Inspection on 12/10/06 for 3 The Droveway

This inspection was carried out on 12th October 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 40 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 The Droveway 20/11/08

3 The Droveway 31/01/08

3 The Droveway 19/06/07

3 The Droveway 06/03/06

3 The Droveway 17/08/05

3 The Droveway 27/01/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 3 The Droveway Hove East Sussex BN3 6LF Lead Inspector Niki Palmer Unannounced Inspection 12th October 2006 12:00 3 The Droveway DS0000060763.V311399.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 The Droveway DS0000060763.V311399.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 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 The Droveway Address Hove East Sussex BN3 6LF 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) 01273 563935 www.caremanagementgroup.com Care Management Group Limited Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is six (6). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability, who may also have an associated physical disability, can only be accommodated. 06th March 2006 Date of last inspection Brief Description of the Service: 3 The Droveway is one of many homes owned by Care Management Group (CMG), which is registered to provide accommodation for up to six adults with learning disabilities. Residents at this establishment have profound learning and physical disabilities. The home is located on the outskirts of Brighton and Hove. There is nearby access to some local amenities and public transport. A small car parking area is available at the home, although on street parking is permitted in the surrounding areas. The home is a bungalow consisting of six single bedrooms, two bathrooms / shower rooms and a good-sized lounge. There is a separate kitchen and dining area and garden to the rear and side of the property, which is accessible to wheelchair users. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is available on request. The home’s fees as of the day of the inspection range between £1450 - £2082 per person per week dependent on needs. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 3 The Droveway will be referred to as ‘residents’. This unannounced inspection took place on Thursday 12 October 2006 and lasted five hours. Six residents were accommodated on the day of the inspection, four male and two female aged between 21 and 40 years of age. Only one resident was present on the day of the inspection, whilst the others attended day services. In order to gather evidence on how the home is performing, individual discussions took place with two members of staff, whilst the majority of the inspection was undertaken with the deputy (acting) manager of the home. One care record was examined in some detail for the purpose of monitoring care. Other areas and documentation inspected included: the home’s pre-admission procedures, medication practices, the provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. All communal areas and individual rooms were seen. A detailed pre-inspection questionnaire was received prior to the visit to the home. This provided the inspector with information relating to the premises, maintenance and associated records, details of the homes policies and procedures, staffing details and relevant training. Two relatives’ survey questionnaires were received by the inspector prior to the inspection. Following the inspection, telephone contact was made with the District Nursing Team and a care manager. In addition, written feedback was received by a local General Practitioner. Their views are reflected throughout this report. In order that a balanced and thorough view of the home is obtained, this report should to be read in conjunction with the previous inspection report carried out on 06 March 2006. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A number of requirements are outstanding from the previous inspection report. Care planning procedures remain unsatisfactory; residents are at risk of their needs not being appropriately identified and met. Excessive hot water temperatures have once again resulted in an immediate requirement being issued; these concerns have been raised during the home’s two previous inspections. Despite a risk assessment being completed for the storage of 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 7 hazardous substances, residents and/or visitors to the home still have unlimited access to these despite a lock being fitted to the door. The home has been without a manager since January 2006 and this absence is becoming apparent, particularly in relation to administrative tasks, health and safety aspects of the home and the reviewing and monitoring of care. The home is required to ensure that a suitably experienced and competent person is recruited to manage the home. Additional staff training must be provided in order to ensure that all staff have the competencies and skills to meet the assessed needs of residents including: epilepsy, pressure area care, Adult Protection, fire safety, moving and handling and food hygiene. 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 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has good systems in place to ensure no person is accepted whose needs cannot be met. EVIDENCE: Due to the complex healthcare needs of the residents accommodated, it is crucial for the home to ensure that as much information as possible is gathered prior to admission in order to ensure that the home can meet their needs. CMG employs a team of centrally based assessment referral officers, who are responsible for considering and assessing all initial referrals for each of the care homes across the South East region. The deputy manager confirmed that there has only been one new admission to the home since the last inspection. A detailed pre-admission assessment form was seen for this person. It was noted to be exceptionally detailed and covered the following areas: general background, physical, communication, activities of daily living, community presence and participation, occupational education, relationships and spiritual needs. There was clear evidence to demonstrate that this had been undertaken with the person’s previous place of residence, family members and care manager. It was pleasing to receive a comment from one parent who stated: ‘The transition process was handled very well and sensitively. I knew about the accommodation in depth before they [the resident] moved in’. