The home’s environment in the main appeared safe and there are written individual and environmental risk assessments in place to minimise risks to people who use the service and staff working in the home. Maintenance of the home and its equipment are satisfactory. 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 24 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 3 3 x 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 25 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 Standard YA20 Regulation 13(2) Requirement Medication must be stored safely at all times to ensure that the system is robust and prevents medication errors. There must be a review of the risks attached to the employment of a lone worker in the home at night taking into account gender issues so that People who use the service and staff are not placed at risk. This is re-notified to you (last date of compliance 30/3/08) Timescale for action 30/05/08 2 YA33 18(1)(a) 30/08/08 3 YA33 18(1)(a) A review of staffing levels must 30/08/08 occur to ensure that at all times sufficient, skilled staff are on duty to meet the needs of people who use the service safely both in and when on outings outside of the home. The homes manager application for the registered manager post must be completed. 30/08/08 4 YA37 8(1)(2) 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations The homes Statement Of Purpose and Service Users guide should be updated to accurately reflect the management arrangements in the home. The home’s manager should undertake multi-agency training on the protection of vulnerable adults from abuse and cascade this to staff working at the home. Evidence that consultation with service users in gaining their views in who will live or work at the home should be gained. The proportion of staff qualified to NVQ level 2 should be increased towards achieving the 50 level indicated in the National Minimum Standards. Staff should be provided with regular, recorded individual supervision and more regularly held staff meetings. Staff should have copies of the General Social Care Council’s Code of Practice. An environmental health inspection of the premises should be arranged. Policies and procedures such as adult protection, complaints and medication should be reviewed and easily accessible to staff for their reference in their daily work 2 YA37 3 YA39 4 YA35 5 YA36 6 7 8 YA34 YA43 YA40 3 Pendarves Road DS0000009115.V361984.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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