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit that care staff appear to have a good understanding of residents’ needs; care planning procedures are inadequate. Residents’ personal and healthcare needs are at risk of not being met due to care plans not being implemented, completed and reflecting actual current practice. EVIDENCE: All residents have a template care plan in place, titled ‘All about me’. One of these were examined in some detail following an in-depth look at their preadmission assessment. A number of concerns were noted: despite specialist pressure relieving equipment being place, there was no mention of this or guidance for staff to follow. The deputy manager confirmed at the previous inspection that all residents would be provided with a comprehensive health booklet. It was therefore disappointing to note that within the person’s care plan, this was incomplete and minimal information had been recorded. There were no written records of recent healthcare appointments or admissions to hospital, epilepsy management guidelines or good practice infection control 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 11 procedures that should be followed. Requirements have been made in respect of this. Daily records are kept separately from individual plans of care. It was concerning to note that those seen were brief, insufficiently detailed and in some instances contain inappropriate language. The home is required to maintain accurate daily records within individual care plans. These must include the details of any specialist interventions e.g. the outcome of all hospital appointments or visits by healthcare professionals. All of the residents living at the home have profound physical and learning disabilities and are therefore reliant on care staff, their relatives and other health and social care professionals to act in their best interests and make decisions on their behalf about many aspects of their lives. Relatives confirmed that they are involved in this process as much as possible. Albeit that residents’ verbal communication is limited, staff working in the home were observed to interpret individuals’ subtle level of communication and include residents in the daily routines of the home wherever possible. One relative commented: ‘All members of staff try to act appropriately when [the resident] indicates what they may like or wish to do, although this can be hard for them to interpret’. A number of core risk assessments for activities of daily living are in place within individual plans of care. Whilst on the whole these were noted be concise and there was evidence that a number of them had been recently reviewed, it was noted that one person’s risk assessment for epilepsy was inaccurate and did not clearly reflect what the potential risks posed were. For example it stated that the person was at risk of falls, yet this person is a fulltime wheelchair user. This indicates that template risk assessments are being completed as a matter of course rather than being person centred and specific to individuals. A requirement has been made in respect of this. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst structured daily activities are in place for most residents, the home has failed in at least one instance to provide appropriate and meaningful stimulation and occupation for one person. All residents are encouraged to maintain relationships with family and friends. The provision of food is good. EVIDENCE: CMG owns a development centre, which is accessed by a number of CMG’s nearby care homes on a daily basis Monday to Friday. This provides opportunities for five of the residents to engage in informative and creative activities should they wish, including sensory stimulation, art, postural movement, Speech and Language Therapy, physiotherapy, music, and IT. There is no day care provision in place for one person at this current time. Consequently they are spending most of the day at home with care staff. Through observation, discussions with staff and the examination of care records, it was identified that there are minimal opportunities in place for this 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 13 person to engage in activities outside of the home. The deputy manager explained that this was due to their healthcare needs; namely their epilepsy, yet there was no risk assessment in place or guidelines for staff to follow to ensure that any potential risks were identified and so far as possible eliminated. The home is required to ensure that suitable arrangements are in place for all residents to engage in meaningful and stimulating activities both within and outside of the home. 3 The Droveway has access to a minibus, however the deputy manager of the home explained that this has not been in use for over four months as it failed its MOT. Since this time the home has been reliant on using transport from other nearby CMG homes, consequently impacting on the number of community activities that residents can take part in. A number of alternative community activities during this interim period were discussed on the day of inspection. It is strongly recommended that priority be given to ensuring that the minibus is roadworthy, safe to use and accessible to residents and staff. Each of the returned questionnaires and conversations with staff confirmed that visitors are always made to feel welcome to the home. All visitors are requested to sign in to the home on arrival in a book located at the main entrance of the building. Two of the residents accommodated are fed by specialist feeding tubes. Only care staff who have received the appropriate training are permitted to support these individuals as per their feeding regimes. It was pleasing to note that they are encouraged to dine with other residents and staff during mealtimes and that they not excluded from this sociable activity. Since the last inspection the home has put together a folder of colour photographs and pictures in order to encourage residents to take part in the weekly planning of menus. One to one support is offered to each resident in turn on a weekly basis to choose the evening meal for the week. The chosen meals are then displayed on a notice board in the dining area. Staff confirmed that residents are also supported to go shopping to the local supermarket with staff. Staff commented that residents really benefit from the different sensory stimulation of these trips e.g. the smells of the bakery, the hustle and bustle of the checkouts and interaction with members of the public. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the personal and healthcare needs of residents are identified and met. Medication practices are sufficient. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all appointments as necessary. Due to the complex healthcare needs of residents, District Nurses visit the home on a regular basis. Feedback received from a GP and District Nursing Team confirmed that they are satisfied with the overall provision of care. All personal care is carried out in the privacy of one of the communal bathrooms or in residents’ own bedrooms. All residents require a minimum of 2-1 support from staff; this is due to safe manual handling procedures. Staff commented that there is currently only one hoist available throughout the home, impacting on the needs of residents particularly at busy times, namely in the mornings and evenings. The home is required to ensure that sufficient moving and handling equipment is in place in order to meet the assessed 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 15 needs of residents. This must take into account the accessibility of the equipment during the busier times of the day. CMG employs a Speech and Language Therapist and Physiotherapist, who work regularly into 3 The Droveway, whilst other specialist healthcare referrals are made as necessary. Four of the residents living at the home have epilepsy and whilst some staff have received training in this area including the administration of emergency medication, it emerged through discussions with care staff that they were unaware of the different types of seizures that individuals have. The home is required to ensure that epilepsy management guidelines are clear, precise and include a brief history of the person’s seizures, a description of what form the seizure takes and instructions for staff to follow in the event of a seizure occurring. Additional training must be provided to all staff. Due to the complex physical healthcare needs of residents, a number of them are at risk of developing pressure area care damage to their skin. Although specialist equipment is in place to help reduce the risks of tissue breakdown there is no record of this or guidance in place within individual care plans for staff to follow e.g. what the level of risk is or where, how often residents’ position needs to be changed, what the programme of care is or any records to indicate that any of the above needs are being met. A requirement has been made in respect of this. The home’s medication records and storage systems were inspected. The home uses a pre-packed blister pack, which is delivered by the local pharmacy on a monthly basis. Only members of staff who have received the relevant training and have been assessed as competent in the administration of medicines are able to carry out this task, whilst only senior members of staff hold responsibility for the reordering and returning of medicines to the pharmacy. All medicines were found to be appropriately stored in the main office with accurate records maintained. Whilst clear guidelines were in place for most residents who require medication on a PRN basis (as and when), some topical creams require clearer guidance for staff. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately and improved procedures to ensure that residents are protected from harm, neglect or abuse. Additional Adult Protection training for all staff is required. EVIDENCE: The home has a detailed complaints procedure in place, which was seen on the day of inspection. It details how a complaint can be made, how the complainant can expect it to be dealt with and includes the contact details of the CSCI. The deputy manager of the home confirmed that there has been one complaint made since the last inspection, which was investigated by the Regional Operations Manager, however full details of this were not available for inspection as records are kept at the organisation’s head office. It is recommended that a record of all complaints received by the home is kept. This must include details of the investigation undertaken and the outcome. There have been no complaints received by the CSCI since the last inspection. Following the last inspection, the home’s Adult Protection and Whistle-blowing policy and procedure were updated to clearly state that all allegations of suspected abuse must be referred to Social Services under local multi-agency guidelines. The deputy manager has also incorporated some information regarding the PoVA list within the home’s policies and procedures. It is recommended that this be more detailed to provide staff with clearer guidance regarding the referral process. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 17 Staff spoken with confirmed that they have received some in-house training in relation to Adult Protection, however this was some time ago. The home is required to ensure that all staff receive up to date refresher training. No alerts have been raised since the last inspection. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 3 The Droveway presents as a reasonably clean and well-maintained home, however residents and staff will be better safeguarded when action is taken to address the shortfalls identified in the health and safety procedures. EVIDENCE: 3 The Droveway provides residents with a homely and comfortable place to live, which consists of six single bedrooms, two bathrooms / shower rooms and a good-sized lounge. Since the last inspection the lounge area and three bedrooms have been redecorated. One room was in urgent need of redecoration following a fire, which broke out in a resident’s bedroom. The fire brigade were called; all residents remained unharmed. It is thought that this was caused by a faulty electrical fan. All fans were checked on the day of inspection for evidence of a recent portable electrical appliance test (PAT), however one was noted to be in need of this. A requirement has been made. Concerns were raised at the last inspection regarding the storage of hazardous substances in an unlocked laundry room. Consequently the home was required to undertake a risk assessment for this and take the appropriate 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 19 action. Albeit that a lock has been installed to the door indicating that the risk assessment identified that the risks were too great to leave it unlocked, on the day of the inspection the door was noted to be unlocked and therefore accessible. This was discussed with the deputy manager and a requirement made. Since the last inspection window restrictors have been fitted to all windows. This helps to promote the security for staff and residents, working and residing at the home. An immediate requirement was issued at the last inspection for a hot water outlet to be fitted with a thermostatic valve. Whilst this was promptly dealt with by the home, it was concerning to find another shower facility on the day of inspection to deliver hot water at a maximum temperature of 52°C above the recommended 43°C. Similar concerns have been raised during inspections carried out on 17/08/05 and 06/03/06. Another immediate requirement was made, in addition to a letter being sent to the Responsible Individual. The deputy manager confirmed that all staff are responsible for the day to day upkeep of the home including laundry. A part-time cleaner is shared with a nearby CMG care home who works at 3 The Droveway for two mornings per week. In line with good infection control policies and procedures, one person’s laundry requires to be washed at a high temperature separately from the other residents. It was therefore concerning to note that the deputy manager said that the washing machine is not equipped for this. The home is required to ensure that suitable laundry facilities and arrangements are in place to prevent infection and the spread of infection at the home. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improved recruitment procedures are in place to protect the well-being, health and security of residents, although the home currently has three full-time vacancies. Additional staff training needs to be undertaken in order to meet the assessed needs of residents. EVIDENCE: In addition to the deputy manager the home employs a total of nine support workers, only one of which has obtained an NVQ Level 2 certificate in care, whilst two are currently working towards this. Three staff members have left since the last inspection. All of the staff spoken with and feedback received from relatives commented that the home’s reduced staffing numbers can at times be difficult. The deputy manager confirmed that the organisation is in the process of recruiting new staff. Shortfalls were identified at the previous inspection in relation to the home’s recruitment of staff. The recruitment files for two newly appointed members of staff were examined. It was pleasing to note that application forms were sufficiently detailed, two satisfactory written references had been obtained and there was evidence of a PoVA First check and Criminal Record Bureau (CRB) check in place. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 21 The deputy manager confirmed that all new staff undertake a TOPSS induction. The inspector provided the manager with up to date information under new legislation, which relates to the Common Induction Standards, which replaced TOPPS in September 2006. The home is required to work towards implementing these. Staff confirmed that training courses are mostly in-house. Recent training includes: fire safety, first aid, PoVA, manual handling, an overview of legislation and keyworking. It remains an outstanding requirement for three members of staff to attend fire training, although this is planned for the end of October 2006. Staff training records were examined and it was noted that a number of staff are in need of refresher training for food hygiene and manual handling in addition to other areas that have been mentioned elsewhere in this report. Further requirements have been made. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 22 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, 39, 40 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of clear management and leadership structure within the home is detrimental to the well-being of residents and staff. EVIDENCE: The home has been without a registered manager since January 2006, despite a requirement being made at the last inspection. Since this time, the deputy manager has been acting up, with very little guidance or job description from the organisation. This has had a huge impact on the home’s care planning procedures, health and safety aspects and quality assurance systems. One relative commented: ‘CMG have consistently failed to employ a full-time manager and the reasons for this are unclear’. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 23 It is required that an application is submitted to the CSCI for a suitably qualified, competent and experienced person to be registered as the manager of the home. CMG have provided the home with a quality assurance manual, which has yet to be implemented. Lengthy discussions took place between the inspector and the deputy manager during the inspection regarding the importance of quality assurance systems and a number of suggestions put forward. A requirement has been made in respect of this. A number of the home’s policies and procedures were inspected during the inspection. Not withstanding that the majority were considered adequate, it is strongly recommended that they are signed and dated in order to evidence that they are regularly reviewed and current. Evidence provided within the home’s returned inspection questionnaire identified that regular health and safety checks are carried out including fire safety, emergency lighting, adaptations and other equipment and gas installation, however in light of requirements made in respect of hot water temperatures, electrical equipment, the storage of hazardous substances and laundry facilities, the inspector concludes that the health, safety and welfare of residents and care staff is poor. 3 The Droveway DS0000060763.V311399.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 1 X 1 3 X 1 X 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation Requirement Timescale for action 31/12/06 2. YA6 YA19 3. 4. YA6 YA9 5. YA12 YA13 6. YA18YA18 15(1)(2) (a- That care plans are up to date d) and contain detailed information pertaining to an individuals’ care. These must be consistent, reflect actual current practice and be regularly reviewed [Outstanding from 31/04/06]. 15(1)(2) (a- That health booklets are up to d) date and provide detailed written information for staff to follow in relation to pressure area care, epilepsy, weight, medication and any other healthcare needs. These must be regularly reviewed. 17(1)(a) That accurate daily records are (3)(a) maintained for each resident. 13(4) That epilepsy risk assessments are reviewed, updated and person centred. These must represent the potential risks posed. 16(2)(m)(n) That suitable arrangements are in place for all residents to engage in meaningful and stimulating activities both within and outside of the home. 16(1) That sufficient moving and DS0000060763.V311399.R01.S.doc 31/12/06 31/12/06 31/12/06 31/12/06 28/02/07 Page 26 3 The Droveway Version 5.2 YA29 23(2)(c) 7. YA6YA6 YA19 12(1)(a)(b) 8. 9. YA19 YA35 YA6 YA19 12(1)(a) 18(1)(c)(i) 12(1)(a)(b) 15(1) 10. 11. YA19 YA35 YA20 12(1)(a) 18(c)(1)(i) 13(2) 17(1)(a) Schedule 3(i)(k) 13(6) 13(4)(a)(c) 12. 13. YA23 YA35 YA24 YA42 YA24 YA42 YA27 YA42 14. 15. 13(4)(a)(c) 13(4)(a) handling equipment is in place in order to meet the assessed needs of residents. This must take into account the accessibility of the equipment during the busier times of the day. That individual epilepsy management guidelines are clear and precise. These must include a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. That up to date epilepsy training is provided to all staff. That sufficient guidance and information for staff to follow is detailed within individual plans of care for all residents who are at risk of pressure area care damage. This must include recording charts. That specialist advice and training is sought from a tissue viability nurse. That clearer guidance for PRN topical creams is recorded within the medication administration records. That up to date Adult Protection refresher training is provided to all staff. That all portable electrical appliances are PAT tested to ensure that they are safe for use. That the laundry door is kept locked at all times as per the risk assessment. That a risk assessment be implemented for the shower delivering hot water above the recommended 43°C and the appropriate action taken [Immediate Requirement]. DS0000060763.V311399.R01.S.doc 31/12/06 31/01/07 31/12/06 31/01/07 31/12/06 31/01/07 31/10/06 12/10/06 12/10/06 3 The Droveway Version 5.2 Page 27 16. YA27 YA42 13(4) 17. YA30 YA42 YA32 13(3) 18. 18(1)(a) 19. 20. YA33 YA35 18(1)(a) 18(1)(a)(c) 21. YA35 YA42 YA35 23(4)(d) 22. 18(1)(a)(c) 23. YA37 18(1)(a) 24. YA39 24(1)(a)(b) 24(3) That a thermostatic temperature control is installed at the shower delivering hot water above the recommended 43°C. All hot water outlets must not deliver hot water above 43°C [Outstanding from 17/08/05]. That suitable laundry facilities and arrangements are in place to prevent infection and the spread of infection at the home. That 50 of care staff are qualified to at least NVQ level 2 in care or equivalent [Outstanding from 31.12.05]. That adequate numbers of staff are employed to meet the assessed needs of residents. That the new Common Induction Standards replacing TOPPS are observed and implemented. That all staff are kept up to date with fire training [Outstanding from 30/04/06]. That refresher training is provided for some members of staff in relation to food hygiene and manual handling. That an application for a registered manager be forwarded to CSCI for processing [Outstanding from 30/06/06]. That effective quality assurance systems are in place and implemented in order to review the quality of care provided at the home. 19/10/06 31/10/06 31/03/07 31/12/06 31/03/07 31/12/06 31/12/06 31/03/07 31/03/07 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 28 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. 3. 4. Refer to Standard YA13 YA22 YA23 YA40 Good Practice Recommendations That priority be given to ensuring that the minibus is roadworthy, safe to use and accessible to residents and staff. That a record of all complaints received by the home is kept. This should include details of the investigation, the action taken and the outcome. That information relating to PoVA is more detailed to provide staff with clear guidance regarding the referral process. That all policies and procedures are signed and dated in order to evidence that they are regularly reviewed and current. 3 The Droveway DS0000060763.V311399.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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